Telehealth use has increased in specialty clinics, but there is limited evidence on the outcomes of telehealth in primary cardiovascular disease (CVD) prevention.The objective of this study was to evaluate the initial outcomes of CardioClick, a telehealth primary CVD prevention program.In 2017, the Stanford South Asian Translational Heart Initiative (a preventive cardiology clinic focused on high-risk South Asian patients) introduced CardioClick, which is a clinical pathway replacing in-person follow-up visits with video visits. We assessed patient engagement and changes in CVD risk factors in CardioClick patients and in a historical in-person cohort from the same clinic.P<.001) and they did so in lesser time  than the patients in the historical in-person cohort. Patients who completed the CardioClick program achieved reductions in CVD risk factors, including blood pressure, lipid concentrations, and BMI, which matched or exceeded those observed in the historical in-person cohort.In this study, 118 CardioClick patients and 441 patients who received in-person care were included. CardioClick patients were more likely to complete the clinic’s CVD prevention program (76/118, 64.4% vs 173/441, 39.2%, respectively; Telehealth can be used to deliver care effectively in a preventive cardiology clinic setting and may result in increased patient engagement. Further studies on telehealth outcomes are needed to determine the optimal role of virtual care models across diverse preventive medicine clinics. The COVID-19 pandemic has accelerated the adoption of telehealth and will likely lead to the permanent inclusion of virtual care delivery models in health care systems . Cardiovsecondary prevention of CVD have achieved equal or superior reductions in risk factors when compared to those achieved in traditional in-person clinics and cardiac rehabilitation [primary CVD prevention, however, is less conclusive. A randomized controlled trial of a web-based lifestyle intervention for patients with familial hypercholesterolemia did not find significant improvements in CVD risk factors, and a meta-analysis evaluating telehealth in primary CVD prevention concluded that there was insufficient evidence to determine its effectiveness [Previous studies have suggested that telehealth is as effective as traditional in-office visits in improving the control of chronic diseases such as diabetes . Telehealitation -14. Evidtiveness ,16.There is some evidence that substituting telehealth visits for in-person visits in preventive cardiology clinics may be effective. An observational evaluation of clinic-based telehealth follow-up visits for CVD risk reduction in remote Saskatchewan, Canada found increased visit completions and similar risk reductions with telehealth as compared to that with usual care, but this study included only 9 patients in the intervention arm . FurtherThe SSATHI clinic consists of a multidisciplinary care team of cardiologists, an insulin resistance specialist, and registered dieticians. Patients enrolled in the SSATHI prevention program complete initial visits and 2 follow-up visits with a physician and a dietician. Patients undergo a comprehensive risk assessment, including an advanced cardiometabolic panel comprising lipid subfraction, inflammatory markers, lipoprotein(a), and apolipoprotein B/A1 ratio tests. Patients then receive personalized treatment focused on intensive risk reduction through lifestyle interventions and pharmacotherapy, including treatment of hypertension and hyperlipidemia as per the American College of Cardiology and American Heart Association guidelines. Dieticians act as lifestyle intervention specialists in the areas of Nutrition and metabolism, Exercise, Sleep, Transcend stress management (NEST) and medication adherence. A lifestyle questionnaire is administered at the beginning and the end of the program. Based on questionnaire responses, cardiometabolic risk factors, and patient engagement, culturally tailored lifestyle recommendations are provided at each visit. Program completion is defined as completion of baseline and follow-up laboratory tests and at least 2 physician and dietician visits.In 2017, CardioClick, a novel telehealth clinical pathway, was implemented in SSATHI. Patients enrolled in CardioClick participated in the same prevention program as traditional SSATHI patients, but all follow-up visits with physicians and dieticians were provided as video visits rather than in-person visits . Unpaired two-tailed P=.009) and had lower baseline triglyceride levels  than the in-person cohort patients. The cohorts were otherwise similar in terms of demographics, comorbidities, and baseline CVD risk factors  and they did so in lesser time  than the in-person cohort patients. CardioClick patients were also more likely to utilize clinic services. Of the 3 dietician visits offered, the typical CardioClick patient completed all 3 visits, while the typical patient in the historical in-person cohort only completed 1 visit. Patients who completed CardioClick experienced significant reductions in CVD risk factors, including systolic and diastolic blood pressure, total cholesterol levels, low-density lipoprotein cholesterol levels, triglyceride levels, and BMI  (P=.02). Reductions in other risk factors were not significantly different between patients completing the prevention program in the 2 cohorts  . In cont cohorts .The use of telehealth has rapidly expanded as a result of the COVID-19 pandemic; however, there has been limited and inconclusive evidence on the effectiveness of telehealth in primary CVD prevention ,15. The CardioClick patients completed the prevention program at a higher rate and in a shorter amount of time on average, suggesting that telehealth may decrease barriers to care in settings with readily available in-person specialty care and not just in low-access settings, as has been demonstrated previously . We founTo our knowledge, this study represents the first evaluation of a telehealth care model for primary CVD prevention in a clinic setting with patients completing visits from home. The risk factor reductions observed support the continued use of telehealth in preventive medicine clinics and motivate further study of its impact on care delivery and outcomes.This study should be interpreted in the context of several limitations. The intervention was implemented at a single center with a patient population that was majority male, middle-aged, and of South Asian origin. It is unclear whether the observed reductions in CVD risk factors would be generalizable to diverse patient populations. Although patients were enrolled in CardioClick by default, there may exist unobserved differences between the cohorts, which accounted for the observed differences in the outcomes. Finally, it is unknown whether the risk factor reductions achieved will be sustained in long-term follow-up.Implementation of CardioClick, a clinic-based telehealth primary CVD prevention program, was associated with increased patient engagement and significant reductions in risk factors among those completing the program. The success of this initiative suggests that telehealth can be utilized to deliver care effectively in the preventive cardiology clinic setting. Further research is needed assessing telehealth outcomes with randomized evaluations across diverse patient populations.


The variants of chronic inflammatory demyelinating polyneuropathy (CIDP) differ not just in their clinical, pathological and electrophysiological characteristics, but often in their indifferent response to conventional immunosuppressive agents which are effective in typical CIDP. High quality evidence is lacking as far as the management of these atypical variants is concerned. In this review, we summarize the treatment approaches to each of these CIDP variants based on existing data. Distal acquired demyelinating symmetric polyneuropathy (DADS) has the phenotype of a symmetric, demyelinating sensory, length-dependent polyneuropathy and is frequently associated with paraproteinemia and anti myelin associated glycoprotein (MAG) antibodies. While the management of idiopathic DADS (DADS-I) is the same as CIDP, DADS-M responds suboptimally and has a favorable response to rituximab. Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) manifests as a chronic progressive demyelinating mononeuropathy multiplex which can evolve to a confluent pattern indistinguishable from CIDP. Evidence favors treating MADSAM with conventional immunomodulatory therapy (IMT), but this disorder responds less favorably than CIDP. Some patients present with purely sensory symptoms, known as pure sensory CIDP or chronic inflammatory sensory polyradiculoneuropathy (CISP), the latter localizing to a pre-ganglionic pathology. Both respond well to first line IMT, particularly to intravenous immunoglobulin (IVIG), but patients relapse without maintenance therapy. Pure motor CIDP resembles multifocal motor neuropathy with conduction block (MMNCB), but the previously reported worsening status after steroid treatment was not reproduced in recent studies, and IVIG remains the first-line therapy. Some focal forms of CIDP defy exact classification, but respond well to first-line IMT including IVIG. Overall, atypical CIDP responds to treatment with first-line IMT, but has a suboptimal response compared to CIDP. There is evidence for effectiveness with agents such as rituximab, especially in DADS-M, and this medication can also be used in cases refractory to conventional IMTs. Rituximab is also effective in CIDP with IgG4 antibodies which has distinct clinical features and is mostly refractory to first-line IMT. The term “atypical CIDP” generally denotes those variants that deviate from the classical symmetrical, proximo-distal, motor, and sensory presentation of CIDP. The EFNS/PNS criteria list the following types of “atypical CIDP”: predominantly distal  or asymmetric , focal , pure motor and pure sensory   1). Stu. Stu1). Distal acquired demyelinating symmetric neuropathy (DADS) is defined by the symmetrical presentation of sensory or sensorimotor symptoms starting distally in the lower limbs without proximal limb or cranial nerve involvement and having abnormally increased distal motor latencies on nerve conduction studies (NCS) . DADS coDADS without monoclonal paraproteinemia or anti-MAG antibody, also referred to as DADS-I, is considered as a variant of CIDP. The initial report by Katz et al.  demonstrA causal association of monoclonal gammopathy with DADS is significantly stronger for IgM than for IgG or IgA monoclonal gammopathies . From thThe pathology of anti-MAG positive DADS, involves deposits of IgM and complement, with splitting of myelin lamellae resulting in demyelination and conduction block. The response to treatment in DADS with paraproteinemia (DADS-M) to the first line agents effective in CIDP is suboptimal , 8. InitMADSAM is a painless, demyelinating, mononeuropathy multiplex, and is the most frequently encountered variant of CIDP in most series. The distinct nature of MADSAM pathology is that the brunt of the macrophage-mediated demyelination is multifocal and distributed mainly in mid-limb or proximal nerve segments , 25. In The pure sensory variant of CIDP was initially recognized by Oh et al.  who firsCISP is often considered a pure sensory CIDP due to its similarities in clinical presentation, but with the distinctive feature of sensory pre-ganglionic root involvement as evidenced by normal sensory NCS, abnormal sensory evoked potentials (SEP), and thickened spinal roots on MRI. In the initial case series of 15 patients with CISP, six patients were significantly disabled and required treatment, four of whom received IVIG and two received steroids . All of Pure motor CIDP resembles multifocal motor neuropathy (MMN) in its clinical presentation but is more symmetrical and is classified as an atypical form of CIDP. Motor conduction blocks are the most common electrophysiological finding in this entity, and in many cases there is an absence of sensory nerve conduction abnormalities, again similar to MMN , 35. Fron = 84) and Japan (n = 40)  , 5. The (n = 40) . It was (n = 40) , all but(n = 40) –48. In a(n = 40) . Focal CInvestigations for possible biomarkers of CIDP have led to the identification of pathogenic autoantibodies directed against several nodal and paranodal antigens amongst the subset of patients with CIDP . IgG4 anThe data on the treatment of atypical variants of CIDP are of low-quality and limited in patient numbers. Large prospective series or clinical trials are non-existent other than possibly for the DADS phenotype. Furthermore, the diagnostic separation of these variants is not clearly demarcated and some entities such as DADS or pure motor CIDP and focal CIDP may represent overlapping phenotypes. These variants can be impossible to distinguish from other entities such as MMN or MADSAM. Other than in anti-MAG positive DADS, the existing literature indicates a favorable treatment response with conventional first-line IMT used in typical CIDP. Given reports of some patients with pure motor and pure sensory CIDP worsening with steroids, IVIG may be preferred as the first-line agent in these variants. Agents such as rituximab are currently being re-explored in anti-MAG neuropathy and in IgG4 antibody associated CIDP earlier in the treatment algorithm. A revision of the guidelines to clearly define the diagnostic criteria for these entities is required in order to undertake prospective clinical trials and improve our understanding of atypical CIDP.DM was involved in the review of literature, drafting the work, and revising it critically for important intellectual content. HK was involved in drafting the work and revising it critically for important intellectual content. VB was involved in designing, review of literature, revising it critically for important intellectual content, and final approval of the version. 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.


