Breast cancer has emerged as the most commonly diagnosed cancer and primary cause of cancer-related deaths among women worldwide. Although significant progress has been made in targeting the primary tumor, the effectiveness of systemic treatments to prevent metastasis remains limited. Metastatic disease continues to be the predominant factor leading to fatality in the majority of breast cancer patients. The existence of a prolonged latency period between initial treatment and eventual recurrence in certain patients indicates that tumors can both adapt to and interact with the systemic environment of the host, facilitating and sustaining the progression of the disease. In order to identify potential therapeutic interventions for metastasis, it will be crucial to gain a comprehensive framework surrounding the mechanisms driving the growth, survival, and spread of tumor cells, as well as their interaction with supporting cells of the microenvironment. This review aims to consolidate recent discoveries concerning critical aspects of breast cancer metastasis, encompassing the intricate network of cells, molecules, and physical factors that contribute to metastasis, as well as the molecular mechanisms governing cancer dormancy. Approximately 341,960 new cases of breast cancer were estimated in the United States in 2022 , and aboCollectively, this molecular stratification into subtypes now helps inform treatment strategies, and in a large fraction of patients with early-stage disease, present-day treatments can be curative in 70%–80% of patients . ManagemUnlike early-stage breast cancer, advanced breast cancer, though treatable, is considered incurable and is responsible for the vast majority of cancer-related deaths . Among HIn metastasis, cells initially disseminate from the primary tumor and locally invade the surrounding tissue . DissemiThe development of newer technologies like single cell RNA sequencing (scRNA-seq) are providing an unprecedented level of molecular refinement on top of previous work to capture both spatial and molecular information across the breast cancer landscape . DespiteBeyond the intrinsic molecular heterogeneity seen in breast cancers, precisely how tumor cells escape and survive the unchartered landscape of metastasis remains unclear. Acclimatization or adaptation by tumor cells is a prerequisite for successful metastasis. Tumor cells must exhibit a level of cellular plasticity, enabling them to change their cellular state and functional behaviors to disseminate, survive, and colonize a distant organ. Often these cell-state transitions are bidirectional and can be transient or permanent depending on the context and degree of engagement. The epithelial-to-mesenchymal (EMT) transition instructs epithelial cells during embryonic development, tumor progression, or wound healing to acquire more mesenchymal traits . This prCTCs comprise a subgroup of tumor cells that detach from the primary tumor and enter the bloodstream. Interestingly, very few CTCs can complete the requisite steps of metastasis, yet there is a need to understand the biology of such disseminated cells given that a subset represents the precursor to metastatic disease. CTC detection in the circulation is linked to poor clinical outcome, and such cells have been detected as single cells or multicellular aggregates comprised of either homotypic or heterotypic partners . In breaMetastasis critically hinges upon the intricate coordination between tumor cells and their microenvironment at each stage. Though significant strides have been made in identifying pivotal interactions that influence metastatic activities of tumor cells, our comprehension of metastasis remains somewhat incomplete. A wealth of research has probed into the distinct physiological traits of the local cellular microenvironment, also known as the ‘niche’, of primary tumor cells, and the cells in metastatic sites. The subsequent segments offer a comprehensive analysis of the essential cellular and molecular elements thought to engage and create the conducive environment that defines the metastatic microenvironment.Cooperation between tumor cells and non-malignant cells in the TME represents a major area of study regarding metastatic progression of solid tumors like breast cancer. The TME consists of a diverse repertoire of stromal cell types and non-cellular extracellular matrix (ECM) components that provide a rich cellular and structural landscape for tumor cells . Collectet al. originally demonstrated that MSCs derived from bone-marrow elicit a reciprocal CCL5/CCR5 paracrine loop between MSCs and tumor cells to enable metastatic competence of otherwise indolent tumor cells  as a trigger for MSC homing to primary tumors, facilitated in part by CCL5/CCR5 and an additional reciprocal MSC-tumor cell feedback loop promoting placental growth factor (PGF) expression by breast tumor cells to reinforce MSC recruitment, angiogenesis, and increased lung and lymph node metastasis  are a type of multipotent stem cell originally found in the bone marrow but also discovered in other locations like fat tissue, cord blood, and more. They play key roles in the upkeep and restoration of an array of connective tissues such as bone, adipose tissue, cartilage, and muscle . While tor cells . Chaturvtastasis . MSCs artastasis . More retastasis .in vivo after their recruitment to primary tumors and lung metastases  in breast cancer, where they identified many WBCs as Ly-6G+ pro-tumoral N2 neutrophils. Patients with these CTC-associated neutrophils had a significant decrease in progression-free survival. These clusters showed increased expression of vascular endothelial growth factor (VEGF) and proliferation signatures, suggesting an increased capacity for circulation entry, survival, and metastatic seeding -activated MSCs expressed chemokines CXCL1, CXCL2, and CXCL5, recruiting chemokine receptor positive (CXCR2+) neutrophils to the TME. The interaction of these neutrophils and breast tumor cells results in increased expression of TGF-β, IL-6, MMP12, and MMP13 with increased metastasis to the lungs . Szczerb seeding . Neutrop seeding . Additioresponse . Of courresponse . Though + T lymphocytes, reinforces a pro-tumor behavior in TAMs which activates epidermal growth factor receptor signaling to fuel metastasis to the lungs (+ T regulatory cells (Tregs), can create an immunosuppressive environment by promoting immune tolerance to tumor cells (Another major immune cell type associated with the TME are tumor associated macrophages (TAMs). There is significant evidence endorsing the role of classical inflammatory monocytes and macrophages in promoting metastasis. A pivotal investigation utilizing the MMTV-PyMT mouse model for breast cancer revealed that the absence of colony stimulating factor 1 (CSF-1), a factor necessary for the growth of CSF-1-dependent cells like monocytes and macrophages, led to slower transition of mammary tumors into metastasis . Real-tihe lungs . In factor cells  and by eor cells . Regardior cells . Thus, Net al. found that CAA-derived IL-6 and leptin upregulate expression of procollagen-lysine, 2-oxoglutarate 5-dioxygenase 2 (PLOD2), a lysyl hydroxylase necessary for collagen stability, and activate proliferation and migration pathways JAK/STAT3 and AKT  hematopoietic progenitor cells accumulate in specific sites in the lungs prone to metastatic lesions  or extracellular particles (EVPs) derived from either plasma membrane budding (microvesicles) or through endocytic pathway release (exosomes and exomeres) carry important cargo to these distant sites . EVs andhe lungs . In tranhe lungs . In expehe lungs . In the he lungs . Of couret al. demonstrated that angiopoietin 2 (Angpt2), MMP3, and MMP10 expressed by melanoma cells increase vascular instability in the lungs, and knock down of these genes significantly decreases the ability of MDA-MB-231 breast cancer cells to metastasize  and are often compromised by the tumor-mediated expression of specific cell adhesion receptors and secreted factors which alter vessel permeability . Most exet al. revealed the extravasation stage consists of an initial weak arrest of CTCs followed by a more-stabilized adhesion between CTCs and endothelial cells that prevents detachment provoked by bloodstream shear forces . In contrast, the sprouting neovasculature promotes DTC growth by enhancing TGF-β1 signaling . Recent . Although several studies highlight the importance of the perivascular niche in metastasis, we are only just beginning to understand the nature of this local niche with respect to organ tropism, dormancy, and therapeutic resistance. Recent studies targeting integrin-mediated interactions between DTCs and the perivasculature to sensitize dormant cells to chemotherapy highlight the promising opportunity to target this niche in the clinical setting of metastasis  as two key ECM constituents important for regulating the fitness of tumors cells in the perivascular niche . Analysitastasis . How thiDespite some triumphs associated with targeted therapies and immunotherapies, metastasis and drug resistance are common outcomes for patients. Metastatic recurrence typically happens long after primary tumor removal  and tumoOne of the most widely studied mechanisms in tumor dormancy and proliferation is the ERK and p38 signaling pathways . Strong in vivo and in vitro , is widely involved in juxtacrine interactions across development, stem cell self-renewal programs, proliferation and differentiation cues, and other cellular processes . Analyse+ and CD8+ T cells were reported to promote dormancy by both immune dependent and independent functions. In breast cancer patients, dormant tumor cells in the bone marrow are closely associated with increased presence of CD4+ and CD8+ T cells  . Followic niches . In breac niches , while ic niches .Inflammatory signals, especially chronic inflammation, may play a critical role in deciding the dormant state of cancer cells. Inflammation is correlated with breast cancer recurrence in patients, and this inflammation link to recurrence is present within other cancer types . InflammThough systemic and targeted therapies are efficacious in most non-advanced