According to its “harmonized” definition, metabolic syndrome (MetS) is described as a cluster of metabolic factors that increases the risk of cardiovascular diseases, diabetes (DM) and associated morbidities such as dementia. More specifically, the combined occurrence of at least three of the following five risk factors would qualify a person for MetS: hyperglycemia, hypertriglyceridemia, low high-density lipoprotein (HDL) cholesterol levels, hypertension and abdominal obesity. MetS can be modulated by genetics and epigenetics factors, fostered by sedentary lifestyle, influenced by the quality of food and sleep and controlled by gut microbiota. It has been estimated that more than one in three adults in the United States, and approximately 40% of people over the age of 40, have MetS, making it a major health hazard of the modern world .From a mechanistic perspective, finely tuned, redox-dependent signal transduction mechanisms underlie and control metabolic dysregulations. Moreover, low-grade systemic inflammation is usually associated with such endocellular redox alterations and eventually leads to a dysfunctional metabolic rewiring .Nutrition is one of the most important modifiable factors affecting human health. Appropriate dietary patterns have, indeed, been demonstrated to effectively counteract the immunometabolic alterations leading to MetS development . Along tIn the first paper, Valenzano et al. have evaluated the effect of a very low-calorie ketogenic diet (VLCKD) in a population of obese patients. The study drew inspiration from the current knowledge on the effects of caloric restriction and dietary ketosis on the reduction of visceral adipose tissue (VAT). By employing an integrated in vivo and ex vivo experimental approach, the authors demonstrated that VLCKD was able to decrease VAT, ameliorating adiposity and blood chemistry parameters. Moreover, the short-term mild dietary ketosis did not appear to have a cytotoxic effect, nor was it a condition able to increase oxidative stress. Relevantly, the study also demonstrated for the first time an effect of the VLCKD upon the orexinergic system. As a whole, these data further support the usefulness of such a therapeutic dietary intervention to promote obesity reduction via hypothalamic mechanisms .Nigella sativa (NG), in an in vitro model of low-grade inflammation in human macrophages. The authors demonstrated that both EVO and NG oil reduced low-grade inflammation through antioxidant and epigenetic mechanisms. Indeed, both oils were able to restore normal expression levels of DNMT3A and HDAC1 (but not DNMT3B), which were altered under inflammatory conditions. Moreover, EVO oil was able to prevent the increase in TET2 expression and reduce global DNA methylation that were measured in inflamed cells. Interestingly, NG oil seemed to be more efficient in the control of proinflammatory cytokines, whereas EVO oil better helped to counteract redox imbalance [In the light of the strict interconnections between the Mediterranean diet, epigenetics and inflammation, Bordoni et al. investigated the nutrigenomic properties of two high-quality oils, extra virgin olive (EVO) oil and that of mbalance .It is now well established that dietary interventions can exert positive effects on MetS and also induce alterations of gut microbiota. Along these lines, Guirro et al. have assessed the effects of the citrus polyphenol hesperidin in an in vivo model of MetS with the aim to elucidate the host–microbiome interplay with extensive anthropometric and biochemical characterizations. Interestingly, the authors demonstrated that hesperidin supplementation ameliorated the plasma lipid profile, as well as blood pressure, insulin sensitivity and relevant markers of arterial stiffness and inflammation. Coherently, metabolomics also revealed an improvement of the lipidomic profile, a decrease in circulating amino acids and a lower excretion of inflammation- and oxidative stress-related metabolites. Relevantly, animals excreted larger amounts of microbial-derived metabolites, which positively correlated with the Bacteroidaceae family. As a whole, these data do support the hypothesis for a potential use of hesperidin as a prebiotic in the combo therapy of MetS .Besides the beneficial effects of dietary patterns to prevent and/or counteract MetS development, supplementation with plant-origin extracts has been widely explored over the last decade. Within this remit of intense research, the study from de la Fuente-Fernandez et al. has analyzed the protective effects of a carob fruit extract (CSAT+®) on the cardiometabolic alterations associated with MetS in mice. The authors discovered that CSAT+® supplementation was able to ameliorate both the glucidic and lipidic plasma profile, significantly reducing peripheral insulin resistance (IR), inflammation and oxidative stress. Moreover, CSAT+® treatment also prevented MetS-induced hypertension, improved vascular response and attenuated endothelial dysfunction (ED). Finally, cardiomyocyte apoptosis and an ischemia–reperfusion-induced decrease in cardiac contractility was also prevented by the fruit extract supplementation . A key issue in the development of MetS is the difference between metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO) phenotypes, partly attributable to genetic traits that modulate body fat distribution and obesity-related metabolic aspects. Within this context, no solid reports are available on the genotypic effect of the leptin receptor (LEPR) gene on fat distribution and obesity-related metabolic abnormalities in the Korean population. Along these lines, the study by Jang et al. evaluated whether the difference between MHO and MUO phenotypes might be partly attributable to the LEPR rs8179183 polymorphism in obese Korean females. Interestingly, the results of the work revealed that LEPR rs8179183 was associated with metabolic health status in a Korean population with obesity. Moreover, the paper reported on MUO individuals with the GG genotype having the most unfavorable values of glucose-related markers, lipid profiles, adipokines, oxidative stress markers and regional fat distribution [Epidemiological data clearly show that, within dietary patterns and lifestyles, sugar-sweetened beverages (SSBs) are deeply implicated in MetS development. In light of scanty mechanistic insights underlying this process, Benade et al. have established a unique rat model of long-term SSB consumption to deeply analyze the link between SSB consumption and the onset of type 2 diabetes mellitus (T2DM). Interestingly, the authors showed that SSB consumption increased hepatic ER stress and altered hepatic mitochondrial dynamics, antioxidant response and calcium handling across mitochondria-associated ER membranes. Relevantly, the authors underlined that at this relatively early stage of SSB intake, the liver could be able to initiate adaptive responses to significantly counteract such stressors. However, the observed increased mitochondrial fission and decreased fusion could represent a possible mechanism responsible for the development of MetS and T2DM in the longer term .−/− mice and the effect of nitrite supplementation on the rescue of systemic, hepatic and adipose tissue insulin sensitivity. Interestingly enough, the authors demonstrated that chow-fed adult iNOS−/− mice exhibited systemic IR, dyslipidemia and metabolic perturbations. Relevantly, nitrite supplementation significantly counteracted IR and glucose tolerance and reduced lipid accumulation by improving hepatic insulin sensitivity and glucose and lipid homeostasis. While demonstrating that nitrite supplementation improves insulin sensitivity and metabolic homeostasis, the authors further highlight the metabolic role of iNOS [Nitric oxide (NO) is widely reported to play a pivotal role in cardiovascular and metabolic regulations. Coherently, nitrite, a precursor of the NO reservoir abundant in green leafy vegetables, has been proposed to exert protective effects against T2DM and cardiovascular diseases. On the other hand, while the role of iNOS as a pro-inflammatory agent is well established, its protective role under normal physiological conditions and cardiovascular disorders is less well investigated. Along these lines, the work by Aggarwal et al. investigated the incidence of IR in chow-fed iNOS of iNOS .It has been demonstrated that NO, together with glutathione (GSH), is involved in the modulation of the hepatic regulation of glucose metabolism. Taking into account the incomplete current knowledge of the metabolic action of GSH and NO in glucose homeostasis, the study from Sousa-Lima et al. was designed to evaluate whether treatment with S-nitrosoglutathione (GSNO) could revert high-sucrose diet-induced IR in vivo. Interestingly, GSNO administration was able to revert IR induced by sucrose feeding in a dose-dependent manner, demonstrating an insulin-sensitizing effect in vivo. From a mechanistic perspective, these effects were associated with an increased expression of both insulin receptors and p-Akt in muscle cells after GSNO treatment. In line with this, the authors suggested that GSNO may act as a potential pharmacological tool for the treatment of IR in obesity and T2DM .T2DM-induced hyperglycemia has been demonstrated to lead to oxidative stress-mediated fibrosis in different tissues and organs. The endothelial-to-mesenchymal transition (EndMT) has been proposed to play a role in T2DM-associated fibrotic conditions. Along these lines, Giordo et al. have investigated whether EndMT is implicated in the diabetic retinopathy fibrotic process and evaluated if resveratrol could counteract EndMT in vitro. Interestingly, the authors discovered that the treatment of primary human retinal endothelial cells (HRECs) with high glucose (HG) resulted in an increase in intracellular ROS levels and fostered phenotype shifting towards EndMT. The mechanism appeared to be mediated by a PKC involvement leading to NADPH-associated ROS generation. Interestingly, resveratrol was able to counteract EndMT via a downregulation of NADPH oxidase, suggesting a resveratrol-based potential protective therapy to prevent diabetic-associated complications .Childhood obesity and its metabolic complications have been related to deficient antioxidant capacity and oxidative stress. Erythrocytes (RBCs) are constantly exposed to oxidative stress and hence are provided with powerful antioxidant systems strongly depending