Mild cognitive dysfunction was positively correlated with NREM-DFA  and negatively correlated with an NREM-fast ratio . This suggested that altered EEG activity during NREM sleep is associated with MCI in patients with PDS. NREM sleep EEG characteristics of the power spectral analysis and DFA correlate to MCI. Slowing of EEG activity during NREM sleep may reflect contribution to the decline in NREM physiological function and is therefore a marker in patients with PDS-MCI.Early identification and diagnosis of mild cognitive impairment (MCI) in patients with parkinsonism (PDS) are critical. The aim of this study was to identify biomarkers of MCI in PDS using conventional electroencephalogram (EEG) power spectral analysis and detrended fluctuation analysis (DFA). In this retrospective study, patients with PDS who underwent an overnight polysomnography (PSG) study in our hospital from 2019 to 2020 were enrolled. Patients with PDS assessed by clinical examination and questionnaires were divided into two groups: the PDS with normal cognitive function (PDS-NC) group and the PDS with MCI (PDS-MCI) group. Sleep EEG signals were extracted and purified from the PSG and subjected to a conventional power spectral analysis, as well as detrended fluctuation analysis (DFA) during wakefulness, nonrapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep. Forty patients with PDS were enrolled, including 25 with PDS-NC and 15 with PDS-MCI. Results revealed that compared with PDS-NC patients, patients with PDS-MCI had a reduced fast ratio /(delta + theta)) and increased DFA during NREM sleep. DFA during NREM was diagnostic of PDS-MCI, with an area under the receiver operating characteristic curve of 0.753 (95% CI: 0.592–0.914) ( Parkinsonism (PDS) is a syndrome with various causes characterized by bradykinesia, rigidity, and rest tremor , usuallyThe cumulative prevalence of PD dementia is approximately 75–90% in patients with a disease course exceeding 10 years. This increases the mortality rate and severely impacts the quality of life . SimilarCurrently, in clinical practice, cognitive function is usually assessed using questionnaires or scales. These are well-established methods and easy to use; however, the specificity and sensitivity of many scales remain unsatisfactory  due to tThe quantitative analysis of electroencephalogram (EEG) signals provides a method for assessing cognitive function in various diseases. For example, numerous studies focusing on EEG have demonstrated correlations between quantitative EEG (qEEG) biomarkers and cognitive function in Alzheimer's disease . Some stHowever, previous studies have mainly focused on the association between resting awake EEG alterations and cognitive dysfunction in patients with PDS and rarely addressed sleep EEG. However, sleep EEG also provides a window of insight into cognitive dysfunction .For example, previous studies have shown that alterations in sleep EEG are associated with brain function in the aging population . DecreasIt remains unclear, however, whether sleep EEG is associated with mild cognitive impairment in PDS patients.Nowadays, power spectral analysis is the most common method used in these EEG studies.In addition, due to the nonlinear dynamics and nonstationarity of EEG signals limiting the conventional power spectral analysis, a simpler alternative method, the detrended fluctuation analysis (DFA) method, has been used for various nonstationary physiological signals in recent years . This isTherefore, this study sought to determine sleep EEG biomarkers of polysomnography (PSG) related to MCI in PDS patients. We hypothesized that the power spectral analysis features of overnight sleep EEG are related to cognitive function in patients with PDS.Patients with PDS who underwent overnight PSG monitoring were enrolled in this study, and their overnight EEG was analyzed using conventional spectral analysis and DFA. Differences between patients with normal cognitive function and those with MCI were compared to identify EEG markers reflecting cognitive impairment.A total of 45 consecutive patients who were admitted to our neurology department with PDS from August 2019 to August 2020 and underwent overnight PSG in our sleep lab were enrolled in this study.This retrospective study was approved by the ethics committee of Peking University First Hospital, and the requirement for obtaining informed consent was waived . The study adhered to the Declaration of Helsinki, and patient confidentiality was maintained.Compliance with the criteria for PDS includes bradykinesia, in combination with either resting tremor, rigidity, or both PDS was not secondary to identified structural, toxic, or metabolic disorders or conditionsInclusion criteria are as follows: Poor quality of PSG-EEG signals, high impedance, excessive electromyography (EMG), or presence of motor artifactsDementia cases where substantial impairment is present in one or more cognitive domains and the impairment must be sufficient to interfere with independence in everyday activities Other medical conditions that cause EEG changes, such as epilepsyOther medical conditions that may affect cognition, such as strokeExtremely severe motor symptoms affecting patients' cooperation with cognitive evaluationsExclusion criteria are as follows: Among the 45 patients with PDS, we excluded two patients with high signal impedance, excessive myoelectricity, or motion artifacts; moreover, three cases of PDS with dementia were excluded. A total of 40 patients were finally enrolled.All patients were interviewed, and a detailed medical and medication history was acquired. The cognitive function was evaluated based on clinical examination, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE). All cognitive evaluations were performed when PD patients were in the “on” state and when the other parkinsonian patients were in relatively better conditions. Subjects were stratified into two groups based on cognitive evaluations: PDS with MCI (PDS-MCI) group and PDS with normal cognition (PDS-NC) group. There are no diagnostic criteria for PDS-MCI. We defined the PDS-MCI group based on the criteria of mild neurocognitive disorders  and MCI 2), abdominal and chest movement, and leg movements were recorded according to the American Academy of Sleep Medicine (AASM) guidelines . Compared to healthy individuals, the EEG signals from AD patients have less complexity, and this complexity is considered a potential biomarker for the functional abnormalities in AD [33]. Our result suggests that reduced EEG complexity may also be associated with cognitive decline seen in patients with PDS; DFA is a promising marker for it.The main limitations of the study are as follows. (1) In this retrospective study, NREM sleep EEG characteristics were correlated with MCI, but it remains to be investigated whether there is a causal relationship and whether it can predict MCI. (2) To assess whether MCI is independently correlated with these EEG parameters, a regression analysis would be more appropriate. However, the sample size was too small to allow for a regression analysis. This study is a preliminary study, and the sample size can be increased for subsequent analysis.The early prediction of MCI in patients with PDS is important for early intervention prior to the development of dementia. Recent studies suggest that EEG changes precede the onset of the clinical signs of cognitive impairment in PDS , 32. ThiIn summary, this study demonstrated that the power spectral analysis and DFA characteristics of NREM sleep EEG were related to MCI in patients with PDS. DFA can be used as a biomarker reflective of cognitive function. Slowing of EEG activity during NREM sleep may reflect the decline in NREM physiological function and is therefore a marker in patients with PDS-MCI. The early prediction of MCI in patients with PDS is important for early interventions prior to the development of dementia.