breast cancers, metastatic disease eventually reappears months to years after successful treatment of the primary tumor. A diagnosis of metastatic disease is often terminal for these patients, and these prognostic odds must change. The processes that determine the timing and site of relapse remain a puzzle in cancer research. Given that breast cancer remains the most diagnosed cancer among women worldwide, identifying tumor-intrinsic and extrinsic drivers and predictors of recurrence and metastasis is pivotal to challenging the paradigm in patient care. Axillary lymph node status remains the most important predictor of breast cancer patient outcomes, yet up to 30% of node-negative cases metastasize . Recent in lieu of repeat tumor biopsy  for quantitative assessment of mutation status identified in circulating tumor DNA (ctDNA) to support current clinical diagnostics and detection of therapeutic relapse r biopsy . Predictr biopsy . Experimic niche . OverallThe seemingly unpredictable nature of metastatic relapse in breast and other cancers exemplifies both a challenge and opportunity clinically. Understanding the biology of the metastatic niche, from dormancy to emergence, is essential to appropriately validate the utility of pre-clinical models that accurately reflect the clinical course of metastatic progression for patients and achieve therapeutic success. This includes immune competent models that allow inclusion of tumor extrinsic cell types and consider how inflammation and the immune landscape participate in context. Such models will be imperative to identify therapeutic opportunities based on the biology of metastasis gleaned from rigorous experimental inquiry. The application of single cell and spatial transcriptomics and proteomics technologies will undoubtedly provide immense value in both experimental and clinical settings of metastasis to help deconvolute the cellular landscape encompassing metastatic disease. These spatial tissue atlases are just beginning to be constructed and utilized effectively. Access to these technologies holds great promise in navigating emergent data from clinical trials and patient-centered studies to determine how cellular composition and transcriptomic hallmarks contribute to encompassing metastasis biology. The process of breast cancer metastasis, which is still fraught with many unknowns, heavily relies on complex mechanisms. Among these, the role of disseminated tumor cells—their origins and how they contribute to metastasis—stands as a key area requiring deeper understanding. The mysterious processes governing cancer cell dormancy and subsequent reactivation also present intriguing research prospects. Noteworthy is the complex interplay between cancer cells and their microenvironment, a relationship that may potentially shed light on tumor progression, metastasis, and resistance to therapy. This is particularly relevant given that breast cancer’s preference to metastasize to certain organs—a phenomenon known as organotropism—has yet to be completely understood. The challenges in metastatic breast cancer treatment, particularly therapy resistance, underscore the urgent need for comprehensive inquiry. Understanding both intrinsic and acquired resistance to cancer therapies, stemming from complex cellular and molecular mechanisms, remains a significant challenge in oncology. This complexity is further compounded by the substantial heterogeneity of breast cancers, with variations seen both between different patients and within an individual patient’s tumor. As the role of immunotherapy in cancer treatment expands, deciphering why certain tumors either do not respond or develop resistance to these therapies is emerging as a critical area of investigation. Identifying accurate predictive and prognostic biomarkers could pave the way for earlier and more precise interventions, in addition to potentially preventing metastasis. There is a growing momentum towards personalized therapies tailored to individual genetic profiles of patients and their tumors. This could revolutionize treatment outcomes, setting a new paradigm in the fight against metastatic breast cancer. However, these areas of research are still under development and require further investigation for their full potential to be realized. Success in the field of breast cancer metastasis will most likely occur from thoughtful discourse between researchers, clinicians, and patient advocates to generate new hypotheses and clinical trial designs directed at targeting the molecular underpinnings of metastasis to improve patient survival.


The emergence of genome-wide association studies (GWAS) has identified genetic traits and polymorphisms that are associated with the progression of nonalcoholic fatty liver disease (NAFLD). Phospholipase domain-containing 3 and transmembrane 6 superfamily member 2 are genes commonly associated with NAFLD phenotypes. However, there are fewer studies and replicability in lesser-known genes such as LYPLAL1 and glucokinase regulator (GCKR). With the advent of artificial intelligence (AI) in clinical genetics, studies have utilized AI algorithms to identify phenotypes through electronic health records and utilize convolution neural networks to improve the accuracy of variant identification, predict the deleterious effects of variants, and conduct phenotype-to-genotype mapping. Natural language processing (NLP) and machine-learning (ML) algorithms are popular tools in GWAS studies and connect electronic health record phenotypes to genetic diagnoses using a combination of international classification disease (ICD)-based approaches. However, there are still limitations to machine-learning - and NLP-based models, such as the lack of replicability in larger cohorts and underpowered sample sizes, which prevent the accurate prediction of genetic variants that may increase the risk of NAFLD and its progression to advanced-stage liver fibrosis. This may be largely due to the lack of understanding of the clinical consequence in the majority of pathogenic variants. Though the concept of evolution-based AI models and evolutionary algorithms is relatively new, combining current international classification disease -based NLP models with phylogenetic and evolutionary data can improve prediction accuracy and create valuable connections between variants and their pathogenicity in NAFLD. Such developments can improve risk stratification within clinical genetics and research while overcoming limitations in GWAS studies that prevent community-wide interpretations. HighlightsNovel genome-wide association studies have extensively studied the genetic risk variants in nonalcoholic fattyl disease (NAFLD).NAFLD phenotyping from electronic health record data.Applications of artificial intelligence can improve The clinical consequences of most pathogenic genetic variants are still undetermined.Evolution-based artificial intelligence algorithms can improve genetic risk stratifications in NAFLD.1. NAFLD is often associated with a sedentary lifestyle, a high-fat diet, and obesity; as a result, the most common ‘cure’ for NAFLD is weight loss. Scientific evidence suggests that NAFLD can contribute to insulin resistance and dyslipidemia and has been correlated with the development of diabetes and the metabolic syndrome1. Most people with NAFLD suffer from the less complicated form, steatosis, which is simply defined by the accumulation of fat in the liver. A certain percentage of patients may suffer from Nonalcoholic steatohepatitis (NASH), the more progressive form of NAFLD, which can result in liver cirrhosis, and the accumulation of scar tissue can eventually render the liver damaged beyond repair. If NAFLD and NASH were left untreated, extensive cirrhotic and fibrotic changes can eventually progress to hepatocellular carcinoma (HCC), treatment for which remains difficult. Amongst patients with both NASH and cirrhosis, the risk of developing HCC is high (12.8%) over a time period of 3 years2.Nonalcoholic fatty liver disease (NAFLD), one of the most common diseases in the world, is characterized by adipose tissue deposition in the liver4. Improvements in the prognosis of end-stage liver cancer requires robust identification strategies across NAFLD and NASH patients earlier in their care. As a result, the heritability of NAFLD has emerged to become a popular area of clinical research and has been extensively studied in genome-wide association studies (GWAS). Genome studies have linked various Single-Nucleotide Polymorphisms on genes such as Phospholipase domain-containing 3 (PNPLA3) and MBOAT7 that are associated with hepatic steatosis, fibrotic changes of the liver, and the acceleration of HCC development in patients with metabolic syndrome 5. Evolution-based artificial intelligence (AI) has emerged as a new technological model, which aims to improve variant identification of NAFLD-associated genes. However, the lack of risk stratification algorithms that could apply to international communities makes it challenging to accurately predict NAFLD-associated variants across ancestries. This review highlights the promising role of evolution-based AI in genome-wide studies to stratify genetic risk variants in NAFLD progression, improve risk stratification, and influence therapeutic implications.While the development of HCC is multifactorial, increased iron absorption in NASH, insulin resistance, and certain genetic polymorphisms are observed to have an important role in its pathophysiology6.Several environmental and genetic factors play a significant role in the heritability of NAFLD, ranging from 22 to 50%8. With consistent improvements in the definition of NAFLD and NASH, GWASs have greatly improved our understanding on its etiologies and pathophysiology in at risk patients with metabolic phenotypes9. There have been several studies linking nonsynonymous single-nucleotide polymorphisms in PNPLA3 and, more recently, Transmembrane 6 Superfamily member 2 (rs58542926), which was originally associated with the nearby neurocan (NCAN) gene10. Following subsequent investigations, it has been determined that both genetic relationships are associated with clinically significant outcomes, including