on the pentose phosphate pathway (PPP). Along these lines, in their work, Gonzalez-Dominguez et al. aimed to assess the efficacy of the PPP (through its NADP dehydrogenases) to provide reducing power in the RBCs of obese children with IR as compared to a group of metabolically healthy obese participants and a group of healthy controls. Interestingly, the authors demonstrated that obese children with IR present higher levels of oxidative damage, blunted capacity to generate reducing power and hampered function of key NADPH-dependent antioxidant enzymes. This condition resulted in a deficient response to a glucose overload as compared with the other study groups. Interestingly enough, the authors found a physiological deviation of redox balance (oxidative eustress) in obese children without IR and a supraphysiological deviation (oxidative distress) in the IR group .It has widely been recognized how IR and T2DM can play a key role in the etiopathogenesis of neurodegenerative pathologies. Additonally, an increasing number of nutraceuticals have been evaluated for their potential to exert protective effects in this regard. Within this remit of research, Amato et al. reviewed experimental data on the ability of curcuminoids, silymarin, chlorogenic acid and Aphanizomenon flos-aquae-derived compounds to exert beneficial effects on neurodegeneration and in particular in Alzheimer’s disease models .Hypomagnesemia is commonly observed in both cardiovascular diseases and several risk factors associated with MetS, such as T2DM and hypertension. Interestingly, low serum magnesium (Mg) has been proposed as a predictor for cardiovascular and all-cause mortality. In their review, Liu et al. reported on the possible mechanisms by which Mg deficiency could play detrimental roles in cardiovascular diseases and reviewed the results of clinical trials of Mg supplementation for heart failure, arrhythmias and other cardiovascular diseases . Eryptosis is a coordinated, programmed cell death culminating in the disposal of cells without disruption of the cell membrane and the release of endocellular oxidative and pro-inflammatory milieu. While providing a convenient form of death for RBCs, dysregulated eryptosis may result in a series of detrimental and harmful pathological consequences. In light of the crucial role played by the eryptotic process in MetS-related endothelial dysfunction (ED), Restivo et al. reviewed the molecular mechanisms leading to eryptosis in MetS-related conditions . Moreover, the authors also reported the clinical evidence supporting or proposing a role for eryptosis in ED associated with MetS cardiovascular complications .MetS and non-alcoholic fatty liver disease (NAFLD) are two different entities sharing common clinical and physio-pathological features, with IR being the most relevant. In the last review, Rinaldi et al. reported on the “bad company” constituted by MS and NAFLD and discussed both the mechanistic aspects and the clinical impact related to these pathological conditions .


Arsenicosis is caused by long term (6 months plus) ingestion of arsenic above a safe dose, characterized by skin lesions and possible involvement of internal organs. Arsenicosis is common in India and Bangladesh where naturally occurring high concentrations of arsenic in the earth's crust contaminate ground water, causing adverse health effects.We report a case of a 55-year-old Indian male, resident of a known arsenic endemic region of Uttar Pradesh who suffered from characteristic pulmonary and cutaneous features of chronic arsenic toxicity which included radiological findings of interstitial lung disease, hyperkeratotic lesions over the palms and soles, rain drop like pigmentation over the trunk, and carcinomatous changes at the wrist joint. The patient was started on chelating agents (d-penicillamine) and oral retinoids (isotretinoin) followed by the surgical excision of the carcinoma.Environmental contamination with arsenic is a well-known health hazard in South Asian countries. The main source is consumption of contaminated ground water for domestic purposes. Cutaneous lesions, internal organ involvement including interstitial lung disease and carcinomas as observed in our patient have been reported in the literature. Various mechanisms like epigenetic changes and arsenic-induced immune suppression have been proposed for the development of cutaneous carcinomas with prolonged exposure to arsenic. Among the various causes of palmo-plantar hyperkeratosis, arsenicosis should be kept in mind when presenting in combination with pigmentary changes and carcinomatous growth from an arsenic-endemic region.People residing in arsenic-endemic regions should be made aware of arsenic-related health hazards. Rainwater harvesting and good nutrition are the simplest measures which could be adopted by the exposed population in affected areas. Several methods have also been employed by governmental and non-government organizations to separate arsenic from contaminated water to combat arsenic-related diseases and carcinomas.The authors declare no competing financial interests. Acute arsenic poisoning is associated with nausea, vomiting, abdominal pain, and severe diarrhea, while chronic arsenic toxicity