Lung cancer is a significant health problem worldwide. Unfortunately, current therapeutic strategies lack a sufficient level of specificity and can harm adjacent healthy cells. Consequently, to address the clinical need, novel approaches to improve treatment efficiency with minimal side effects are required. Nanotechnology can substantially contribute to the generation of differentiated products and improve patient outcomes. Evidence from previous research suggests that nanotechnology-based drug delivery systems could provide a promising platform for the targeted delivery of traditional chemotherapeutic drugs and novel small molecule therapeutic agents to treat lung cancer cells more effectively. This has also been found to improve the therapeutic index and reduce the required drug dose. Nanodrug delivery systems also provide precise control over drug release, resulting in reduced toxic side effects, controlled biodistribution, and accelerated effects or responses. This review highlights the most advanced and novel nanotechnology-based strategies, including targeted nanodrug delivery systems, stimuli-responsive nanoparticles, and bio-nanocarriers, which have recently been employed in preclinical and clinical investigations to overcome the current challenges in lung cancer treatments. Lung cancer creates a significant global disease burden and is the most common cause (accounting for 18%) of cancer-related deaths worldwide . There aNanotechnology-based therapy has been shown to be a promising strategy by which cancer cells can be treated without harming healthy cells . This ha® was the first nanoparticle-based drug delivery approved by the FDA in 1995, and it encapsulates doxorubicin (DOX) chemotherapeutic drugs in liposomal nanoparticles to improve the drug’s prolonged circulation time and toxicity profile . L. Lin vitsive NPs B. Employsive NPs A 98]. C. Cin vitsive NPs C. Redox-sive NPs B. Furthe®, in 2000 to treat disorders associated with the eye ..in vitroIn vivo evaluation showed effective drug accumulation in the tumor and inhibition of tumor growth with minimal organ damage and body weight loss ..in vitroin vitro and no damage to normal tissues in animal studies. In addition, in vivo assessments demonstrated that the intratumoral injection of NPs can completely eradicate the tumor, and its intravenous injection can inhibit tumor growth and decrease tumor mass [DTX/PPN@PPY@HA is another NP that takes advantage of HA as a targeting agent. This NP was based on a fatty acid phase-changing core, photoresponsive polypyrrole outer layer, HA, and DTX combination. In tumor cells, polypyrrole stimulation with laser irradiation causes local hyperthermia, resulting in fatty acid core melting and heat-triggered drug release. This study suggested that NP DTX/PPN@PPY@HA had excellent cellular uptake and remarkable photothermal chemotherapeutic effects, while the blank PPN@PPY@HA showed no cytotoxicity mor mass . The preNumerous clinical studies have been conducted to evaluate the efficacy and safety of nanodrug delivery systems, however, to date, the FDA has approved only a few for use with lung cancer patients. Genexol-PM, a polymeric micelle formulation of PTX, and nab-PTX are two nanotechnology-based drugs currently used to treat lung cancer . The majBIND-014 is a polymeric nanocarrier carrying DTX in hydrophilic polyethylene glycol corona decorated with ligands that target the prostate-specific membrane antigen (PSMA) . OverexpTargomiRs are nonliving bacterial minicells loaded with an miR-16-based mimic microRNA (miRNA). Panitumumab, a human monoclonal antibody, selectively binds to overexpressed EGF receptors to efficiently target tumor cells ,166. TheSGT-53 is another active targeted NP that delivers the tumor suppressor gene TP53 to tumor cells and restores the function of the p53 protein . p53 is Smart nanotechnology-based drug delivery systems provide new hope that we may be able to overcome the current limitations of the anticancer agents used for lung cancer treatment. As we see in the case of Abraxane, the advantages of nanotechnology-based drug delivery were so significant that it ended the monopoly of a traditional chemotherapeutic agent (Taxol). Even though Abraxane gained considerable success, it solely uses passive targeting strategy to reach the tumor site, which, compared to new “smart” NPs, has fewer advantages. Furthermore, this novel strategy could play a key role in precision and personalized medicine in the near future. However, there are still many challenges that need to be addressed in the development of nanotherapeutics with multifunctionalities to improve cancer nanomedicine clinical trials. As NPs become more complicated in terms of structure and formulation, industrial scale-up production becomes more challenging. In addition, it is more difficult to control the physicochemical properties of these smart nanoformulations due to their complexity. Discovering the exact mechanism of smart NPs in the human body seems crucial for the further growth of this field. Differences in endogenous factors  between individuals is another challenge since it could alter the efficiency of smart NPs. This issue became problematic in the case of stimuli-responsive NPs that target one or more endogenous stimuli. In contrast, controlling exogenous stimuli are more straightforward, but optimization is needed to reduce damaging normal tissue and adjust tissue penetration depth. Comprehensive standard protocols for the toxicological profiling of nanoformulations could help to determine the critical physical or chemical properties of NPs which cause their toxicity. Novel nanoformulations and safer strategies for application could result from optimizing the physicochemical properties of NPs while also increasing their therapeutic efficacies. New approaches, such as machine learning and in silico methods, could be employed as a powerful tool in nanomedicine to develop novel nanoformulations and find suitable treatment strategies.


Cancer represents an important public health concern as the main leading cause of death worldwide. Current monotherapies, including radiotherapy, chemotherapy and molecular targeted therapy, show limited efficacy due to rapidly emerging resistance as a result either of target mutations, or engagement of parallel oncogenic pathways or onset of adaptive survival mechanisms. Moreover, the complexity of signaling networks and the activation of bypass pathway(s) render molecular targeted therapies ineffective. Therefore, combinatorial strategies could be more effective therapeutic approaches.Li et al. evaluate the development of prodrugs based on targeting hypoxia. They outline existing hypoxia-activated products and analyze their potential benefits in cancer treatment along with their effects in combination setting with traditional chemotherapeutics. In their second paper  go into detail for the hypoxia-activated prodrug TH-302 and its potential for combinatorial regime with other anti-cancer treatments, including radiotherapy, immunotherapies, anti-angiogenic agents and tissue oxygen modulators.The most solid malignancies are characterized by hypoxia, which plays a relevant role in cancer resistance to conventional treatments . TherefoZhu et al. report that metformin, an agent that exerts broad anti-cancer effects through activating AMPK and inhibiting mTOR, enhances the cytotoxicity of anlotinib, a multi-targeted tyrosine kinase inhibitor. Metformin enhances the effect of anlotinib on NADP+/NADPH ratio, indicating that the combination regulates intracellular redox homeostasis and promotes switching to oxidative state. The molecular mechanisms underlying the anlotinib/metformin synergistic effect involve PARP1 and caspase-3 increased cleavage and Bax/Bcl-2 enhanced ratio, suggesting that the combinatorial treatment triggers apoptosis. ROS-mediated induction of p38/JNK MAPK and ERK signaling might explain the activation of Bcl-2/Bax-caspase signaling pathway and lead to apoptosis  enrichment which underlies chemotherapy resistance. Wnt signaling inhibition reduces TNBC CSCs population and resensitizes carboplatin-resistant TNBC to the drug. CSCs are key players in cancer resistance to conventional protocols of radiotherapy, chemotherapy and molecular targeted therapy, thus causing the failure of cancer therapy and tumor relapse , glioblastoma, pancreatic and colorectal cancer. However, the chemotherapeutic efficacy is often limited by the occurrence of resistance whose molecular bases are still poorly understood. In the effort to identify the molecular mechanisms of carboplatin resistance in TNBC,  relapse . The limLi et al. construct transcriptomics- and network-based prediction models to screen the potential drug combinations for prostate cancer treatment and evaluate their accuracy by in vitro assays. Their approach identifies drugs combinations to be further investigated in preclinical and clinical trials. Gondal et al. present a novel computational framework using a literature-derived in silico Drosophila Patient Model for treating colorectal cancer (CRC) patients. The proposed model identifies synergistic combinations for treating different CRC patients and could be deployed in preclinical settings to evaluate potential combinations before an in vivo evaluation. The computational approaches might help to design specific and personalized interventions taking into account the inter-individual variations occurring on genomic, biochemical, behavioral and environmental levels. Gondal and Chaudhary present a review of existing computational resources that the scientific community can utilize for evaluating existing repositories of biomolecular cancer data, in conjunction with simulation software for the development of personalized cancer therapeutics. The authors present a critical review on existing methodologies and recognize limitations in them. Crook et al. profile advanced or refractory solid cancers by multi-analyte molecular and functional tumor interrogation [Encyclopedic Tumor Analysis (ETA)] to select personalized combination treatment regimens. The ETA-guided combined treatments of mTOR inhibitors with several anti-neoplastic agents, targeting different tumor-associated signaling pathways, improve significantly the Progression Free Survival of treated patients, thus providing clinical evidence of the therapeutic benefit achieved by personalized combinatorial strategies compared to mTOR inhibitors as monotherapies.The large number of anti-cancer drugs available implies a huge number of possible combinations to be assessed to identify the synergistic ones for cancer treatment. The computational methods could represent useful tools to screen drug combinations, thus restricting the prohibitive cost and intense labor required for the experiments.  Xia et al., which combine immunotherapy and PTT  might benefit of immunotherapy in combination setting. This strategy could enhance the efficacy with a limited toxicity of the treatment. Although the immunotherapy in combination setting is the subject of other Frontiers in Oncology Research Topics, the paper of and PTT  for locaIn summary, this Research Topic is focused on the combinatorial treatment strategies to fight cancer which target cancer hallmarks, including signaling pathway dysregulation, hypoxia, oxidative stress, metabolic reprogramming, angiogenesis and stemness. The papers included in this Research Topic strengthen the relevance of combined approaches compared to single treatments in preclinical and in clinical setting.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.This work was supported for GM by the College of Pharmacy, University of Louisiana Monroe start-up funding and the National Institutes of Health (NIH) through the National Institute of General Medical Science Grants 5 P20 GM103424-15, 3 P20 GM103424-15S1.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