steatohepatitis grade, cirrhosis or hepatic fibrosis stage, and, in the case of PNPLA3, hepatocellular carcinoma in NAFLD patients13.GWAS is a research strategy to discover genetic variations statistically related to disease risk. In this approach, the genomes of numerous individuals are scanned to identify genetic variants that are more prevalent in people with the disease or traits than those without the disease. These genomic variants are often used to locate neighboring variants that are directly responsible for the disease or trait once they have been found. Across GWAS studies investigating NAFLD severity, the condition is often identified based on visceral fat content and histological fibrosis severity to accurately represent steatosis in populations across clinical databases10. Recent studies using exome sequencing have correlated elevated alanine amino transferase (ALT) with an HSD17B13 SNP (rs6834314) in a general patient population and further demonstrated that this polymorphism is linked to NAFLD. This is widely supported by two more investigations15. In addition to the PNPLA3 effect, the GWAS suggests that IL17RA and other biologically significant genes play a significant role in the severity of NAFLD16.While variations in or near LYPLAL1 and PNPLA3 do not affect serum lipid levels, those in or near neurocan (NCAN), glucokinase regulator (GCKR), and PPP1R3B do. Glycemic characteristics are also impacted by variations close to GCKR and PPP1R3B. Thus, it demonstrates the genetic basis of NAFLD and increases the variety of common genetic variations associated with this characteristicP-value of 4.68 10 717. Both AST and ALT were found to share a new impact at 2p22 close to the Xanthine Dehydrogenase (XDH) gene, which are expressed in the liver and involved in the oxidative metabolism of purines. This enzyme catalyzes the conversion of xanthine to uric acid and hypoxanthine to xanthine. Therefore, XDH-produced uric acid and reactive oxygen species may result in inflammation and oxidative stress. Recent research has demonstrated a correlation between the serum level of XDH and blood metabolic markers associated with obesity, including triglycerides, cholesterol, and glucose18. The transmembrane heparan sulphate proteoglycan Syndecan-1 , which is abundantly expressed in the liver, also exerts metabolic effects and is suggested to cause a strong impact on liver enzyme levels; previous studies have corroborated with this hypothesis given that NAFLD patients exhibit higher serum levels of syndecan-119. In addition to these genes, recent reports have also suggested that HSD17B13 is relevant to NAFLD through several genetic polymorphisms linked to lower risks of steatosis20.A case-only GWAS using standardized liver enzymes as a quantitative phenotype found a strong association between the PNPLA3 risk allele and higher ALT levels. The highest effect was found for ALT at rs738409, with a 22. Certain polymorphisms in PNPLA3 and LYPLAL1 are known to induce hepatic steatosis without the presence of common metabolic characteristics such as insulin resistance and obesity in patient groups. These distinct correlation patterns suggest that hepatic steatosis is potentially regulated by various metabolic pathways, and is not just limited to lipid dysregulation or oxidative stress to the liver. Addressing genetic variation in the etiology of hepatic steatosis may create new avenues for individualized treatments, but there is a growing need to improve the accuracy and efficiency of these identification studies with modern technology.Contrary to PNPLA3 and LYPLAL1, variants near NCAN (which encodes for an adhesion molecule), PPP1R3B (which encodes for a protein that regulates glycogen breakdown), and GCKR  are linked to distinct alterations in serum and liver lipids as glycemic traits23. In clinical genomics, AI computer systems can replicate applications requiring human intelligence through deep learning algorithms, thus improving image-based diagnostics, EHR phenotyping, and genetic variant classifications. Examples of these algorithms include computer vision (image acquisition), time-series analyses, automatic speech recognition, and Natural Language Processing (NLP)24.AI has wide-ranging applications in clinical practice and stimulates human intelligence in computer-based networks. In the broad scheme of medicine, AI has been commonly known to maintain electronic health records (EHR) and assist patient consults, while machine-learning has been implemented to facilitate surgical procedures and assist in radiographic diagnostics24. A summary of AI applications to genetics research is shown in Figure Convolution neural networks (CNN) drive the use of these AI algorithms, which are computational systems that consist of artificial neurons that take input data based on their trained interpretations. CNN allows for deep learning by interpreting features  from complex datasets to drive genomic research. Though reports have found certain AI algorithms are limited and impractical compared with human intelligence, there have been major developments and improvements in CNN-based algorithms for genomics analyses. A review led by Dias in 2019 best summarizes adaptations that address the limitations of current AI-algorithm including deep variant caller algorithms to improve the accuracy of variant identification in a genome, combined annotation dependent depletion approach algorithms to predict deletions of variants. The use of primate AI to identify known pathogenic variants using cross-species analyses, and other CNN-based applications that would improve phenotype-to-genotype mapping and vice-versa 25. Given the propensity of NLP use in studies, multiple ML algorithms have been employed to identify the severity of NAFLD and its risk of progression to advanced disease such as cirrhosis. The Path AI research platform established in Boston trained a deep neural network to interpret over 600 liver biopsies and showed high concordance with liver histopathological interpretations made by trained pathologists. Such algorithms have also shown wide applications in identifying steatohepatitis from imaging, analyzing liver biomarkers such as ALT or gamma glutamyl transferase, and fibrosis staging27. As a result, AI has bridged several gaps in the knowledge of NAFLD progression, especially in risk stratification.NLP is one of the most commonly utilized AI-based algorithms that can extract important clinical information from EHRs, such as biopsies or images, and provide a molecular diagnosis with a combination of genotypic and phenotypic information. In particular, AI-based NLP approaches are often used to connect EHR phenotypes to genetic diagnoses through hierarchical statistical models and are often used for phenotype-to-genotype diagnostics. By detecting certain terms from the natural human language, NLP-based algorithms can computationally extract documents from phenotypic inputs and derive genetic variants of conditions. In NAFLD, the use of NLP in GWAS studies has risen in popularity and use, as NLP has shown an accuracy in detecting image-proven and biopsy-proven steatosis. A recent study led by Van Vleck supported these findings. NLP performed better in identifying NAFLD based on radiology notes and fibrosis scores from biopsies compared to traditional approaches using ICD-based approaches30. This may be the root cause of common limitations in NAFLD GWAS studies, such as underpowered sample sizes and the lack of replication due to the unknown association of certain variants31. As a result, most GWAS studies are limited to small cohorts that may not accurately represent the risks detected in populations. Data from EHRs have the potential for errors in lab measures and clinical diagnoses despite studies adjusting for confounding factors. This may also affect the clinical accuracy of quantitative liver enzyme tests that are not entirely specific to NAFLD, thus increasing the need for larger sample sizes and replication31.Despite major steps in identifying NAFLD variants underlying disease pathogenicity and progression, limitations of ML and NLP-based algorithms have been overlooked and may limit the strength of studies and there is still more room for growth in efficient algorithms that would stratify the risk of developing advanced liver disease based on genetic variants in studies. Current developments in AI models may be efficient, but the clinical consequences of over 98% of pathogenic variants in disease-associated genes have not yet been defined32. Certain proposed models include genotype-to-phenotype predictions, which can improve risk stratification of NAFLD progression to HCC. However, current models are not equipped to predict the risk of developing HCC based on genotypes associated with liver phenotypes and do not represent causal relationships between risk factors. The accurate prediction of phenotypes from genotypes poses a huge problem, as the effects of genetic mutations are highly variable and can pose a barrier in personalized risk stratification for NAFLD.Given that the NAFLD population is at a higher risk of developing HCC, it is crucial to identify variants that may increase the risk of irreversible advanced-stage liver cirrhosis33. By predicting the pathogenicity of over 36 million variants in over 3000 disease-associated genes, it was suggested that evolutionary information across species and ancestries provide better evidence on single variants tied with clinical phenotypes compared to traditional models. Experimental results of EVE disseminated the function of variants in BRCA1, TP53, MSH2, and PTEN with known disease links, accurately predicting the function of variants34.Evolution-based AI models are a topic of interest, as traditional state-of-the-art models rely on known disease labels such as ICD codes, which are subject to inaccuracies. By combining genomic information with evolutionary and phylogenetic data : NA.mehedi.bmb.mbstu@gmail.com (MMH)Mohammad Mehedi Hasan, Department of Biochemistry and Molecular Biology, Faculty of Life Science, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh. e-mail: No data available.Not commissioned, externally peer-reviewed.