is characterized by multi-system involvement and cancers of various organs like the lungs, liver, bladder, and skin.3The main source of arsenic exposure for humans is contaminated ground water, which is used for domestic purposes across various regions of India. Arsenic contamination occurs through natural mineral deposits as well as anthropogenic sources like mining activities, electronic manufacturing processes, smelting of metals and pesticides used in farming.3 There have been several reports of groundwater arsenic contamination in states situated on the Ganga-Brahmaputra and the Padma-Meghna fluvial plains.4 Moreover, indiscriminate pumping of ground water in the northern states of India has led to a large increase in arsenic concentrations beyond safe levels. There are also reports documenting elevated levels of arsenic in tube well water samples in the area. People residing in these arsenic-affected areas manifest various types of cutaneous diseases including ulcers, pigmentation, hardening of palmar skin and various cancerous growths in the body.In India, chronic arsenic toxicity was first reported in Chandigarh in 1976 and later from the state of West Bengal in 1984.Figure 1). Multiple hyperkeratotic papular lesions of size 4–5 mm were present on both palms and soles . Hyper and hypo-pigmented macules were present on the trunk, upper and lower limbs. A single, 3 × 2 cm, mobile, hard, non-tender lymph node was present in the right axilla . No organomegaly was noted. Keeping in mind the differentials like arsenicosis, plantar and palmar warts and epidermodysplasia verruciformis, several investigations were performed.A 55-year-old male, farmer by occupation, presented to us with the chief complaints of rough raised lesions over the palms and soles for the last 3–4 years, hyper and hypo-pigmented macules over the trunk, upper and lower limbs for last 2–3 years and a painful ulcer over the right wrist for the last 2 years. He also had a history of cough, shortness of breath, on and off paresthesia on the upper right limb, hypertension, and weight loss (undocumented). To treat these symptoms, the patient took multiple over-the-counter medications for pain (undocumented), but his condition continued deteriorating. Various social factors were responsible for the patient's hesitancy to seek treatment for his symptoms, including illiteracy, lack of understanding of the seriousness of his symptoms, financial difficulties, and lack of access to good medical facilities in his area of residence. On further inquiry, the patient revealed a history of consumption of ground water (hand-pumped) for domestic purposes. The patient was a farmer by occupation and did not report any history of occupational exposure to arsenic contaminated aerosols/dust related to mining or industrial activities, and no such mines or industries were located near his residence. There was no history of similar complaints among others in the same locality, past intake of indigenous medicine, headache, weakness, easy fatiguability, insomnia, memory loss, tremors, vision loss, anorexia, nausea, vomiting, diarrhea, abdominal pain or mucosa pigmentation. Written informed consent for physical examination, clinical pictures and biopsy was obtained from the patient. On clinical examination there was a single well-defined, ulcero-proliferative growth of size 8 × 7 cm, with elevated margins, covered with yellowish, foul smelling discharge, tender and fixed to the underlying structures on the volar aspect of the right wrist . High resolution computed tomography (HRCT) of the chest showed hyper-inflated bilateral lung with patchy fibrotic changes and focal pleural thickening in bilateral upper lobes with bronchiectatic changes in the right middle lobe with tiny nodules in the bilateral lung fields. His electrocardiogram and electroencephalogram were normal. Histopathological examination from the papular lesions over the palms revealed hyperkeratotic, hypertrophic stratified squamous epithelium with parakeratosis, and the underlying squamous epithelium zone showed fibro-collagenous tissue with mild inflammatory lymphomononuclear cells. Biopsy from the edge of the ulcer at the right wrist showed malignant epithelial neoplasms in clusters and sheets. Individual cells were pleomorphic and medium-sized with high nucleocytoplasmic ratio, enlarged vesicular nuclei, occasional prominent nucleoli with scanty cytoplasm, and a few keratin pearls were also seen . On the basis of the above findings, diagnosis of arsenicosis with squamous cell carcinoma on the right wrist joint was made. Possibilities of warts and epidermodysplasia verruciformis were ruled out. The patient was started on oral d-penicillamine 250 mg, folic acid 5 mg and isotretinoin 20 mg with topical 10% urea cream and 6% salicylic acid cream to be applied on the keratotic lesions.His hemogram, liver and renal function tests, blood sugar and serum lipid profile were within normal limits. Metal analysis was carried out by inductively coupled plasma-optical emission spectrometry (ICP-OES) after microwave digestion of samples as described method by Ansari Figure 8).Right forearm amputation was advised by the surgeon for the carcinomatous ulcer at the wrist