With recent technical advances and diminishing sequencing costs, single-cell sequencing modalities have become commonplace. These tools permit analysis of RNA expression, DNA sequence, chromatin structure, and cell surface antigens at single-cell resolution. Simultaneous measurement of numerous parameters can resolve populations including rare cells, thus revealing cellular diversity within organs and permitting lineage reconstruction in developing tissues. Application of these methods to the enteric nervous system has yielded a wealth of data and biological insights. We review recent papers applying single-cell sequencing tools to the nascent neural crest and to the developing and mature enteric nervous system. These studies have shown significant diversity of enteric neurons and glia, suggested paradigms for neuronal specification, and revealed signaling pathways active during development. As technology evolves and multiome techniques combining two or more of transcriptomic, genomic, epigenetic, and proteomic data become prominent, we anticipate these modalities will become commonplace in ENS research and may find a role in diagnostic testing and personalized therapeutics. Cellular diversity has long been known to exist in the enteric nervous system (ENS), with enteric neuronal subclasses traditionally defined based on their morphology, anatomic location of their cell bodies and projections, and neurochemical profile. Immunohistochemistry has been most commonly used to identify the panel of neurotransmitters expressed by different neurons as a way of classifying them into functional subtypes ,2. The iTools for analysis at single-cell resolution, such as high-resolution microscopy and flow cytometry, have existed for decades. However, these traditional methods are limited to measuring a small number of parameters in a single assay. Other techniques, such as bulk RNA sequencing and mass spectrometry-based proteomics, can assess many parameters in a single experiment but measure average signal from a large number of cells. Highly parameterized studies on bulk populations have generated important biological insights, such as identifying conserved transcription factors in mouse and human enteric neuron development , but theIn this review, we summarize current single-cell sequencing modalities, consider insights from single-cell sequencing of ENS cells, and comment on ways these technologies may impact the field in coming years. Because the ENS is neural crest-derived, we include papers that discuss the early specification and differentiation of the neural crest lineage. To our knowledge, no papers in the peer reviewed literature have yet applied single-cell technologies other than RNA sequencing to the ENS. However, we expect that single-cell measurement of other variables will be performed on ENS populations in the near future, and it is important for ENS researchers to be aware of these technologies, so they are discussed here. While exciting advances are occurring in mass spectrometry-based methods for single-cell proteomics ,7, such Single-cell sequencing technologies can be classified based on their approach to isolating single cells or, in some cases, single nuclei, and by the feature or features they measure. From a technical perspective, cells can be isolated by sorting or limiting dilution into single wells, followed by amplification and library generation; such methods include Smart-Seq ,9 and CERegardless of the method used for applying unique barcodes to individual cells, sequencing libraries are constructed from pools of many single cells (or nuclei), and sample barcoding can allow cells from several replicates or unrelated experiments to be combined into a single library. The libraries are sequenced on next-generation platforms. Software pipelines, such as 10× Genomics’s Cell Ranger suite , have beHeterogeneous gene expression within tissues, even among superficially indistinguishable cells, has been appreciated for some time. Consequently, attempts at single-cell transcript sequencing date back three decades, when Eberwine and colleagues described a method for generating cDNA libraries from the whole transcriptome of individual hippocampal rat neurons . This eaIt has long been appreciated that unicellular organisms of the same species, and genome sequences among the many cells of multicellular organisms, are not necessarily identical . This isThere has been rapid growth in the techniques for analyzing epigenetic variables in single cells. Such variables include chromatin accessibility, DNA methylation, histone modifications, and transcription factor binding. While numerous methods for assessing DNA methylation have been reported ,48,49, nThe explosion in single-cell sequencing technologies over the past decade has naturally caused interest in the simultaneous assay of multiple variables in individual cells. Multiome technologies that simultaneously measure parameters from two or more biological traits are increasingly common. Such measures are particularly valuable when one variable, such as expression of a known set of genes, is considered a gold standard for distinguishing populations and another, such as the histone methylation pattern, is expected to vary between populations but would not suffice alone to determine cell identity confidently. Multiome data can also provide snapshots of the relationship between chromatin structure and gene expression across diverse cell populations, allowing investigators to generate testable hypotheses regarding transcriptional regulation and identify candidate transcription factors controlling cell programs. Multiome approaches have been described in single cells for joint RNA and ATAC , T cell All the single-cell sequencing tools discussed thus far require dissociation of cells from their native tissue environment. This eliminates spatial information and prevents these tools from understanding how complex cell types are arranged functionally within organs. Techniques for in situ RNA and genome sequencing have been described to overcome these shortfalls ,60. ThesSox10, Erbb3, and Plp1, without any neuronal gene expression; (2) cells co-expressing glial and progenitor genes along with neuronal genes, such as Tubb3 and Elavl4; and (3) cells expressing only neuronal genes. A small group with low expression of all ENS genes was also identified, which are possibly contaminant cells. Using principal component analysis, the authors demonstrated these three groups of cells exist along a continuum between the purely glial/progenitor cells and the purely neuronal cells, and they identified Ret as a possible driver of neuronal differentiation based on its high level of expression in both neuronal cells and cells with a mixed phenotype.As single-cell sequencing modalities have matured and become widely available, scientists have used these platforms to study development, diversity, and function in the ENS. The first application to the ENS was reported in 2017 by Lasrado and colleagues, who used a fluidic system to capture 192 single cells marked by a tdTomato reporter driven by Sox10 expression from mouse embryos at E12.5 . After fDanio rerio embryos and approximately 137,000 cells from Xenopus tropicalis embryos, in both cases pooling cells from sequential time points [Xenopus model. By examining the genes expressed at stages between the blastula to the early neural crest, they found no evidence of a persistent transcriptional program beyond the blastula. While conceding that functional pluripotency could be maintained by epigenetic mechanisms or other, non-transcriptional regulatory mechanisms, they argued that it is most likely that the neural ectoderm reacquires multipotency during early neurulation.A short time later, a group led by Allon Klein published two large-scale studies of vertebrate model systems at various embryonic stages. The authors used a droplet-based approach to sequence approximately 92,000 cells from e points ,17. BothWnt1Cre;R26Tomato transgenic mice around postnatal day 21. Of the ENS cells, over 90% were enteric glial cells. While in-depth analysis of the ENS was not reported, they did note that their clustering algorithm suggested seven distinct subtypes of enteric glial cells, including actively proliferating cells. Nine subtypes of enteric neurons were identified, including nitrergic neurons expressing Nos1 and Chat-expressing cholinergic neurons. Despite the limited analysis of the ENS undertaken by the authors, this paper hinted at significant diversity among both neurons and glia in the ENS. The dataset has been a valuable resource for the ENS community.In a tremendous undertaking, Zeisel et al. reported single cell sequencing of 509,876 murine nervous system cells , 492,949Phox2b), autonomic neurons (Neurog2), and mesenchymal cells (Prrx1). This model of sequential binary fate decisions correlates with the results of Morarach et al. [Without directly addressing the developing ENS, Soldatov and colleagues combined scRNAseq with in situ hybridization to identify cell fate decision points during neural crest differentiation . They peh et al.  . Nmu and Klhl1 were present in murine IPANs, whereas in humans, NMU labeled IPANs and KLHL1 labeled a distinct population. This study was published around the same time as the paper by Morarach et al. [May-Zhang et al. used several approaches to transcriptionally profile duodenal, ileal, and colonic enteric neurons from both adult human gut tissue and mice . Human mh et al. , so neitThe Koohy and Simmons groups collaborated to perform scRNAseq and spatial RNA sequencing of full-thickness intestinal samples from 8- to 22-week-old human embryos . They caHigh/PLP1Low, GFAPLow/PLP1High, and GFAPMid/PLP1Low. Simultaneous ablation of both Plp1+ and Gfap+ glial cells in mice caused catastrophic intestinal mucosal breakdown, resulting in death within several days, indicating that glial cells play an essential role in epithelial homeostasis. They found that Gfap+ glial cells were significantly increased in mice following radiation- or cytokine-induced inflammatory injury, and that these Gfap+ cells facilitate epithelial repair by providing Wnt ligands to support the epithelial stem cell niche. They correlated these results with a previously published scRNAseq dataset of mesenchyme from both healthy and ulcerative colitis human colon tissue [High/PLP1Low murine cells is increased in UC tissue. While this study establishes a functional role for glial cells in intestinal epithelial homeostasis, it does not delineate whether the myenteric plexus glia and submucosal glia have distinct effects on the epithelium. Notably, neither scRNAseq dataset used was specifically enriched for ENS cells and the murine dataset only included cells from submucosal tissue, so the results may not be representative of myenteric plexus glia.Baghdadi et al. paired scRNAseq techniques in mice and humans with in vivo ablation of specific enteric glial cell (EGC) populations to define the heterogeneity of glial cells and identify their role in intestinal stem cell homeostasis . This pan tissue , findingOver the past five years there have been numerous ENS applications of scRNAseq, resulting in important biological insights. There is significant transcriptional diversity among ENS neurons and glial cells, the functional implications of which will require further work to unravel. In the case of neurons, transcriptional diversity has been carefully validated by immunostaining . Less efNotably, the numerous studies published to date have reported varying numbers of neuronal and glial populations. The numbers of glial clusters identified range from three types of mouse glia found by Drokhylansky et al.  to sevenExciting work has been done in recent years to develop single-cell sequencing methods for interrogating epigenetic traits such as chromatin accessibility and histone modifications ,55,62. HFinally, we anticipate that single-cell tools will find applications in clinical diagnostics. Cost concerns may be prohibitive with currently available sequencing modalities, but continued technological advances are expected to reduce sequencing costs in the coming years. The ability of single-cell sequencing to quantify the relative size of diverse cell populations and to identify transcriptional alterations within populations could make it a powerful tool for diagnosing and classifying human disease. For example, despite aganglionosis usually being limited to the distal colon in Hirschsprung disease, there is evidence of altered intestinal motility throughout the gut in mouse models of the disease , presumaIn many respects, the challenges of single-cell data acquisition in ENS populations are the same as with any other tissue. Individual cells or nuclei must be obtained from a complex in situ environment with minimal cell loss and without significantly altering the cells’ signaling and transcriptional milieus. The ENS is particularly challenging due to the scarcity of ENS cells within the intestine and the tight apposition of cells within enteric ganglia . A pauciThere has been tremendous growth of single-cell sequencing methods during the past decade. Over the past five years, scRNAseq has been applied extensively to the ENS. Thus far these technologies have predominantly been used to characterize cell populations in normal and diseased states and have revealed significant diversity in many tissues and uncovered previously unknown cell populations. Single-cell methods have already characterized neuronal and glial subpopulations, identified signaling pathways that promote neurogenesis, clarified transcription factors that regulate neuronal function, and suggested how the ENS interacts with non-ENS cells. As sequencing costs decline and tools for single-cell library construction become more widely available, we anticipate that single-cell methods will become a commonplace tool for testing hypotheses and tracking cell behavior in the ENS. Emerging tools for single-cell epigenetics, such as single-nucleus CUT&Tag and single-nucleus ATAC-seq, will soon illuminate mechanisms that maintain or restrict cell fate potential during ENS development and postnatal homeostasis. As tools for robust, high-parameter protein measurement in single-cells mature, we expect that the integration of single-cell transcriptomics, epigenetics, and proteomics will allow scientists to understand how perturbations impact the ENS and ENS-interacting cells on a systems level. These new discoveries have the potential to revolutionize our understanding of disease mechanisms and our development of new treatments.