Are there differences in how safety-net vs non–safety-net hospitals report the availability of substance use disorder (SUD) services across the US?This cross-sectional analysis of 2846 hospitals from the 2021 American Hospital Association annual survey data found that safety-net hospitals have significantly lower odds of offering 5 hospital-based SUD services compared with non–safety-net hospitals.These findings suggest that safety-net hospitals may face additional barriers to offering SUD programs compared with their non–safety-net counterparts, and further research is needed to understand these barriers and to identify strategies that support the adoption of evidence-based SUD programs in safety-net hospital settings. This cross-sectional study examines differences in the delivery of different substance use disorder programs in safety-net hospitals vs non–safety-net hospitals across the US and evaluates whether these differences are increased in certain types of safety-net hospitals depending on ownership. Safety-net hospitals (SNHs) are ideal sites to deliver addiction treatment to patients with substance use disorders (SUDs), but the availability of these services within SNHs nationwide remains unknown.To examine differences in the delivery of different SUD programs in SNHs vs non-SNHs across the US and to determine whether these differences are increased in certain types of SNHs depending on ownership.This cross-sectional analysis used data from the 2021 American Hospital Association Annual Survey of Hospitals to examine the associations of safety-net status and ownership with the availability of SUD services at acute care hospitals in the US. Data analysis was performed from January to March 2022.This study used 2 survey questions from the American Hospital Association survey to determine the delivery of 5 hospital-based SUD services: screening, consultation, inpatient treatment services, outpatient treatment services, and medications for opioid use disorder (MOUD).A total of 2846 hospitals were included: 409 were SNHs and 2437 were non-SNHs. The lowest proportion of hospitals reported offering inpatient treatment services , followed by MOUD , and outpatient treatment services . The majority of hospitals reported offering consultation  and screening . In multivariable models, SNHs were significantly less likely to offer SUD services across all 5 categories of services . With the exception of MOUD, public or for-profit SNHs did not differ significantly from their non-SNH counterparts. However, nonprofit SNHs were significantly less likely to offer all 5 SUD services compared with their non-SNH counterparts .In this cross-sectional study of SNHs and non-SNHs, SNHs had significantly lower odds of offering the full range of SUD services. These findings add to a growing body of research suggesting that SNHs may face additional barriers to offering SUD programs. Further research is needed to understand these barriers and to identify strategies that support the adoption of evidence-based SUD programs in SNH settings. These models are often referred to as inpatient addiction consultation or liaison services, although a variety of hospital-supported models have been characterized in the literature.7 The addiction consultation model has demonstrated strong potential to improve morbidity and reduce mortality among patients with SUDs, although implementation challenges remain.12Hospitals have a crucial role to play in addressing the SUD crisis. Because patients with a history of injection drug use have high rates of secondary related infections , hospitalization is a crucial juncture to engage patients in care. Hospitals support a range of services that includes formal treatment programs, such as partial hospitalization and withdrawal management in the inpatient setting and formal outpatient rehabilitation services. The evidence is strongest, however, for medication for OUD (MOUD) treatment with either buprenorphine or methadone.14 In underserved communities, hospitals are vital institutions tasked with providing preventive services and health care to communities.15 SUD-related admissions are more common in SNHs and are increasing rapidly.11 Given the location of SNHs in communities where substantial disparities exist, these hospitals are ideal sites to support the local opioid service infrastructure through their formal medical services and partnerships with outpatient organizations.These services may be even more critical in safety-net hospitals (SNHs), which disproportionately serve historically minoritized communities, Medicaid beneficiaries, the uninsured, and the underinsured.17 of hospital-based SUD programs point toward multiple barriers to successful implementation, including financial strain, inadequate personnel, stigma, and perceived lack of expertise. Financial barriers are further complicated by factors such as limited community partnerships and stigma, which may also limit support for SUD programs.18 These barriers may be more pronounced in SNHs, which often have small operating margins and may face limitations on available resources to staff initiatives or to financially invest in sustaining successful efforts.20 For example, a qualitative study12 of an SNH emergency department (ED) identified multiple barriers to providing care for socially disadvantaged patients with SUDs, including the need to balance the needs of substance-involved patients with the necessity of managing limited resources. Successful adoption of SUD programs within SNH settings often entails obtaining seed funding from external partners and making a business case to executive leadership.10Prior studies11 The aim of our study is 2-fold. First, our primary objective is to examine differences in the delivery of different SUD programs in SNHs vs non-SNHs across the US. Second, we conducted subpopulation analysis to investigate whether these differences are more pronounced in certain types of SNHs depending on their ownership. Although the vast majority of US hospitals are nonprofit, a sizable minority are publicly owned or for-profit. Previous research has found that ownership may impact hospital decisions to offer new services and technologies,23 hiring practices,24 hospital efficiency,26 and quality of care.27 Understanding these differences can help develop targeted interventions to support the implementation of a wider range of SUD services in hospitals serving safety-net populations.SNHs may face unique barriers in offering SUD programs, and these difficulties have important implications for health equity. However, most studies to date have been qualitative or examined utilization within a single SNH setting, thus limiting generalizability.28 linked to County Health Rankings29 and Opioid Prescribing Data30 to examine the associations of safety net status and ownership with the availability of SUD services across hospitals. The AHA survey is an annual census of more than 6000 US hospitals and health care systems, with a response rate greater than 75% each year, and is a widely used source of data on US hospitals.31 Hospitals are identified by state, local, and national organizations, Medicare and Medicaid centers, and governmental bodies.27 This study was exempt from institutional review board approval and informed consent, because no human participant data were used, in accordance with 45 CFR §46, and it follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.In this cross-sectional study, we used the 2021 American Hospital Association (AHA) Annual Survey of Hospitals29 Screening and consultation were measured as a series of binary variables of service availability across 4 settings  . MOUD was defined as the use of use of medications approved by the Food and Drug Administration for the treatment of SUDs. Outpatient services were described as organized hospital services that provide medical care or services to outpatients for whom the primary diagnosis is alcoholism or other chemical dependency. Inpatient services were defined as organized hospital services providing intensive day or evening outpatient services of 3 hours’ duration or longer, distinguished from other outpatient visits of 1 hour. We created separate binary outcome variables to indicate whether a hospital offered MOUD, outpatient services, or inpatient services across any of the entities.32 We operationalized ownership as a categorical variable .Hospitals were defined as safety-net organizations if their percentage of Medicaid inpatient days was 1 SD above the state mean.We measured hospital size as a categorical variable of the number of staffed hospital beds . We assessed teaching status with a binary variable . We measured religious affiliation with a binary variable.33 to classify counties as rural (codes 7-9) and nonrural (codes 1-6). We obtained the percentage of the population of White race in the county and the percentage of population who were unemployed using the 2019 American Community Survey. We obtained county-level overdose rates from the Centers for Disease Control and Prevention34 and opioid prescription rates  from amFAR.35We used the 2013 Rural-Urban Continuum Codest tests or χ2 tests. Next, we estimated 5 separate multilevel logistic regression models that accounted for the clustering of hospitals in states to examine differences in the availability of SUD services by safety-net status after controlling for organizational and environmental covariates. In secondary analysis, we ran separate regression models for screening and consultation, stratified by treatment setting, and MOUD, inpatient, and outpatient services stratified by treatment entity. Finally, we conducted subgroup analyses by estimating similar multilevel logistic regression models by the 3 ownership types. A 2-sided P < .05 calculated by the χ2 tests, t tests, and multivariable regression was considered statistically significant. Analyses were computed with Stata SE statistical software version 17 (StataCorp).36Data analysis was performed from January to March 2022. In descriptive analyses, we calculated the mean value of organizational and county variables, including the availability of SUD services, by SNH and non-SNH groups, and compared these values using After we excluded 1569 non–general medical hospitals, 209 federal hospitals, 55 hospitals located in territories, 1715 hospitals that did not respond to SUD treatment questions on the survey, and 37 hospitals with missing data on county variables, our analytic sample included 2846 hospitals. Comparisons of hospitals with and without missing data found that hospitals that did not answer the SUD survey questions were smaller (122 beds vs 190 beds) and were less likely to be teaching hospitals (2% vs 7%) and SNHs (5% vs 14%). A total of 409 hospitals (14.3%) were identified as SNHs, and 2437 (85.7%) were non-SNHs. Consistent with prior literature, the counties where SNHs were located had significantly higher overdose rates and unemployment, lower rates of White populations and opioid prescription rates, and were more likely to be classified as rural compared with counties without SNHs. SNHs also differed from non-SNHs in terms of organizational characteristics. Compared with non-SNHs, SNHs were larger (higher mean bed size), were more likely to be teaching hospitals, were more likely to be publicly owned, and were less likely to be a nonprofit or religious hospital .Hospital participation in OUD programs ranged from 27% to 79%. The lowest proportion of hospitals reported offering inpatient SUD services , followed by MOUD , and outpatient SUD services . The majority of hospitals reported offering consultation  and screening . In bivariate analyses, no differences emerged when comparing the availability of SUD services between SNHs and non-SNHs.Multilevel logistic regression results indicate that, after controlling for organizational and environmental covariates, SNHs had significantly lower odds of offering all SUD services  . In secoTo further examine these findings, we conducted subgroup analyses by ownership type by estimating multilevel logistic regression models by ownership categories  of surveyed hospitals did not have buprenorphine or naloxone on their inpatient formularies. Studies38 of MOUD prescribing in Veterans Affairs hospitals found that only 15% of patients with OUD received opioid agonist therapy, whereas a study39 of 143 hospitals across 21 states found that MOUD was initiated among only 19% of adults with OUD during hospitalization. These findings highlight the importance of addressing barriers and expanding access to evidence-based SUD programs in hospitals.In this cross-sectional study of US hospitals, we found marked variation in the types of SUD services offered, with only approximately one-third offering MOUD, suggesting a critical underutilization of evidence-based SUD programs by hospitals. These findings are consistent with prior studies40 Moreover, we observed significant differences based on hospital ownership type. Public and for-profit hospitals, compared with nonprofit hospitals, had lower odds of offering all 5 OUD services. For example, the odds of offering MOUD were 5 times higher in nonprofit hospitals than in for-profit hospitals. Although the underlying reasons for this disparity require further investigation, possible factors could include variations in organizational priorities and access to specialized staff and resources. These