joint of the same side. At first this treatment was unacceptable to the patient as his dominant hand had to be amputated. His difficulty comprehending the seriousness of his diagnosis owing to illiteracy and compounded by financial constraints led to delay of his surgical amputation by six weeks after starting his oral medications. Almost six weeks later, when the patient was both mentally and financially prepared, right below elbow amputation along with right axillary lymph node dissection was performed after obtaining consent. Histopathological examination of the growth after right below elbow amputation showed well differentiated large cell keratinizing invasive squamous cell carcinoma with clear margins. The stump was found to be healthy at one month follow-up  and arsenate (As+5). Reduction and oxidative methylation occur following absorption in the body and is often excreted through urine. The mechanism of toxicity and organ involvement depends on the valence state of arsenic. Arsenite (As+3) is known to bind with keratins and get deposited in skin, hair, nails, and the gastro-intestinal system, while arsenate (As+5) is deposited in bones.Arsenic can enter the food chain through air, water, and soil. It is principally consumed as arsenite (As12 Keratosis on the soles is suggested to be the most sensitive marker for detection of arsenic toxicity at an early stage. Keratotic lesions are classified on the basis of size into mild (<2 mm), moderate (2–5 mm) and severe (>5 mm) forms. Confluent keratotic plaques can also be present.13Skin lesions are the earliest manifestations in affected patients as was the case with the patient reporting to us. Cutaneous manifestations are the most prominent characteristic finding used in identifying arsenicosis patients.20 Therefore, consumption of arsenic-contaminated ground water by our patient was considered the possible cause for lung involvement after ruling out exposure to arsenic via inhalation due to mining or industrial activities.20 According to the literature, patients with palmo-plantar hyperkeratosis and/or cutaneous cancers were more susceptible to developing respiratory disease due to chronic arsenic exposure, and similar findings were noticed in our patient.3Pulmonary involvement is known to occur with arsenic-contaminated ground water used for drinking purposes, which is further supported by the literature describing increased levels of arsenic in bronchio-alveolar lavage fluid collected from patients who developed diffuse interstitial lung disease due to consumption of arsenic-contaminated drinking water for prolonged duration.Other major health issues resulting from chronic arsenic exposure are anxiety, irritability, sleep disorders, peripheral vascular diseases causing ischemic limbs and gangrene. Although there are limited data from India, cardiovascular disorders can also occur. Anemia and diabetes mellitus have also been reported. Adverse pregnancy outcomes like spontaneous abortion, preterm birth and stillbirth have been reported from the affected regions. Data show that infants and children are more susceptible to chronic arsenic poisoning which affects their physical growth as well as mental development.325 Squamous cell carcinoma and multiple basal cell carcinoma are typical arsenic-induced skin cancers, while Bowen's disease indicates impending skin cancer.28Arsenic is a known carcinogen. Numerous studies report associations between arsenicosis and skin cancer.There are reports that arsenic exposure also leads to immune suppression by acting on T and B cells as well as on macrophages. There is reduced expression of major histocompatibility complex (MHC) class II molecules, CD69, interleukin-1 beta (IL-1β) and tumor necrosis factor-alpha (TNF-α); decreased lymphocyte proliferation, migration and IL-2 secretion; impaired macrophage adhesion, phagocytosis and increased apoptosis of PBMC , and decreased stimulated reactive oxygen species (ROS) production by PBMC. By affecting both cellular and humoral immunity, arsenic exposure leads to an immune-compromised state and finally malignancy along with other effects.2933 As there are no proper treatment protocols for prescribing d-penicillamine in acute as well as chronic arsenic poisoning, our patient, who was found to have raised arsenic blood levels, was given d-penicillamine for two weeks without monitoring blood and urine arsenic levels during and after chelating therapy because of the social factors outlined earlier.33 Although there are mixed responses to d-penicillamine when used for chronic arsenic poisoning, it is preferred over other chelators like dimercaprol because of its ease of administration and better availability.31 Several studies have shown beneficial effects of oral retinoids in treatment of chronic arsenic poisoning induced palmo-plantar hyperkeratosis, considering their anti-keratinizing role in several keratinization disorders.35 Another advantage of using oral retinoids is that they can be used as a chemopreventive medication for arsenic-related cancers, by altering gene expression.35 Among oral retinoids, acitretin has generally been used for arsenic keratosis but due to easy availability, lower cost and better side effects profile, we