This review summarizes in vitro experiments identifying responses and signaling mechanisms underlying axon morphogenesis caused by underappreciated growth factors.Growth cones at the tips of extending axons navigate through developing organisms by probing extracellular cues, which guide them through intermediate steps and onto final synaptic target sites. Widespread focus on a few guidance cue families has historically overshadowed potentially crucial roles of less well-studied growth factors in axon guidance. In fact, recent evidence suggests that a variety of growth factors have the ability to guide axons, affecting the targeting and morphogenesis of growth cones  Throughout organismal development, cell signals activated by extrinsic cues play essential roles in controlling cell fates. For example, by regulating cell survival, differentiation, and morphogenesis, growth factor signaling is crucial for the organogenesis of every tissue in a developing organism. In particular, the central nervous system relies heavily on these signals to assemble intricate neuronal networks. Growth cones at the tips of extending axons probe their surroundings and convert chemosensory signals into mechanical responses that elicit changes in process outgrowth, facilitating attractive and repulsive axon guidance toward target sites. For over three decades researchers have focused on understanding the roles of just a few families of guidance cues in network assembly, yet many more families of growth factors act through similar signaling cascades. Well-studied cues include the Netrin, Semaphorin, Slit, Ephrin, and Wnt family of guidance factors. While these factors have proven to be essential for the guidance and targeting of axons, additional factors likely also play important roles in neural network wiring.in vivo, and analysis of guidance by growth factors in simplified in vitro experiments. We have previously reviewed the compelling evidence for roles of growth factors as axon guidance factors in vivo , which release other factors that influence neurons directly. The reduced conditions provided in vitro have the advantage that direct effects on developing neurons can be tested, but the specific features of the cue conditions subjected to in vivo  may result in very different responses of developing neurons in vivo. In vitro findings inform and support work performed in vivo, and we will highlight here where there are discrepancies or if supporting in vivo evidence is lacking.Three lines of evidence support roles for traditional growth factors as axon guidance cues: the expression patterns of ligands and receptors during development, the effects of manipulation of these expression patterns on axon guidance  in vivo . Here wein vivo. Growth factors are most commonly secreted or released from a tissue source and may become immobilized within the ECM or upon other cells , while those lacking CNTFRα die perinatally , suggestCiliary neurotrophic factor signaling has also been widely explored in the adult retina, particularly with regards to the maintenance of photoreceptor survival and the retinal pigment epithelium . During The Epidermal Growth Factor (EGF) family of receptors includes four receptors: EGFR (aka ErbB1 or HER1), ErbB2, ErbB3, and ErbB4 . These Rin situ hybridization of mouse embryos showed early expression of type I Nrg-1 along the dorsal column of the developing mouse spinal cord, while type III Nrg-1 expression is enriched in the MNs of the ventral column of the spinal cord, in DRGs, and several cranial nerves  as early as E9.5  , support as E9.5 . Similarthe eyes . More dethe eyes . On the the eyes . Other sthe eyes  and Nrg-the eyes . In postthe eyes , as wellthe eyes .Fibroblast growth factor (FGF), was first isolated from cow brain and pituitary in the early 1970s and named for its mitogenic effects on fibroblasts . The FGFXenopus laevis . FGFR1 is exclusively expressed in the ventro-lateral developing MNs , while Fat E10.5 . Perhapsc tectum .cis on the same cell, or in trans with adjacent cells. Importantly, Ret-independent signals downstream of GDNF are also possible, which involve GFRα1-associated NCAM heterodimers  was first isolated from a rat astrocytic cell line (B49) and characterized for its potent trophic effects on dopaminergic neurons from the substantia nigra . Since irodimers , as discin situ hybridization in the developing striatum and caudate putamen  and two cell surface receptors (IGF1R and IGF2R), although no intrinsic tyrosine kinase or other enzymatic activity has been reported for IGF2R . In addiC. elegans to Drosophila to rodents  neurons in salmon and zebrafish, suggesting a role for IGF signaling in reproductive signaling axis development . ConsistIn the developing E16.5 mouse retina, IGF-1 is expressed in specific RGCs that will project to the contralateral LGN, while high affinity IGF binding protein-5 (IGFBP-5) mRNA is detected in RGCs that project ipsilaterally . While tVascular endothelial growth factor (VEGF) was first isolated from solid tumors and was named tumor-angiogenesis factor . It has It is now understood that VEGF contains five family members (A-E) , with thDue to its essential role in vascular development throughout the animal, VEGF and its RTKs are expressed in a spatio-temporal manner consistent with organizing proper ingression of vessels . VEGF isIn the mouse cerebellum, matrix-binding VEGF164 is expressed in the cell bodies and on the dendrites of Purkinje neurons while the granule cells that will eventually synapse onto these dendrites express Flk1 receptors . SimilarMost growth factors are synthesized as premature, inactive pre-pro-proteins which must be processed into their biologically active forms by cleaving the signal peptide and pro-domain either in the secretory pathway or extracellularly. Pro-domains are thought to assist in folding and stabilization of the mature domain, and to direct intra- and extracellular localization, storage, and bioavailability. This added layer of regulation combined with local expression patterns provides a powerful means to control ligand availability and local concentration, especially as some released active ectodomains are diffusible while others become tethered to cell membranes or the ECM, such as to heparin sulfate proteoglycans.For those growth factors secreted as pro-forms and activated extracellularly, there are several classes of proteolytic enzymes known to regulate ligand availability in this way. For example, β-Secretase , plasminogen activators, zinc-dependent matrix metalloproteases (MMPs), and a disintegrin and metalloprotease domain-containing enzyme  family members are responsible for the partial proteolysis and activation of several growth factors .One of the most well-studied and best examples of growth factors that are proteolytically activated extracellularly are the EGF and Nrg family of ligands. All EGF/Nrg isoforms are synthesized as single- or dual-pass transmembrane proteins and require proteolytic cleavage to either release soluble, receptor-binding ectodomains or act through juxtacrine signaling . InteresECM proteins, such as proteoglycans, often have a high affinity for secreted growth factors and provide another means for regulating growth factor signaling through local immobilization. For example, many growth factors bind heparin sulfate proteoglycans, including FGFs, HGF, and IGF . IGF is in vitro. Early studies showed that CNTF promoted neurite outgrowth of acoustic and spiral ganglion neurons in a dose-dependent manner, which was further enhanced by BDNF  enhanced neurite outgrowth of rat hippocampal neurons when bound to a heparin substratum, but in solution had no effect on axon extension of neurons growing upon laminin . On the /laminin , which m/laminin , suggest/laminin . Howeverin vitro . In thisin vitro . In cortin vitro . It is iin vitro . The comin vitro  and GDNF (attractive force) produced more robust turning responses than individual cues, suggesting MN growth cones integrate these signals. This study found that GDNF also reduced the inhibitory effects of EphrinAs, and this effect depended on functional Ret receptors. Adding to the diverse functions of Ret receptors in MN axon guidance, EphrinA receptors on lateral LMC MNs function in reverse signaling with Ret receptors to promote growth toward EphA ligands in the dorsal limb   and downDrosophila  and phosphatidylinositol-3 kinase (PI3K)/AKT pathways . ImportaSignaling downstream of GDNF is complex and poorly understood in growth cones, especially considering all the possible co-receptor combinations that have been identified. As GDNF signals that regulate transcription to influence cell survival have previously been described , here weSeveral studies have investigated the cooperative actions of HGF with other growth factors. While HGF has no outgrowth promoting activity on DRG neurons alone, it does enhance the neurotrophic effects of NGF in a dose-dependent manner on mouse DRG explant axon outgrowth . SimilarNeuronal growth cones express IGF RTKs on their surface , which aVascular endothelial growth factor activates several of the same signaling pathways as the growth factors discussed above that link to the cytoskeleton. For example, VEGF activates Src family kinases (SFKs) in CI growth cones as the Src inhibitor PP2 blocks VEGF-dependent chemoattraction . Similarin vivo and in vitro evidence suggests that growth factors contribute to neural network assembly by regulating neuronal morphogenesis during development. First, growth factor receptors and ligands are properly distributed in embryonic neurons and target tissues across the CNS and PNS, supporting roles at intermediate choice points and final target destinations. Second, many knock-out studies performed in vivo strongly indicate roles for growth factors in network assembly (in vitro show that growth factors can directly influence growth cone motility. In vitro studies have allowed further assessment of molecular mechanisms governing growth factor responses in simplified conditions. Defined conditions in culture will also enable us to better understand how classic axon guidance cues and common growth factors may interact with and modulate one another. This important problem is yet inaccessible in vivo, and we know that growth cones express multiple receptors and function as complex signal integrators (Extensive assembly . Finallyegrators . Crosstain vitro should ultimately be validated in vivo, as responses observed in vitro may not always match observations in vivo. Difference in vitro likely depends on how cues are presented to neurons in simplified culture conditions, compared to highly complex, multi-ligand, and mechanically variable conditions in vivo. However, these complexities in vivo should not discourage experiments designed to identify mechanisms in living organisms, as it is of paramount importance to understand how growth factors function in vivo. In addition, it is also important to examine sensitivities to growth factors and mechanisms of action in human neurons. Working with different classes of human neurons and non-neuronal cells has become possible with advances in stem cell differentiation techniques. One advantage here is that neurons carrying specific disease-causing mutations can be tested. Moreover, while working with human neurons in vivo is possible using xenografts (in vivo-like conditions more feasible (in vivo and in vitro will allow us to one day clearly understand the detailed roles of each growth factor in neural network assembly.Mechanisms identified nografts , recent feasible . Using aTG provided the conceptual framework for this review. TG, MO, and CS wrote the manuscript. TC and SR provided editorial comments. All the 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.