findings highlight the need to address barriers and disparities in the provision of SUD services across different hospital ownership types to ensure equitable access to evidence-based care for individuals with OUD.Although the raw figures showed comparable rates of SUD program adoption between SNHs and non-SNHs, adjusted models revealed stark differences. Across the board, SNHs have significantly lower odds of offering all 5 SUD services after controlling for other organizational and environmental factors. These results add to a growing body of research suggesting that SNHs may face additional barriers to offering SUD programs.41 be penalized for patient readmissions,42 and have a higher uncompensated care burden.43 This may limit the ability of nonprofit SNHs to offer additional services, as well as the funds available for hiring needed personnel.Results from our subgroup analysis further illuminate differences in program adoption by safety-net status and ownership type. Although safety-net status was not significantly associated with a difference in programming between for-profit and public hospitals, among nonprofit hospitals, SNHs were significantly less likely to offer all 5 SUD services. These differences suggest interacting factors between ownership and safety-net status that limit SUD service implementation. In other words, safety-net status matters, but appears to be a more prominent factor for nonprofit hospitals. These findings are concerning given that, compared with non-SNHs, nonprofit SNHs are more likely to lose funding from safety-net subsidy programs,44 From a policy perspective, it is crucial to address the financial challenges faced by nonprofit SNHs to ensure equitable access to SUD services. This may involve targeted funding initiatives, reimbursement models that adequately account for the unique circumstances of SNHs, and policy efforts to reduce the uncompensated care burden. In addition, strategies should be developed to support workforce development and recruitment of personnel with expertise in addiction medicine within nonprofit SNHs. This support can include technical assistance, training, and resources to enhance the capacity of hospitals and clinicians in delivering evidence-based care and addressing challenges in implementing SUD services.The factors underlying the findings of our study are multifaceted, involving challenges at the clinician, hospital, and policy levels.27 Although our approach is consistent with a commonly adopted operationalization of safety-net status, using an alternative definition may lead to different results. Second, because the AHA Annual Survey relies on self-reported data by hospital administrators, there might be biases in the responses, such as overreporting or underreporting of certain services. As a result, there may be nonrandom differences in how different types of hospitals respond to the survey. For example, SNHs, which predominantly serve socioeconomically and medically vulnerable populations, might have a better understanding of patient needs and, thus, might respond differently regarding the services they offer. This potential bias in responses from SNHs could affect the findings and comparisons involving these hospitals. Similarly, the AHA survey data primarily indicate the availability of services in a binary form (yes or no), without providing information on the scale, scope, or adequacy of these services. Consequently, there is a possibility that the reported availability of services does not accurately represent the depth or extent of care provided. For example, a hospital with a single addiction specialist available on a limited basis may report the availability of addiction treatment services, even though it may not meet the needs of a large patient population. These binary responses mask the nuances in service provision that reflect differences in the actual delivery of SUD care.There are several limitations to our study. First, there is wide variation in the conceptualization and definition of SNHs in the literature.Moreover, the lack of granularity in the data restricts the ability to assess the quality and comprehensiveness of services offered, particularly in SNHs, where the demand for certain services may be higher. In addition, although we used available data in the AHA survey, it is possible that important explanatory variables  were not included in our analysis. These omitted variables could introduce bias and affect the observed associations. Future research should strive to incorporate a broader range of relevant factors to better understand the complex determinants of SUD service provision and mitigate potential biases associated with omitted variables. Similarly, the exclusion of hospitals that did not respond to the AHA survey or the portion of the survey on SUD service provision may introduce a nonresponse bias. Furthermore, the observational, cross-sectional nature of our study limits our ability to determine causality. Replication of this study using longitudinal data could enhance confidence in our findings between safety-net status, ownership, and the availability of SUD programs.It is worth noting that our data come from the 2021 AHA Annual Survey of Hospitals, the first full year of data collected following the onset of the COVID-19 pandemic. The COVID-19 pandemic put extreme stress on the health care system in the form of acute staffing shortages and ongoing financial strains. These challenges may have been amplified in safety-net systems, given their role in serving low-income communities that were most affected by the COVID-19 pandemic. Given the cross-sectional nature of our study, it is unclear whether our findings reflect a temporary strain on hospital resources during a public health emergency or entrenched differences in SUD program adoption. Further research is needed to assess patterns in service provisions over time.SNHs are ideal sites to deliver addiction treatment to patients with SUDs. Yet, SNHs had significantly lower odds of offering the full range of SUD services compared with their non-SNH counterparts. These findings underscore the urgent need to address the underresourcing and systemic challenges faced by SNHs, especially nonprofit institutions, to ensure equitable access to evidence-based SUD care. Efforts must be directed toward developing targeted interventions, policy reforms, and resource allocation strategies to bridge the gap in SUD services and promote equitable health care delivery.


Zinc is an essential trace element with various functions in all living organisms. Its bioavailability is tightly controlled by a combination of nutritional availability, binding to proteins, location in cellular organelles, and the presence of zinc transporters. In humans, changes in zinc homeostasis, such as zinc deficiency, have varied impacts on individuals. Zinc affects growth, fertility, immune cell functioning, and disease progression. Zinc homeostasis is compromised in aging, whereby abnormal metabolism contributes to sub-clinical changes and cellular dysfunction that may underlie the early onset of (neuro-)degenerative diseases. Therefore, a better understanding of the normal function of this trace element in health and diseases is highly desired.Our Research Topic brings together eight research articles presenting the most recent developments in zinc nutrition. The collection provides new data on zinc and its potential impact on telomere length, the need for novel biomarkers of zinc status, the usefulness of X-ray fluorescence to detect changes in hair zinc concentrations, the effects of dietary zinc during pregnancy, its role during impaired metabolism in retinal cells and its relationship in the context of ovarian as well as skin cancer.Shi et al. studied the relationship between zinc intake and its potential impact on telomere length among middle-aged and older individuals, using the dataset generated as part of the National Health and Nutrition Examination Survey (NHANES). In this cross-sectional study carried out on 3,793 participants older than 45 years, elevated dietary zinc intake was positively correlated with longer telomere length, especially in women, those with low energy intake and obese individuals. It appears that dietary zinc intake may contribute to changes in telomere length and protect toward telomere attrition.Telomere length is considered a biomarker of aging that dietary and environmental factors can influence. Frederickson et al. determined the potential of using hair samples to detect changes in zinc concentration in response to the consumption of zinc-biofortified wheat flour. The BiZiFED2 effectiveness trial was set up to combat zinc deficiency in Pakistani girls (10–16 years old). The participants received flour from control or zinc-biofortified wheat for 6 months. Zinc and sulfur content were determined in hair samples of all participants using an inexpensive and portable X-ray fluorescence (XFR) detector. The work demonstrated that a modest increase in dietary zinc over 6 months resulted in a detectable increase in sulfur and zinc, offering a sensitive and non-invasive analytical methodology to monitor changes in response to dietary zinc interventions.Han et al. investigated the effects of supplements containing vitamins, minerals, zinc and probiotics on zinc concentrations in breast milk. They found that breast milk of women receiving supplements had higher zinc concentrations at 3 and 6 months of lactation but levels decreased by 12 months. One of the interesting findings was that zinc supplementation from as early as preconception affected the zinc concentrations during lactation. Therefore, early supplementation can ensure adequate maternal zinc status and adequate zinc transfer to the infants. A second, this time case-control study from Palestine by El Bilbeisi et al. assessed dietary and serum zinc levels during the third trimester of 160 pregnant women with and without pregnancy-induced hypertension (PIH). It is rare to see publications from this region. The authors found that the main risk factors of PIH included a familiar history of hypertension, primiparous, previous caesarian section, preeclampsia, oedema and, of course, low maternal dietary zinc intake, highlighting the importance of appropriate zinc status during, and probably, before pregnancy.The zinc content of breast milk is critical for the normal development of an infant. A clinical trial conducted by Álvarez-Barrios et al. used a human fetal RPE cell culture model that recapitulates features of early AMD. The authors specifically studied metallo-transcriptomics and found that altered zinc homeostasis changed the expression of cytosolic zinc-binding proteins, zinc transporters, and metalloproteins, supporting the growing evidence for the direct role of zinc dyshomeostasis in AMD.Zinc status is also important for the older generations. Previous clinical studies conducted by the Age-Related Eye Disease Study (AREDS) showed that dietary supplementation of zinc and vitamins slows the progression of age-related macular degeneration (AMD), one of the major causes of irreversible vision loss in people >65 years. One of the cellular targets in AMD is the retinal pigment epithelium (RPE). Yin et al. explored the relationship between pre-diagnostic dietary copper and zinc and the copper-to-zinc (Cu/Zn) ratio in 701 women diagnosed with ovarian cancer (OC). Higher dietary Cu intake and altered Cu/Zn ratio were related to patients diagnosed as non-serous OC, suggesting that supplementation with trace elements can provide treatment options for longer survival time. Tang et al. carried out a logistic regression analysis on data from NHANES to evaluate serum copper and zinc levels in patients with cutaneous melanoma and non-melanoma skin cancers (NMSC). Not significant relationships were found between serum zinc and the Cu/Zn. However, higher serum copper levels might be associated with a decreased incidence of NMSC. These early findings on different cancers suggest that there is a need for larger, prospective cohort studies to confirm these associations.Considering that dietary intake of trace elements could be relevant for the prevention or prognosis of cancer, Knez and Boy summarizes the current knowledge and recommendations focusing on how to evaluate zinc status in humans. Currently, plasma zinc level can indicate severe zinc deficiency but it is insensitive to detect mild/moderate and early-stage deficiency. The authors discussed the potential to use the gene expression profiles of fatty acid desaturases 1 and 2 (FDAS1/FADS2), the linoleic acid/dihomo-γ-linolenic acid ratio, thymulin levels, changes in the gut microbiome and the presence of different zinc transporters to accurately determine zinc status.Finally, there is a need for adequate, sensitive and specific biomarker for zinc status. The review article by This Research Topic demonstrates the continued interest and the importance of zinc as an essential trace element. With the development of more sensitive and specific biomarkers for zinc status and the evolving routes to increase zinc nutrition we should be able to eradicate the zinc deficiency associated comorbidities faster.HG-I, IL, and BR wrote, revised this article, and co-edited the Research Topic. All authors made a substantial, direct, and intellectual contribution to this work and approved the final version for publication.