preferred isotretinoin.35 Hence, along with d-penicillamine we used oral isotretinoin in our patient. Both of these drugs have shown good outcomes in a few individual cases, but in the present case, it did not have much clinical response and considering the patient's financial limitations, both medications were stopped after their respective duration of therapy. We counseled the patient on nutrition improvements and use of alternative water sources in order to avoid further damage to his health. We invited nearby residents to visit us for free health check-ups to check for further arsenic-related manifestations. Simultaneously, we worked to raise awareness regarding the health risks of ground water contaminated with heavy metals which was prevalent in their area. Finally, a neighbor in a better financial position agreed to provide reverse osmosis treated water free of cost to our patient for drinking purposes.36Chronic arsenic ingestion leads to its accumulation in several organs including the lungs and skin, for which chelation therapy is recommended based on a few individual cases and clinical expert opinion in order to reduce the arsenic burden from these organs and decrease the level of arsenic in blood by excreting it out through urine.37 Good nutrition has also been reported to be effective in combating the adverse effects of chronic arsenic exposure.3Cases of chronic arsenic poisoning continue to rise in India despite multiple programs by governmental and non-government organizations to mitigate the adverse health effects of arsenic.After recovering from surgery and adopting an alternative source of water for drinking purposes, our patient's health improved. After recovery, the patient and his wife returned to their employment in the fields. The patient improved his diet after receiving nutrition counseling. Through all of these efforts, the hazardous health-related effects of arsenic toxicity resulting in interstitial lung disease and carcinoma as observed in our patient can be minimized in an exposed population.


Implemented through five health plans, Ohio’s MyCare demonstration began in 2014 and was designed to coordinate primary, acute care, behavioral health and long-term services in the major urban areas of the state. Individuals who are dually eligible for both Medicaid and Medicare and who reside in specified geographic regions must enroll into a managed MyCare plan. MyCare beneficiaries are assigned to two primary categories: community well and those needing long-term services and supports (LTSS). Individuals receiving the integrated MyCare intervention were expected to have lower acute care hospitalizations, lower long-term nursing home use, better longevity and lower overall health and long-term care costs. Using a propensity score matching design, the evaluation compared MyCare enrollees to comparison group members in non-MyCare counties of the state, using Medicaid and Medicare claims data. The 120,000 MyCare program participants represented about half of the dual eligible individuals in the state.


Congenital sucrase isomaltase deficiency (CSID) is an autosomal recessive disorder which leads to chronic intestinal malabsorption of nutrients from ingested starch and sucrose. Symptoms usually present after consumption of fruits, juices, grains, and starches, leading to failure to thrive and malnutrition. Diagnosis is suspected on detailed patient history and confirmed by a disaccharidase assay using small intestinal biopsies or sucrose hydrogen breath test. Treatment of CSID consists of limiting sucrose in diet and replacement therapy with sacrosidase. Due to its nonspecific symptoms, CSID may be undiagnosed in many patients for several years. We present a case of a 50-year-old woman with persistent symptoms of bloating in spite of extensive evaluation and treatment. Congenital sucrase isomaltase deficiency (CSID), also known as genetic sucrase deficiency, is a multifaceted intestinal malabsorption disorder with an autosomal recessive mutation in the sucrase-isomaltase (SI) gene on chromosome 3 3q25-q26). Sucrase-isomaltase is a type II membrane enzyme complex and member of the disaccharidase family required for the breakdown of α-glycosidic linkages in sucrose and maltose. When this enzyme complex is deficient, nutrients from ingested starch and sucrose cannot be absorbed sufficiently. Infants and young children generally develop symptoms such as explosive watery diarrhea, abdominal distension, colic, and dehydration after consumption of fruits, juices, grains, modified milk formulas, and starches. These dietary symptoms reduce an individual's absorption of essential dietary nutrients and cause malnutrition. In infants and children, this commonly manifests as failure to gain appropriate weight and height and presents as low body weight in adults. However, starch intolerance often disappears during childhood, and symptoms of sucrose intolerance usually improve as the affected child ages . A confi5-q26. SuA 50-year-old Caucasian female with past medical history of hypothyroidism was referred to the GI clinic for complaints of gradually worsening symptoms of intermittent bloating, non-bloody diarrhea (3-4 times a week), flatulence and burping for the