Chronic psychological stress can affect urinary function and exacerbate lower urinary tract (LUT) dysfunction (LUTD), particularly in patients with overactive bladder (OAB) or interstitial cystitis–bladder pain syndrome (IC/BPS). An increasing amount of evidence has highlighted the close relationship between chronic stress and LUTD, while the exact mechanisms underlying it remain unknown. The application of stress-related animal models has provided powerful tools to explore the effect of chronic stress on LUT function. We systematically reviewed recent findings and identified stress-related animal models. Among them, the most widely used was water avoidance stress (WAS), followed by social stress, early life stress (ELS), repeated variable stress (RVS), chronic variable stress (CVS), intermittent restraint stress (IRS), and others. Different types of chronic stress condition the induction of relatively distinguished changes at multiple levels of the micturition pathway. The voiding phenotypes, underlying mechanisms, and possible treatments of stress-induced LUTD were discussed together. The advantages and disadvantages of each stress-related animal model were also summarized to determine the better choice. Through the present review, we hope to expand the current knowledge of the pathophysiological basis of stress-induced LUTD and inspire robust therapies with better outcomes. Stress is an adaptive reaction of the organism in response to the effects of different external and internal adverse events (or stressors) . PsycholDespite the findings from clinical studies, the pathophysiological mechanisms of chronic psychological stress-induced LUTD have still not been clearly defined. Instead of the inherent limitations  of clinical studies, the application of stress-related animal models facilitates further exploration and acknowledgement of the interplay of psychological stress and LUTD. These animal models appear to share multiple key characteristics of LUTDs such as increased voiding frequency , enhanceHowever, different psychological stressors have their own natures and likely stimulate separate brain regions to elicit appropriate responses . Due to A comprehensive electronic literature search was conducted using the PubMed database to identify publications related to chronic psychological stress-induced LUTDs. The keywords included the following terms: “stress,” “animal model,” “bladder,” “lower urinary tract,” “pain,” “voiding,” “micturition,” “micturition frequency,” “urinary frequency,” or “frequency,” using single or combination of words. The search was restricted to studies published between January 2000 and August 2021. Each article’s title and abstract were reviewed for their appropriateness and relevance to the topic. The reference lists from the articles identified by this search strategy were also examined to find additional sources.Lower urinary tract dysfunction, such as OAB or IC/BPS, is commonly a symptom-based diagnosis, and symptoms are associated with urine storage and voiding phases. The hallmark symptoms appear to be urinary frequency and bladder-related pain. Due to the subjective nature of symptoms, the animal cannot communicate intent or relate their urinary symptoms to researchers. Therefore, it is necessary to apply surrogate markers for the symptoms of LUTD instead of intentional acts. Several technical methods have been developed to quantify the voiding activities and bladder nociception on the basis of feasibility and physiological relevance .Three common methods have been applied to assess voiding activities, which include micturition cage, urine blotting patterns, and cystometry. In the approach of the micturition cage, a single animal will be placed into a micturition cage to record voiding frequency, interval, and volume, as well as water intake in real time . For theTwo main methods have been developed to determine bladder nociception in animals. VMR, a pseudo-affective reflex, is considered to be a reliable and reproducible marker to quantify pain sensation and study analgesic agents . It is rAlternatively, von Frey suprapubic hyperalgesia is used to be a surrogate metric for assessing referred bladder hyperalgesia. It is measured by response to suprapubic mechanical stimuli with a calibrated series of nylon Von Frey monofilaments .via particular mechanisms  by staying on the platform, causing potent psychological stress. WAS has previously been shown to be associated with increased anxiety-like behavior in rodents and visceral hyperalgesia in their guts . CurrentHowever, the choices of rodent species, gender, and stress paradigm vary in different studies. Selecting the rodent species apparently limits the selection of specific strains based on their own characteristics. Wistar-Kyoto (WKY) rats are genetically predisposed to elevated levels of anxiety , commonlFunctionally, WAS exposure in rats potently produces a phenotype characterized by increased anxiety-like behaviors, urinary frequency, and bladder hyperalgesia . Using mAdditionally, WAS could also result in different kinds of histopathological changes in rat bladder. Harvested bladder tissue from stressed rats showed inflammatory conditions, which include ulcerated areas, edema, vascular congestion, inflammatory cell infiltration, increased angiogenesis, and an increased number of mast cells in the mucosa . Meanwhivia ceftriaxone treatment attenuated hyperalgesia and voiding dysfunction after WAS exposure , usually mimicking bullying–childhood violence, has been shown to induce distinct voiding dysfunction in rodents. In the common social stress paradigm, the subordination of one male by another larger and more aggressive male could increase the risk of anxiety and depression . Male miAfter social stress exposure, rodents develop micturition alterations resembling partial bladder outlet obstruction in many ways. Furthermore, social stress leads to hypertrophy and remodeling of the rodent bladder , 2012. CThese aforementioned studies shed some light on potential mechanistic pathways linking social stress to LUTD from peripheral involvement to central participation. One of them involved a clear-cut change in the bladder calcineurin–NFAT pathway, the inhibition of which by cyclosporine A resulted in amelioration of the post-stressed abnormal voiding phenotype . A recenIn addition, the effect of social stress on the bladder seems context- and duration-dependent. After social stress, increased voiding frequency can occur first , 2015 buIn contrast to other stressors, social stress is ethologically relevant and suitable to create more innovative and effective management for children presenting voiding dysfunction with bullying or childhood violence history. Context- and duration-dependent effects are typical features of the social stress paradigm. However, an apparent limitation comes from its uneconomic process, such as essential single cage housing to avoid developing social rank hierarchies even among sibling littermates. In addition, another compelling issue is whether social stress can exert an effect on female rodents because current reports are all focused on males.Early life stress, or early adverse events, has been shown to serve as a strong predictor of a painful voiding phenotype later in life. Several translational studies have tried to examine the impact of ELS on the bladder using two main types of animal models, namely neonatal maternal separation (NMS)  and neonThe NOSC model was initially developed to mimic attachment to an abusive caregiver. The main advantage of the ELS model is to initiate adult physiological changes by a childhood psychological intervention, which expands our knowledge of how ELS predisposes an individual to develop LUTD during adulthood. This model has both face validity and construct validity, as well as incorporation of a non-invasive induction. Given that NMS dramatically affects the function of the HPA axis, it is important to control environmental stimuli during both the neonatal and adult periods.To mimic the variety of life stressors experienced by humans on a daily basis, an RVS model is established to elucidate the connection between stress and voiding dysfunction . GeneralSeveral plausible mechanisms were offered for the RVS-induced voiding alterations. The main advantage of the RVS protocol is that it is well-established, reproducible, and more relevant to human daily life stressors. Also, novel stressor exposure on a daily basis could lead to a lack of habituation.Chronic variable stress (CVS), or the chronic mild stress model, was initially utilized in the psychological research field for studies on depression. Similar to RVS, CVS included a series of stressors. In Yoon’s protocol, female SD rats were exposed to scheduled stress environments that include starvation, low temperatures (4°C), immobilization, and changes in the diurnal rhythm for 7, 14, and 28 days . In thisThe pivotal feature of the CVS model is to utilize various unpredictable stressors to investigate the micturition pattern alterations reflecting long-term stressful human life events. Different stressors may contribute to the absence of adaptation. While obviously, establishing the CVS model needs much more time and total experimental cost.Intermittent restraint stress (IRS), a notable psychological stressor to rodents, is also applied to study stress-induced LUTD. In Ihara’s study, male C57BL/6 mice were subjected to IRS during zeitgeber times 4–6 for 2 h/day for 5 consecutive days and exhibited higher voiding frequency and smaller urine volume or voiding in the light (sleep) phase . This vovia CRF1 pathway  and foot shock stress (FSS) are also applied to explore the mechanisms underlying stress-induced LUTDs. IEC produced purely psychological stress without physical stress intervention . Male WK pathway . FSS was pathway . FSS-str pathway  or oxyto pathway . Acute s pathway , 2010 an pathway  can alsoVarious epidemiological studies have demonstrated that gender bias in human LUTD is apparent and that women are more vulnerable to the development of LUTD . TherefoAnother point that should be noted is that the results of lower urinary function tests vary among strains. As mentioned above, WKY rats are more genetically predisposed to anxiety than SD rats. Robbins’s study reported that chronic psychological stress (WAS) significantly enhanced bladder nociceptive responses only in WKY rats rather than SD rats . SimilarHowever, more studies are necessary to determine the sex- and strain-specific differences in stress-related LUTD models.As mentioned above, various studies on different chronic psychological stress models have yielded incremental pieces of evidence for stress-induced LUTDs. However, the results from them appeared to be disparate for a definite conclusion. By integrating the evidence together, we could create a reasonable picture of the pathophysiology of stress-induced LUTDs . The pos2S. Hence, psychological stress could significantly affect the cerebral regions related to stress responses and micturition circuit, which contributes to the development of LUTDs.Limbic–hypothalamic–pituitary–adrenal axis is crucial to coordinate behavioral, physiological, and molecular responses to chronic psychological stressors . In partvia different approaches , another classic pathway for initiation and coordination of stress responses, appears to be involved in stress-induced LUTDs. SAS mainly consists of central  and peripheral  elements . Activatproaches , SAS parproaches . Activatproaches , guanethproaches , or naftproaches  could miproaches .Apart from these supraspinal mechanisms, spinal ones may also be engaged in stress-induced LUTDs. Chronic stress seems to enhance spinal signaling transductions, as evidenced by