Point-of-care photography and photo sharing optimize patient outcomes and facilitate remote consultation imperative for resident surgeons. This literature review and external pilot survey study highlight the risks associated with current practices concerning patient privacy and biometric security. In a survey of 30 plastic surgeon residents and attendings, we found that the majority took photos of patients with their iPhones and shared them with colleagues via Apple iMessage. These findings corroborate previous reports and highlight a lack of physician user acceptance of secure photo-sharing platforms. Finally, we frame a successful example from the literature in the context of a postulated framework for institutional change. Prioritizing the privacy and safety of patients requires a strategic approach that preserves the ease and frequency of use of current practices. Whether to monitor the progression of lower extremity wounds, share “before-and-after” aesthetic photos, or depict intraoperative techniques for a complex surgical case, clinical photography is essential in the practice and progression of plastic surgery. Today, plastic surgeons are equipped with exceptional means for potable capturing, sharing, and storing standardized, high-resolution clinical photographs that improve patient care.Logically, most plastic surgeons use their smartphones to capture (50–90%) and store (46–57%) clinical photography.Plastic surgeons face conflicting responsibilities to provide the best possible care for their patients and protect their confidentiality. Merging these duties requires implementing a secure digital tool for point-of-care clinical photography. However, our survey reveals a gap in the institutional and user acceptance of HIPAA-compliant software. Only 57% of plastic surgeons reported having access to an HIPAA-approved method for clinical photo sharing, and 53% cited using the said platform. Marwaha et al present a framework that helps health care organizations (HCOs) navigate institutional and individual barriers to deploying technology, stressing the importance of conducting site-specific needs assessments and interdisciplinary collaboration.Mayo Clinic realized that an outright banning of smartphones was impractical and led to inconsistent behaviors. In response, Mayo Clinic conducted an interdisciplinary review of its local regulations, site-specific policies, institutional framework, and technological bandwidth.Ultimately this communication presents the potential consequences of the ongoing widespread disorganization of clinical mobile-photo sharing and offers a solution for individual HCOs to adapt to their unique institutions. The field of plastic surgery and patient confidentiality depends on prioritizing these matters.


Such precision medicine approach is increasingly recognized . It also changes . The und2, and resulted in a redistribution of ventilation to the dorsal lung region despite no changes in global lung inhomogeneity and tidal volume.In this Journal’s issue, Benites et al.  investigShould we now put all our ventilated ARDS patients in flat-supine position to optimize their mechanics? We are not sure yet. Benites’s study revealed a large variability in the response to trunk inclination, which was likely partly driven by the heterogeneity in ARDS severity of patients enrolled (study enrolment criteria ranged from mild to severe ARDS). For instance, despite no significant group-level changes in global and regional end-expiratory lung impedance (EELI), individual patients could show either increases or decreases in ventral and/or dorsal EELI. Increased EELI indicates improved lung aeration. Potentially, the position-dependent effect on lung aeration may aid in identifying those patients, whose respiratory mechanics could benefit from a body position change. From a physiological perspective, the amount of recruitable lung tissue could influence the response to trunk inclination . ShiftinEspecially, since the pandemic, there has been increasing interest in applying very simple maneuvers to modify respiratory mechanics, including changes in body position, and chest wall or abdominal loading. Physiological research is needed to determine the response and therapeutic potential of such maneuvers and the elegant study of Benites et al.  provides


Biodetoxification using intravenous lipid emulsion (ILE) in acute poisoning is of growing interest. As well as for local anesthetics, ILE is currently used to reverse toxicity caused by a broad-spectrum of lipophilic drugs. Both pharmacokinetic and pharmacodynamic mechanisms have been postulated to explain its possible benefits, mainly combining a scavenging effect called “lipid sink” and cardiotonic activity. Additional mechanisms based on ILE-attributed vasoactive and cytoprotective properties are still under investigation. Here, we present a narrative review on lipid resuscitation, focusing on the recent literature with advances in understanding ILE-attributed mechanisms of action and evaluating the evidence supporting ILE administration that enabled the international recommendations. Many practical aspects are still controversial, including the optimal dose, the optimal administration timing, and the optimal duration of infusion for clinical efficacy, as well as the threshold dose for adverse effects. Present evidence supports the use of ILE as first-line therapy to reverse local anesthetic-related systemic toxicity and as adjunct therapy in lipophilic non-local anesthetic drug overdoses refractory to well-established antidotes and supportive care. However, the level of evidence is low to very low, as for most other commonly used antidotes. Our review presents the internationally accepted recommendations according to the clinical poisoning scenario and provides the precautions of use to optimize the expected efficacy of ILE and limit the inconveniences of its futile administration. Based on their absorptive properties, the next generation of scavenging agents is additionally presented. Although emerging research shows great potential, several challenges need to be overcome before parenteral detoxifying agents could be considered as an established treatment for severe poisonings. Biodetoxification using drug scavenging agents is of growing interest, as drug overdoses represent a major health problem accounting for thousands of deaths annually worldwide, most often among the young. Poisoning is responsible for more than 3 million calls to US poison control centers annually . Two thiThe use of intravenous lipid emulsion (ILE) as an antidote to reverse local anesthetic-related systemic toxicity (LAST) has gained widespread support following convincing data from successful case reports and animal studies . ILE wasEvidence for ILE use in poisoning is evolving. Several mechanisms of action have been hypothesized , includiWith functional toxicants, the most common approach to manage poisoning is to provide the support needed to maintain organ function, relying on the endogenous ability to metabolize and eliminate the toxicant. Gastrointestinal decontamination, including gastric lavage and activated charcoal administration, can minimize absorption, but these techniques are controversial and poorly effective more than 1–2 h post-ingestion ,8. ExtraNumerous experimental and clinical studies have established that ILE can increase the blood tissue partitioning of lipophilic drugs, improve cardiac performance, and result in relevant beneficial effects such as post-conditioning, direct inotropy, and the activation of cytoprotective pathways ,5,6. By ® , clinicians proposed the use of intravenous (IV) fat emulsions as drug binders or components of extracorporeal lipid dialysis. Russell et al. reported that IV cottonseed oil could shorten the duration of thiopental anesthesia [®, B. Braun, Taguig City, Philippines) could bind chlorpromazine in vitro and save rats from lethal chlorpromazine toxicity [In 1962, after the commercial release of Intralipidesthesia . Adding esthesia , and oneesthesia . In the esthesia ,14. Laboesthesia . Krieglstoxicity . ThereafWeinberg et al. published their original findings demonstrating that resuscitation or pretreatment with ILE resulted in the improvement of cardiac toxicity associated with bupivacaine in rats and dogs ,18. FollILEs are sterile nanometer-sized droplets of triglyceride oils in water stabilized by phospholipid surfactants . The aveILEs may contain varying types  and concentrations of triglyceride oils . Droplets have similar shapes and sizes to physiological chylomicrons and are similarly metabolized. Fatty acids represent the lipid phase of ILE with neutral long-chain triglycerides (LCTs) or a mix of medium-chain triglycerides (MCTs) and LCTs.® is the most often studied product among ILEs. It is an emulsion containing 20% soybean oil, 2.25% glycerin, and 1.2% egg phospholipids [® is currently manufactured with lipid concentrations of 10, 20, and 30% and commonly used for parenteral nutrition, drug carrier vehicles, lipid rescue therapy, and ischemia-reperfusion injury attenuation therapy [® is the most often administered lipid rescue therapy, the use of other products has been reported [Intralipidholipids . Intrali therapy . Althougreported ,23. The ILEs are useful carriers for lipophilic drugs . They ar® 20% was reported to have a zeta potential between −45 and −40 mV, indicating that the emulsion has significant surface charge [Of note, the octanol/water partition coefficient (LogP) used to reflect lipophilicity  differs e charge . Recentle charge . LogD acRecently, two other new parameters, i.e., drug accommodation capacity and drug capture kinetics, were described to characterize the drug capture capability of lipid emulsions and their resulting effects on PK in overdose . Drug caTo summarize, the charged portion of ionized drugs could interact with the surface of lipid droplets through electrostatics, while the uncharged portion could interact with the oily interior and the phospholipid bilayers to maintain drug sequestration. The clinical utility of these absorptive properties  lies in increasing drug sequestration to provide recovery from toxicity. Various predictors of drug capture have been proposed, including LogP, LogD, and drug accommodation capacity. However, the best predictor, if considering their emergent availability at the bedside versus their prediction accuracy, remains debated.The mechanisms responsible for ILE-based detoxification remain the subject of ongoing extensive studies and debate ,34,35. BThe “lipid sink” or “PK sequestration” theory is the one most studied. Triglyceride oils in ILE exhibit a high affinity for lipophilic drugs and create a lipid-rich PK compartment within the bloodstream, drawing them away from their targets and free blood. A new equilibrium is established thereafter, reducing tissue concentrations and helping to restore organ function, allowing the drug’s metabolism and elimination. ILE inactivates a portion of lipophilic drugs by acting as alternative binding surfaces, making them unavailable to act on their target organs .® [ILE has been reported to reverse the toxicity caused by drugs lacking any common mechanism, site of action, chemical structure, or clinical effects except lipophilicity . The par® . The onl® ,43.The infused lipid emulsion appears in the blood as emulsified oil droplets acting on the lipophilic drug-induced cardiovascular failure through (1) redistribution of the toxicant from its targeted tissues , (2) mitochondrial increase in fatty acid uptake and enhanced cell energetic production (metabolic theory) (3) limitation of the toxicant interference with the sodium channels, thus promoting calcium entry via voltage-dependent calcium channels (membrane and ionotropic theory), (4) activation of protein kinase B , leading to the cytoprotective signaling cascade (cytoprotection theory), (5) attenuation of endothelium-dependent nitric oxide-mediated vasodilation and post-ischemic vasodilation by decreasing nitric oxide bioavailability (nitric oxide theory), and (6) acceleration of liver shunting (pharmacokinetic theory). The arrow thickness represents the suggested probability rate of each postulated mechanism based on the literature.