last six months. The patient was unable to provide a clear relationship of her symptoms to any specific type of food and denied any symptoms when she is sleeping. She denied any overt bleeding, unintentional weight loss, and significant family history of gastrointestinal malignancies, celiac disease or inflammatory bowel disease. In addition to levothyroxine, the patient was occasionally using ibuprofen (3-4 times a week) for knee pain. She tried over-the-counter omeprazole for two months without any relief of symptoms. Patient’s physical examination was completely unremarkable. Her laboratory tests including thyroid function tests, C-reactive protein, IgA TTG, total IgA level and stool studies were unremarkable. Stool studies included fecal calprotectin, bacterial and viral cultures, C-diff PCR, and ova and parasites. She was advised to discontinue ibuprofen use. An upper endoscopy was performed which came back normal Figure .Duodenal biopsies came back with no evidence of celiac disease. Random gastric biopsies came back negative for H. pylori. Her colonoscopy with random colon biopsies was also negative for any evidence of microscopic colitis and inflammatory bowel disease (IBD). Subsequently, a glucose hydrogen breath test was positive for small intestinal bacterial overgrowth (SIBO). She was treated with Rifaximin 550mg TID x 14 days twice with only partial relief of symptoms. Due to persistent symptoms, she underwent repeat upper endoscopy with planned duodenal aspirates to evaluate and direct treatment of SIBO and small intestinal fungal overgrowth (SIFO) via culture and sensitivity as well as small bowel biopsies to evaluate disaccharidase deficiency assay Figure . DuodenaHer duodenal aspirate cultures were negative for SIBO and SIFO. However, her disaccharidase assay results were consistent with sucrase-isomaltase deficiency with sucrase, palatinase, and maltase values markedly low Table .The patient was then referred to a dietician and started on sacrosidase enzyme supplement with complete resolution of symptoms.The first reported case of CSID in 1960 was discovered in children with nonspecific gastrointestinal symptoms of osmotic diarrhea, steatorrhea, and vomiting after consumption of sucrose. In an effort to prevent these symptoms, adequate nutrition from sucrose-containing foods was not received, resulting in failure to thrive, and dehydration . CSID isSucrase-isomaltase (SI) is an enzyme found in the microvilli brush border of the small intestine and assists in the breakdown of disaccharidases like sucrose and products of starch digestion such as dextrins. Normally in a cell, SI is folded, N- and O-glycosylated in the medial Golgi and follows the secretory pathway to be placed on the apical cell surfaces of the brush border . Along tWhile primary, congenital SI deficiency is inherited, acquired forms of SI deficiency may be secondary to other chronic gastrointestinal conditions associated with intestinal villous atrophy, such as enteric H. pylori infection, celiac disease, Crohn’s disease, and other enteropathies affecting the small intestine , 16. To The similarity of symptom manifestations between chronic GI disorders and SI deficiency adds to the diagnostic dilemma that clinicians face. Since CSID is believed to be rare, and symptoms of starch intolerance generally resolve in childhood, a high index of suspicion is required to even consider the diagnosis, the prevalence of CSID maybe higher, under recognized and undertreated in the adult population , 18.There are many diagnostic tools that may be used to diagnose CSID. Regarded as gold standard for diagnosis, the disaccharidase assay is an invasive test that utilizes small bowel biopsy to determine functional enzyme activity levels. The assay shows the levels of various enzymes such as sucrase-isomaltase (SI), lactase, and maltase. Results are consistent with CSID if the amount of sucrose broken down by SI is lower than expected . The invThe only effective and FDA-approved drug treatment option for CSID is enzyme replacement therapy with sacrosidase . The druWe present the case of a woman with complaints of chronic persistent bloating, diarrhea, flatulence, and burping despite undergoing an extensive GI diagnostic evaluation including esophagogastroduodenoscopy (EGD), colonoscopy with mucosal biopsies, treatment of SIBO with partial relief of symptoms before being diagnosed with CSID through a positive disaccharidase assay. This case highlights the presence of CSID in an adult with symptoms like those of a chronic GI disease. Given the overlapping presentations of CSID and IBS, it is important for physicians to consider screening for certain gastrointestinal complaints using non-invasive and invasive tools such as breath tests and biopsy with disaccharidase assay, respectively, to diagnose SI deficiency. Specific management approaches for SI deficiency differs significantly from other chronic conditions given the availability of sacrosidase, which currently is the only FDA-proven enzyme-replacement therapy for symptom relief. The possibility of underestimating the prevalence of CSID in the adult population especially with chronic persistent non-specific GI symptoms should be further investigated.