increased spinal glutamate neurotransmission , PACAP , and CRFOne theory for stress-induced LUTDs is the occurrence of bladder afferent hyperexcitability after chronic stress exposure. As mentioned above, stressed rodents commonly exhibited greater voiding frequency but lower pressure threshold and VMR threshold, which suggests bladder hypersensitivity and hyperalgesia. The activation of bladder C-fiber afferents  or TRPV1in vivo and in vitro methods have demonstrated an enhanced detrusor contraction in stressed rodents (In addition, chronic stress caused other functional and structural changes in the bladder tissues, particularly detrusor muscle and urothelium. Both  rodents , partly  rodents , 2012. T rodents . Particu rodents .Chronic psychological stress can impact LUT function with or without pathological consequences. This study provided a comprehensive overview of stress-related animal models for the study of LUTD and summarized the compensatory mechanisms underlying the emergence of LUTD. Variations in stress duration, the nature of chronic stressors, and differences in animal species, strains, and sex may contribute to different effects on the bladder. Based on the findings from these models, a variety of possible mechanisms and potential treatments have been demonstrated. Future studies should provide experimental means to improve the scientific basis for this common clinical problem, with the hope of ultimately expanding the therapeutic options for those patients with functional bladder disorders.YG: data collection, analysis, and manuscript preparation. LR: project design and manuscript review. Both 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Huntington’s disease (HD) is a fatal neurodegenerative disorder due to an extraordinarily expanded CAG repeat in the huntingtin gene that confers a gain-of-toxic function in the mutant protein. There is currently no effective cure that attenuates progression and severity of the disease. Since HD is an inherited monogenic disorder, lowering the mutant huntingtin (mHTT) represents a promising therapeutic strategy. Huntingtin lowering strategies mostly focus on nucleic acid approaches, such as small interfering RNAs (siRNAs) and antisense oligonucleotides (ASOs). While these approaches seem to be effective, the drug delivery to the brain poses a great challenge and requires direct injection into the central nervous system (CNS) that results in substantial burden for patients. This review discusses the topics on Huntingtin lowering strategies with clinical trials in patients already underway and introduce an innovative approach that has the potential to deter the disease progression through the inhibition of GPR52, a striatal-enriched class A orphan G protein-coupled receptor (GPCR) that represents a promising therapeutic target for psychiatric disorders. Chemically simple, potent, and selective GPR52 antagonists have been discovered through high-throughput screening and subsequent structure-activity relationship studies. These small molecule antagonists not only diminish both soluble and aggregated mHTT in the striatum, but also ameliorate HD-like defects in HD mice. This therapeutic approach offers great promise as a novel strategy for HD therapy, while nucleic acid delivery still faces considerable challenges. Huntington’s disease (HD) is an autosomal dominant neurodegenerative disease, typically showing abnormal movement (predominantly chorea), cognitive impairment, and psychiatric features. The average age at onset is 40 years, followed by an inexorable clinical deterioration and average survival of 15 to 20 years . JuvenilHuntington’s disease pathology is characterized by abnormal protein aggregation and its spread in brain, as seen in Alzheimer’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis ALS; . This isIntensive research has provided substantial insights into the pathological mechanisms in HD. Given the monogenic nature of HD in which the pathology is attributed to production of mutant huntingtin protein (mHTT), lowering of mHTT has emerged as a promising therapeutic approach. Clinical trials are currently planned or underway for novel therapeutics for HD, mostly gene silencing or mHTT-lowering medicines aimed at reducing production of the mHTT. However, delivery of these HTT lowering therapies, such as small interference RNAs and antisense oligonucleotides (ASOs), has proven to be a considerable challenge. It needs injection directly into the central nervous system (CNS) that places a great burden on patients. In addition, these agents are difficult to reach the human brain, especially the striatum in which the most striking neuronal loss is observed. Naked siRNAs do not penetrate the blood-brain barrier (BBB) as well as the cell membrane, and therefore need viral vectors to transport siRNA into neurons through bilateral direct injection into the striatum . AnotherG protein-coupled receptors (GPCRs), also known as seven-transmembrane domain receptors, are one of the most widely exploited targets for therapeutics and account for nearly 30% of the Food and Drug Administration (FDA)-approved drug targets. In particular, most neuropharmacological drugs are well known to control GPCR activity in the CNS . Among tHuntingtin gene encodes a large protein that is broadly expressed throughout the adult body with the highest level in the brain and has multiple interaction domains , playingExpansion of the CAG repeats of the HTT gene to 40 or more causes the adult onset with a mean age of 40 years, whereas patients with juvenile HD, carrying a mutation with more than 55 CAG repeats, show much more aggressively progression . The CAGAs already mentioned, mHTT has an aberrant elongated polyQ tract near the amino terminus. This leads to the accumulation of protein aggregates that initiates a cascade of pathogenic events. The biological and pathological features include transcriptional and synaptic dysfunctions, aberrant axonal trafficking and proteostasis, imperfect nuclear pore complex, oxidative stress, and mitochondrial malfunction . The fulHuntington’s disease is generally diagnosed based on findings from clinical evaluation, patient history (including any family history) and, in most cases, genetic testing for the presence of the CAG expansion in HTT. The characteristic features are motor dysfunction , cognitive impairment (such as deficits in attention and emotion recognition), and psychiatric symptoms . In some cases, especially if a patient’s family history and genetic testing are inconclusive, brain imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), can support the diagnosis. As the disease progresses, these scans typically show symmetrical striatal atrophy of the caudate and putamen, a concomitant increase in size of the fluid-filled lateral ventricle, and often, to a lesser degree, atrophy in cerebral cortical gray matter and subcortical white matter. These atrophy patterns do not necessarily indicate HD, because they can occur in other disorders. A person has normal findings on a CT or MRI scan, while showing early symptoms of HD .The Unified Huntington’s Disease Rating Scale (UHDRS) is a standardized test used to quantify the severity of HD. This test measures the patient’s abilities in four general areas: motor control, cognitive symptoms, behavioral symptoms, and function in day-to-day life. UHDRS allows us to determine how much of an impact a drug or treatment is having on an individual’s HD . The difThe current innovative therapeutic approaches offer great promise as HD modifiers. Most of these approaches focus on targeting mHTT production pathways to tackle the most proximal cause of HD pathogenesis. They include RNA-targeted therapeutics, such as ASOs and RNA interference (RNAi), that inhibits the mHTT expression at the post-transcriptional level. These approaches trigger cleavage, degradation, or transcriptional repression of mutant HTT expression.Antisense oligonucleotides are short single stranded oligomers constituted of chemically modified nucleotides specifically designed as complementary to target mRNA . The hybAntisense oligonucleotides have been demonstrated to exhibit long-lasting reduction of both HTT mRNA and its protein throughout the CNS in multiple transgenic animal models of HD . These eClinicalTrials.gov: NCT03225833) and WVE 120102 , which specifically target the U variant of SNP1 and SNP2, respectively, in mutant HTT mRNA transcripts. In the PRECISION-HD2 trial, WVE 120102 reduced CSF mHTT by 12.4%, whereas total CSF HTT and neurofilament light (NfL) remained unaltered. No results have been disclosed on the PRECISION-HD1 trial  of the HTT gene, rs362307 (SNP1), rs362331 (SNP2), or both SNPs in phase with the CAG repeat expansion, highlighting these SNP variants as promising therapeutic targets for most of the HD patients . Wave LiD1 trial . Only a RNA interference-based approaches employ intrinsic and evolutionarily conserved mechanisms in the cytosol to promote targeted mRNA degradation. Potential modalities include siRNAs , artificClinicalTrials.gov: NCT04120493)  . AMT-1304120493) . This stvia an intrathecal administration. Following administration, they are distributed throughout the brain parenchyma and then incorporated into neurons and glia. In contrast to siRNAs, ASOs do not necessitate a viral vector and cell transformation. Therefore, the repeated administration is needed to maintain therapeutic levels, with adverse events related to injection into the CSF. ASOs follow pharmacokinetics in a dose-dependent manner, allowing for regulated titration of HTT reduction.Antisense oligonucleotides do not penetrate the BBB but can be solubilized in CSF and, therefore, can be delivered directly into the CNS The distribution of ASOs is affected by various elements, including CSF dynamics and clearance paths, volume of the injected bolus, and anatomy of the intrathecal space . Indeed,Viral vectors, such as recombinant AAVs and lentiviruses (LVs), are usually used to convey siRNAs to neurons, since naked siRNAs do not penetrate the cell membrane or the BBB. AAVs and LVs are non-pathogenic and non-replicating and elicit a minimal immune response. AAVs stay as nuclear episomes without integrating into the host genome, leading to stable gene expression at higher levels than LVs . Therefoin vivo. These novel vectors and LNPs may offer a potential solution for non-invasive gene therapy, including CRISPR/Cas9-mediated genome editing, for the treatment of HD in the future.RNA interference expression can be normally achieved in animal models by direct injection into the target brain. However, to achieve this in humans will necessitate stereotaxic neurosurgery, which is highly invasive and at high risk for death and infection. Therefore, RNAi that can be delivered to the CNS through peripheral administration represents a promising alternative. Some AAV serotypes, such as AAV7, AAV8, and AAV9, have been shown to have the ability to transduce neurons as well as other cells in the brain. Among them, AAV9 displays a remarkable ability to transduce not only neurons but also parenchymal brain cells . FurtherG protein-coupled receptors are one of the most intensively investigated drug targets, largely owing to substantial involvement in pathophysiology, pharmacological tractability, and accessibility for small molecule drug discovery . GPCRs cDopamine plays an essential role in psychiatric disorders, such as schizophrenia and bipolar disorder, since all commonly prescribed antipsychotics exhibit antagonistic activity against Gi/o-coupled dopamine D2 receptors enriched in the striatum . The strin vitro. They also found that the lowering of GPR52 suppressed HD-associated phenotypes in both patient iPS-derived neurons and in vivo HD models of Drosophila  acting as an internal agonist and accounting for constitutive activity of the receptor . IntriguThis review highlights GPR52 as a novel candidate target for HD therapy. However, some questions remain. First, it is unclear if GPR52 must be persistently inhibited. GPR52 knockout mice exhibited no change in body weight, brain morphology, and the travel distance. Meanwhile, they exhibited higher frequency of startle but not prepulse inhibition behaviors when treated with the NMDA receptor antagonist MK-801 , and enhIn the last decade, we have seen a transition from symptomatic therapy to disease-modifying. Hence, the development of clinical and imaging biomarkers will be essential to accelerate the translation of HTT lowering therapies. Many HD pharmacodynamic biomarker candidates have been identified, including electrophysiologic clinical measures, biofluid biomarkers, and functional brain imaging . At presThe author confirms being the sole contributor of this work and has approved it for publication.HK is employed by Kyowa Pharmaceutical Industry Co., Ltd.