® resuscitation of LAST [In vivo studies supported a substantial contribution of partitioning in successful lipid resuscitation. Niiya et al. found that pretreating pigs with lipids protected them against amiodarone-induced hypotension . The lip of LAST . Bupivac of LAST . In a ra of LAST . Indirec of LAST . Finally of LAST ,46,47,48 of LAST ,50. A sh of LAST .Emerging evidence suggests that the application of the sink theory should be approached differently. With improved understanding of lipid resuscitation, ILE droplets are viewed as a lipid shuttle responsible for a capture/release mechanism to move a drug around and not only as a sink that captures and isolates the drug. A newly formed IV lipid compartment transiently sequesters the drug and accelerates its movement from drug-susceptible organs such as the brain and heart to organs that can store , metabolize (liver), and excrete  the drug ,51. A trNevertheless, caution is needed, as PK sequestration does not always lead to reduced toxicity. Many questions remain unresolved. The lipid-rich compartment provided by ILE can actually increase the gastrointestinal absorption of lipophilic drugs, which may strengthen the toxicity, as shown in a model where ILE was administered before cardiovascular toxicity onset in contrast to the typical ILE use in humans ,57. ILE PK models assert that a scavenging effect alone cannot account for the rapid recovery from toxicity occurring after ILE administration . ContinuOnly the scavenging effect and a direct cardiac effect considered together can explain the rapid recovery from drug toxicity ,59. ILE The underlying mechanisms allowing ILE-attributed improvement in cardiac output have not been fully elucidated. The infused volume of ILE is a major issue but not the only one, and other contributors are still unclear. The calcium influx and fatty acid hypothesis is the most popular. Fatty acids are supposed to increase calcium influx in the myocardial cells to produce a positive inotropic effect . The appA large lipid load could offset the potent inhibition of fatty acid metabolism caused by the toxicant, providing a source of energy to the myocardial cells . StudiesThe role of the vasoconstrictive properties of ILE on the vasculature has been established. However, the relative cardiac versus vascular contribution to the final effects is unclear . ILE canILE infusion attenuates cardiac ischemia reperfusion injury. Post-ischemic infusion of lipids in rodents, as observed in the experiments with metabolic inhibitors, reduced the likelihood of mitochondrial permeability transition and apoptosis ,76. Ischn = 16 studies) supported the benefits of ILE use in combination with life-support measures to treat LAST, especially in relation to bupivacaine [p = 0.0012) and features of drug toxicity. Similarly, in a model of amlodipine-poisoned rats, the survival rate and hemodynamics were improved with ILE in comparison to controls and methylene blue, although the beneficial effects were small [n = 58 studies) underlined the study heterogeneity and limitations, mainly in relation to the experimental resuscitation conditions such as the appropriate airway management and chest compressions in models including cardiac arrest [A meta-analysis of animal studies  recently assessed the evidence regarding ILE use in acute poisoning . The rigDespite the multiple reports encouraging the use of ILE in the management of acute poisonings involving cardiotoxicants, the voting panel found an absence of evidence to recommend its use in most poisonings and clinical scenarios where its use was previously reported. Thus, the preponderance of neutral votes  likely represents the workgroup’s caution in making recommendations for or against a therapy where so few moderate- or high-quality human data existed . The stu-In bupivacaine-induced cardiac arrest, ILE after standard ACLS started (1D) was recommended (strong agreement), while the recommendation was neutral (equipoise between risk and benefit) regarding its use in cardiac arrest due to other local anesthetics;-In case of cardiac arrest related to other local anesthetics, no recommendation was provided because of a lack of evidence. The considerable variability in lipophilicity and toxicity profiles of the other local anesthetics invalidated recommendations made by analogy rather than data. However, in the risk/benefit balance, harm appeared to be very low, leading to a neutral vote in this setting, meaning that ILE could be used in first line therapy;-In life-threatening toxicity due to bupivacaine, the experts suggested using ILE as part of treatment modalities (2D) and recommended its use for all other local anesthetics if other therapies fail or as a last resort (1D);-In non-life-threatening toxicity due to bupivacaine or other local anesthetics, the recommendation regarding ILE use was neutral;-In cardiac arrest in relation to all other drugs , the recommendation regarding ILE use was neutral;-In life-threatening toxicity due to Class 1 Vaughan–Williams antiarrhythmic drugs, baclofen, ivermectin, and selective serotonin reuptake inhibitors, the recommendation regarding ILE use was neutral;-In life-threatening toxicity due to malathion and other pesticides/insecticides, olanzapine, and other antipsychotics, the experts suggested not using ILE as a first-line therapy (2D);-In non-life-threatening toxicity due to all these drugs, malathion, and other pesticides/insecticides, the experts suggested not using ILE as a first-line therapy (2D).The working group carefully considered several specific questions for 22 toxins. When should ILE be the first-line therapy? Is ILE the drug of choice in cardiac arrest or life-threatening toxicity? Should we ever use ILE in non-life-threatening toxicity of specific drugs? For any detailed analysis of the studies and case reports, the experts directed readers to several recent reviews cited above ,84. Tabl® in human poisonings until comparative studies could be reported [® [Many practical aspects of ILE therapy have not been validated in the clinical setting: the optimal dose for clinical efficacy, the threshold dose for adverse effects, and the minimum or maximum duration of infusion ,5,6. Thereported . Of notereported , while torted [® .Data on ILE dose/response relationships to reverse toxicity in humans are insufficient to determine the optimal duration of ILE therapy,. There is a varied range of bolus doses, infusion rates, and durations reported in the literature, precluding any accurate analysis of the optimal dose regimen. Due to the lack of historical data indicating a recurrence of toxicity once clinical improvement occurs, termination of the infusion should be considered when sustained clinical improvement is obtained or, if this endpoint takes time, until the maximum dose has been reached. However, this is speculative, and studies are needed . To avoiILE stability and sterilization do not represent actual issues. In the poisoned patient, ILE is infused from the manufactured package using a central or peripheral venous catheter with no particular manipulation by caregivers, contrasting with the conditions of its administration for parenteral nutrition. Preserving a stable emulsion with ~300 nm droplet size and a relatively narrow globule size distribution (200–600 nm) is important. No study specifically investigated the emulsion stability requirement in the conditions of ILE infusion to poisoned patients.Complications following ILE administered as part of long-term parenteral nutritional are well known .Those related to ILE administration as « lipid rescue » have been recently reviewed . Such adFinally, the use of extracorporeal membrane oxygenation (ECMO) after or during lipid rescue may be associated with fat deposition in the circuits and increased blood clot formation . ILE mayNumerous meta-analyses, narrative reviews, and national guidelines exist, with slightly different and sometimes contradictory conclusions compared to those of the Lipid Emulsion Workgroup experts ,104,105.Clinical toxicologists are still skeptical, requesting clarifications on how useful ILE may be for poisonings other than LAST ,111. An ILE investigated for biodetoxification has been limited to total parenteral nutrition emulsions, but the range of emulsion design is broad. Absorptive properties could be optimized for drug sequestration to improve the efficacy of emulsion-based detoxification. Reverse engineering of the principles underlying drug delivery will yield efficient and effective scavengers with higher binding capacities and greater specificity ,114,115.The emulsion surface, the surfactant type and concentration, the fatty acid chain length, and the electrostatic uptake of charged drugs represent parameters that could be modified to optimize binding functionality to redistribute the offending toxicant from its target to the blood or to induce its metabolism into innocuous or less active metabolites.All parenteral nutrition emulsions contain triglyceride oils, but some emulsions using oils not derived from triglycerides have been demonstrated to have greater potential for sequestration and uptake than LCTs. However, non-triglyceride formulations may not also have the cardiotonic effects advocated as important mechanisms of action in recovery from toxicity ,117.Liposomes are spherical vesicles of diameters ranging from tens of nanometers to tens of micrometers with an aqueous core surrounded by one or more concentric phospholipid bilayers . These aLiposomes possessing transmembrane pH gradients have been studied for their capacity to efficiently entrap and transport drugs in vitro , ex vivoDespite limited studies, liposomes appear to be as effective as ILE for detoxification due to the stronger interactions observed with various tested drugs and comparable recovery profiles from toxicity obtained in animals. The design versatility  makes liposomes more attractive for future detoxification therapies . AdditioTo reduce drug concentrations below toxic levels in target tissues, important factors still need to be better understood to predict the dynamics of detoxification using colloidal systems. The time scale of sequestration may be significantly shorter than the time required for drug diffusion through tissues or clearance ,134.After drug sequestration by a colloidal system, the reduced free drug concentration will allow its redistribution out of some fast-equilibrating tissues such as the heart and lungs to maintain the equilibrium. However, other tissues may continue to slowly release the drug back into the circulation even after the detoxification therapy has been removed from circulation. Measuring each of these parameters and incorporating all the relevant mechanisms and parameters into PK/PD models would be a useful approach to designing overdose therapies ,47,135.Future detoxification agents may function as multi-purpose agents, removing and capturing the harmful toxicant to accelerate its metabolism to non-active compounds and delivering antidotes. Combining different antidotal strategies may synergistically antagonize the effect of the offending compound.Translation to the bedside will also require the implementation of well-designed in vivo protocols. In several studies, scavenging therapies were administered either before or a few minutes after the toxicant, often injected intravenously. These administration regimens are not representative of acute intoxications, which generally occur outside medical facilities, are not treated immediately, and mostly involve oral ingestion. Reproducing realistic poisoning scenarios in upcoming antidotal studies will be very important before moving forward into humans.http://www.lipidrescue.org/ (accessed on 25 April 2023).Human cases of lipophilic drug poisoning presenting in extremis are infrequent, but RCTs must be undertaken to enable a more informed evaluation of the ILE role in selected poisonings. In order to improve knowledge in this nascent field, guidance with registry data, including both successful cases of ILE use and otherwise, could prove invaluable. One data registry is accessible using the following link Present evidence supports the use of ILE only in LAST and lipophilic cardiotoxicant poisonings when there is an immediate threat to life, and other therapies have proven ineffective. ILE as an antidote remains a nascent field, warranting further preclinical investigations, clinical studies, and systematic reporting of use in humans before extending any recommendation. There is an incomplete understanding of ILE efficacy, mechanisms of action, and safety. We need well-designed RCTs in carefully selected groups of patients to help provide the most effective use of ILE.


Additionally, we critically analyse current research avenues in the development of novel fertility preservation strategies, with a focus on ferto-protective agents.Cytotoxic chemotherapies have been a mainstay of cancer treatment but are associated with numerous systemic adverse effects, including impacts on fertility and endocrine health. Irreversible ovarian damage and follicle depletion are the side effects of chemotherapy that can lead to infertility and premature menopause, both being major concerns of young cancer patients. Notably, many women will proceed with fertility preservation, but unfortunately existing strategies do not entirely solve the problem. Most significantly, oocyte and embryo freezing do not prevent cancer treatment-induced ovarian damage from occurring, which may result in the impairment of long-term hormone production. Unfortunately, loss of endogenous endocrine function is not fully restored by hormone replacement therapy. Additionally, while GnRH agonists are standard care for patients receiving alkylating chemotherapy to lessen the risk of premature menopause, their efficacy is incomplete. The lack of more broadly effective options stems, in part, from our poor understanding of how different treatments damage the ovary. Here, we summarise the impacts of two commonly utilised chemotherapies – cyclophosphamide and cis-diamminedichloroplatinum(II) (cisplatin) – on fertility, and discuss how they cause damage to the ovaries. We also critically analyse recent preclinical studies related to the development of new fertility preservation techniques.Over the past few decades, advances in the detection and treatment of cancer have dramatically improved survival rates in young women. This means that ensuring patients have a high quality of life after cancer treatment has become a new priority. Therefore, it is important to understand and prevent any long-term negative side effects of cancer treatments, with infertility and early-onset menopause being major concerns for women receiving chemotherapy. The current fertility preservation options available to young women have significant limitations. Therefore, the identification of new approaches to protect fertility has been an intense topic of research in recent years. In this review, we provide information on the negative side effects of two commonly used chemotherapy drugs – cyclophosphamide and  Given that approximately 5% of women diagnosed with cancer worldwide are of reproductive age and cancer mortality rates are steadily falling  and subfertility in the short term or cause premature ovarian insufficiency (POI) in the long term  agonists has been shown to reduce the risk of POI in women with breast cancer (cis-diamminedichloroplatinum(II) (cisplatin), and, lastly, the anthracycline antibiotic doxorubicin. However, other agents, such as the anti-metabolite 5-fluorouracil, have been demonstrated to have moderate, short-term ovotoxicity  agents, anti-tumour antibiotics, anti-metabolites, vinca alkaloids, topoisomerase inhibitors and other miscellaneous agents. These different classes of chemotherapeutic agents have diverse mechanisms of action and, hence, varying degrees of ovarian toxicity (ovotoxicity), which have been reviewed extensively , brain cancer and neuroblastoma, all of which affect paediatric and reproductive-age females  impacts on primordial follicles and, thus, long-term fertility; (ii) impacts on growing follicles and, thus, short-term fertility; and (iii) impacts on ovarian stroma and vasculature. Additionally, recent evidence suggests that these agents may also impact upon oocyte mitochondrial function, though the consequences of this are yet to be fully elucidated  or cisplatin (5 mg/kg) is sufficient to eliminate the vast majority of the primordial follicle population within 24 h reatment . These svia homologous recombination in apoptosis-resistant (–/–Puma) mice  and inhibin B) following treatment with either cyclophosphamide-containing regimens or other alkylators  stages – has been reported in rats  oocytes collected from cyclophosphamide-treated mice . More reThe ovarian stroma and vasculature have an important role in coordinating ovarian steroid production (particularly oestradiol and testosterone) and supporting both the health of the ovarian reserve and normal follicular development  direct oocyte damage and apoptosis of primordial follicles and (ii) accelerated primordial follicle activation and ‘burnout’. A third factor may be induction of oxidative stress in vivo mouse studies have demonstrated that primordial follicles sustain widespread DNA damage following cyclophosphamide or cisplatin exposure in the form of double-stranded breaks, predominantly within the oocyte  kinase is activated. ATM can initiate DNA repair pathways but more commonly will phosphorylate and activate TAp63α . Subsequ–/–Puma) mice demonstrated that when rescued from apoptosis, primordial follicles exposed to cisplatin are able to efficiently repair DNA damage via the homologous recombination pathway  with partner or donor sperm to form embryos, which are then frozen. However, this invasive procedure first requires hormone stimulation to produce multiple mature oocytes, which in some cases will require a delay in the commencement of treatment that may not be feasible. Moreover, oocyte retrieval and IVF are inherently expensive and thus are not accessible to all patients  at a later time (Ovarian tissue cryopreservation (OTCP) involves the collection of small slices of ovarian cortex usually ter time . Howeverter time .For prepubertal girls, fertility preservation remains a challenge. Cryopreservation of oocytes or embryos is not possible; thus, cryopreservation of ovarian tissue is the only available option. As well as the issues with OTCP already described above, to date no livebirths have been reported following the reimplantation of prepubertally harvested ovarian tissue into adult survivors of childhood cancer  protein kinase inhibitors and (ii) ceramide-induced death pathway inhibitors . AdditioBCR and cellular-ABL (c-ABL). This chimeric gene, termed Philadelphia chromosome, is strongly associated with the development of leukaemia. Inhibition of BCR-ABL prevents apoptosis by blocking mitochondrial cytochrome c release and caspase activation (via the activation of p73 (Imatinib is a selective inhibitor of breakpoint cluster region (BCR)-Abelson murine leukemia viral oncogene homolog 1 (ABL), a tyrosine kinase produced by the abnormal fusion of two genes – in vitro and in vivo  and checkpoint kinase 2 (CHK2) are both serine–threonine kinases that have important roles in the DNA damage response. Following the induction of DNA damage, ATR activates CHK2 which, in turn, can activate TAp63 and trigger apoptosis within oocytes tellurate (AS101) is an immunomodulator that has also been shown to inhibit PI3K pathway activity  1 inhibitor, and INK128 inhibits mTORC1/2. A recent report showed that the administration of RAD001 or INK128 prevents the depletion of primordial follicles following cyclophosphamide treatment  can prevent chemotherapy-mediated follicle loss. This concept was first investigated by Kano Another study reported that rAMH administration prevented cyclophosphamide-induced primordial follicle depletion; however, robust results were only obtained when primordial follicle number was expressed as a proportion of total follicles within the ovary and not in the raw follicle counts  were used and whether combination therapies were administered. Moreover, ascertaining whether pregnancy outcomes in women have been impacted by chemotherapy-induced uterine-specific damage is often confounded by the ovarian and endocrine damage that occurs concurrently. Future studies in this area are critical to furthering our understanding of the impact of chemotherapy on the uterus and what mechanisms may underlie it. Furthermore, addressing this knowledge gap will be essential in the development of fertility preservation strategies specific to the uterus.Although chemotherapies such as cyclophosphamide and cisplatin remain a mainstay of many cancer treatment regimes, the use of more targeted therapies – such as immunotherapy and small-molecule inhibitors – is becoming more widespread. However, information on whether these newer therapies may also impact ovarian function and fertility, even in preclinical models, is somewhat limited. Recently, we and others critically reviewed the available literature and speculated on the potential impacts of immunotherapies and small-molecule inhibitors on reproductive and endocrine function in women ; KJH – FT190100265 and ALW – DE21010037, the National Health and Medical Research council (NHMRC); JMS-2011299, and the Australian National Breast Cancer Foundation (NBCF) grant no. IIRS-22-092. LRA is supported by an Australian Government Research Training Program scholarship and a Monash Graduate Excellence Scholarship. Figures were created using BioRender.LRA designed tables and figures. All authors contributed to writing and editing the manuscript.