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Uveitis associated with Vogt-Koyanagi-Harada (VKH) disease is a bilateral, chronic, granulomatous autoimmune disease associated with vitiligo, poliosis, alopecia, and meningeal and auditory manifestations. The disease affects pigmented races with a predisposing genetic background. Evidence has been provided that the clinical manifestations are caused by a T-lymphocyte-mediated autoimmune response directed against antigens associated with melanocytes in the target organs. Alongside of T lymphocytes, autoreactive B cells play a central role in the development and propagation of several autoimmune diseases. The potential role of B lymphocytes in the pathogenesis of granulomatous uveitis associated with VKH disease is exemplified within several studies. The early initial-onset acute uveitic phase typically exhibits granulomatous choroiditis with secondary exudative retinal detachment and optic disc hyperemia and swelling, subsequently involving the anterior segment if not adequately treated. The disease eventually progresses to chronic recurrent granulomatous anterior uveitis with progressive posterior segment depigmentation resulting in “sunset glow fundus” appearance and chorioretinal atrophy if not properly controlled. Chronically evolving disease is more refractory to treatment and, consequently, vision-threatening complications have been recognized to occur in the chronic recurrent phase of the disease. Conventional treatment with early high-dose systemic corticosteroids is not sufficient to prevent chronic evolution. Addition of immunomodulatory therapy with mycophenolate mofetil as first-line therapy combined with systemic corticosteroids in patients with acute initial-onset disease prevents progression to chronic evolution, late complications, vitiligo, and poliosis. Furthermore, patients under such combined therapy were able to discontinue treatment without relapse of inflammation. These findings suggest that there is a therapeutic window of opportunity for highly successful treatment during the early initial-onset acute uveitic phases, likely because the underlying disease process is not fully matured. It is hypothesized that early and aggressive immunosuppressive therapy will prevent remnant epitope generation in the initiation of the autoimmune process, the so-called primary response. B cell depleting therapy with the anti-CD20 monoclonal antibody rituximab is effective in patients with refractory chronic recurrent granulomatous uveitis. The good response after rituximab therapy reinforces the idea of an important role of B cells in the pathogenesis or progression of chronic recurrent uveitis associated with VKH disease. Vogt-Koyanagi-Harada (VKH) disease is a multisystem T-lymphocyte-mediated autoimmune disease directed against antigens associated with melanocytes present in the target organs including the uvea, inner ear, meninges, and integumentary system. Several studies demonstrated that tyrosinase family proteins are important antigens specific to VKH disease –3.53, with the most significant risk allele being HLA-DRB1*0405, were found to be genetically associated with VKH disease . The latter HLA class II antigen is known as an important genetic susceptibility factor in VKH disease . Both antibodies and autoreactive T cells against autoantigens cause autoimmune-related cytotoxicity and tissue damage.To distinguish autoimmune from (auto)inflammatory diseases clear definitions and criteria are applicable and these relate to (i) the characterization of specific autoantigens, (ii) a chronic disease course, and (iii) the involvement of adaptive immune cells and molecules, namely T and B lymphocytes with their antigen-specific T cell receptors and antibodies . The cla disease , 35. Mel disease . Future to proof . TherefoCaution and a critical attitude about causal inference remain necessary about infections as triggers for VKH disease . Virus iin vivo and named mutton-fat granulomatous keratic precipitates  and the B-cell-activating factor of the TNF family (BAFF). Consequently, these cytokines play a critical role in B-cell-driven autoimmune diseases . The lev disease –65, and  disease , 66. TheThe original finding of autoantibodies against host antigens and the formation of pathogenetic immune complexes  has beenRituximab is a chimeric mouse/human monoclonal antibody against the pan B cell marker CD20. CD20 is a transmembrane protein expressed on naive and memory B cells, but not on stem cells or fully differentiated plasma cells. Rituximab has emerged as an effective therapy in patients with autoimmune diseases refractory to conventional immunosuppression, with the rationale of depleting pathogenic B cells –69. The Rituximab was reported to be effective in three individual cases of resistant uveitis associated with VKH disease –72. We pIn conclusion, VKH disease is a true autoimmune disorder that has become an example in the field with the demonstration that the combination of research efforts in basic immunology, the use of preclinical animal models and critical attitudes to association and clinical case report studies leads to the cure of initial-onset acute VKH disease, possible by preventing autoimmunization. In addition, for VKH patients who have progressed into chronic disease, treatment with rituximab to control the damage caused by autoantibodies and by B lymphocytes acting as antigen-presenting cells to pathogenic T cells, represents a therapeutic modality that needs broad attention. Both types of treatments, early aggressive immunosuppression preventing autoimmunization  and rituAA wrote the manuscript. SS, GO, and JV critically edited the manuscript. All authors contributed to the manuscript and approved the final submission.This work was supported by King Saud University through Vice Deanship of Research Chair, Dr. Nasser Al-Rashid Research Chair in Ophthalmology (AA). At KU Leuven, support was provided by the Research Foundation of Flanders (FWO-Vlaanderen) and C1 funding 2017-2023.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The human microbiota is a unique set of microorganisms colonizing the human body and evolving within it from the very beginning. Acting as an insider, the microbiota provides nutrients, and mutualistically interacts with the host’s immune system, thus contributing to the generation of barriers against pathogens. While a strong link has been documented between intestinal dysbiosis  and diseases, the mechanisms by which commensal bacteria impact a wide spectrum of mucosal and extramucosal human disorders have only partially been deciphered. This is particularly puzzling for multiple myeloma (MM), a treatable but incurable neoplasia of plasma cells that accumulate in the bone marrow and lead to end-organ damage. Here we revise the most recent literature on data from both the bench and the bedside that show how the gut microbiota modulates cancer immunity, potentially impacting the progression of asymptomatic monoclonal gammopathy of undetermined significance (MGUS) and smoldering MM (SMM) to full blown MM. We also explore the effect of the gut microbiome on hematopoietic stem cell transplantation, chemotherapy, immunomodulating therapy and cancer immunotherapy in MM patients. Additionally, we identify the most cogent area of investigation that have the highest chance to delineate microbiota-related and pathobiology-based parameters for patient risk stratification. Lastly, we highlight microbiota-modulating strategies  that may reduce treatment-related toxicity in patients affected by MM as well as the rates of undertreatment of SMM patients. Escherichia coli alkylate DNA on adenosine residues and induce double strand breaks, eventually favoring mutations in colorectal cancer , a treatable but incurable neoplasia of plasma cells that mainly accumulate in the bone marrow (BM) causing anemia, hypercalcemia, renal insufficiency, and bone lesions . Full blWhile we refer all interested readers to a more comprehensive review on this topic , in our Bacteroides, Clostriudium leptum and Rothia are enriched in MM patients when compared to family members, who usually share the microbiome  and immunomodulating drugs  . PI treausnitzii . F. prauroducers , thus suA higher prevalence of beneficial bacteria belonging to Bifidobacterium and Lactobacillus genus has been found in mice exposed to dexamethasone . SignifiBacteroidetes and Verrucomicrobia are significantly reduced in mice treated with CTX (Cyclophosphamide (CTX) is an alkylating agent that stimulates type I interferon response and Th1/Th17 lymphocyte polarization . Becausewith CTX . CTX trewith CTX , 114.Similarly, melphalan administration in rats causes severe injury to the small intestine, weight loss and infections . These eBacteroides intestinalis with upregulation of mucosal IL-1β and IL-17 in patients with ICI-related gastrointestinal adverse events (Bifidobacterium was sufficient to ameliorate ICI-related immunopathology in mice without dampening antitumor immunity (A strong correlation exists between gut microbiome and response to immune checkpoint inhibitors (ICIs) , 117–123e events . Adminisimmunity . This stRuminococcacaeae, and Lachnospiraceae, which produce SCFA, in patients achieving complete remission (The gut microbiota can promote the expansion and persistence of adoptively transferred cytotoxic T cells (CTLs) both in humans and mice . In miceemission . Becauseemission , it willemission , 134.The information gathered so far strongly suggest that interfering with the insider  may limit MM progression and increase susceptibility to therapies. These strategies include dietary intervention, administration of prebiotics, probiotics and postbiotics, but also FMT Figure 1Clinical trials aimed at modulating the gut microbiome to improve therapeutic response in hematopoietic malignancies are ongoing Table 1 The natural tropism of bacteria for tumors have been exploited to design bacterial therapy for cancer . CommensMicrobiota-derived metabolites  and micrModulation of the gut microbiota and its derivatives should be time and context dependent. While propionate can provide radioprotection , butyratLactobacilli) can cause bacteriemia although the mechanism of transmission from probiotic to blood is unclear  under IG2018- ID. 21808 to MB and was supported by a grant from the Leukemia & Lymphoma Society (# 6618-21) to MB. AB was supported by a fellowship from the Fondazione Italiana per la Ricerca sul Cancro/AIRC (Grants #22316 to AB).Matteo Bellone and Arianna Brevi are co-owner of the following patent: WO2020/109620A2. bacterial strains for medical uses.The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.