Non-muscular invasive bladder cancer (NMIBC) is one of the most common cancer and major cause of economical and health burden in developed countries. Progression of NMIBC has been characterized as low-grade (Ta) and high grade (carcinoma in situ and T1). The current surgical intervention for NMIBC includes transurethral resection of bladder tumor; however, its recurrence still remains a challenge. The BCG-based immunotherapy is much effective against low-grade NMIBC. BCG increases the influx of T cells at bladder cancer site and inhibits proliferation of bladder cancer cells. The chemotherapy is another traditional approach to address NMIBC by supplementing BCG. Notwithstanding, these current therapeutic measures possess limited efficacy in controlling NMIBC, and do not provide comprehensive long-term relief. Hence, biomaterials and scaffolds seem an effective medium to deliver therapeutic agents for restructuring bladder post-treatment. The regenerative therapies such as stem cells and PRP have also been explored for possible solution to NMIBC. Based on above-mentioned approaches, we have comprehensively analyzed therapeutic journey from traditional to regenerative interventions for the treatment of NMIBC. According to analysis of National registry data from U.S Surveillance Epidemiology and End result (SEER) program data in 2012 suggested that from 1992 to2002, approximately 4790 patients were diagnosed with a high grade NMIBC, of which only one received recommended treatment . T. T151]. t cancer . Taken tNMIBC is still a major health challenge due to its progression and recurrence and the surgical facilities and expertise for TURBT limits its large-scale accessibility to address the clinical demands. Though the intravesical immuno- and chemotherapies are used as adjuvant or salvage to inhibit recurrence and progression of NMIBC, the full recovery remain inadequate. Recent progresses in regenerative therapies including stem cells and PRP also indicate the possible therapeutic opportunities due to ease of access, less complexity and long-term protection; however, further extensive studies and clinical trials are required to optimize the procedure, doses, clinical safety and efficacy for these alternatives. Notwithstanding, based on the positive outcomes of autologous regenerative alternatives, it appears that combined surgical and stem cells/PRP-based approaches might offer enhanced therapeutic efficacy.


Sleep is a critical biological process, essential for cognitive well-being. Neuroscientific literature suggests there are mechanistic relations between sleep disruption and memory deficits, and that varying concentrations of cortisol may play an important role in mediating those relations. Patients with Addison’s disease (AD) experience consistent and predictable periods of sub- and supra-physiological cortisol concentrations due to lifelong glucocorticoid replacement therapy, and they frequently report disrupted sleep and impaired memory. These disruptions and impairments may be related to the failure of replacement regimens to restore a normal circadian rhythm of cortisol secretion. Available data provides support for existing theoretical frameworks which postulate that in AD and other neuroendocrine, neurological, or psychiatric disorders, disrupted sleep is an important biological mechanism that underlies, at least partially, the memory impairments that patients frequently report experiencing. Given the literature linking sleep disruption and cognitive impairment in AD, future initiatives should aim to improve patients’ cognitive performance  by prioritizing and optimizing sleep. This review summarizes the literature on sleep and cognition in AD, and the role that cortisol concentrations play in the relationship between the two. Sleep is a critical biological process, an inevitable and essential aspect of normal human physiology. Nonetheless, questions about the functions of sleep  remained unanswered until relatively recently. Available neuroscience literature provides some of the sought-after answers, suggesting that healthy, uninterrupted sleep is vital to ensuring that, for instance, consolidation of memory traces acquired during waking hours occurs smoothly and efficiently. Of particular interest here is that cortisol appears to play a particularly important role in mediating the sleep-memory relationship, especially because of its function in maintaining the integrity of sleep architecture , 2.Patients with Addison’s disease (AD) require lifelong glucocorticoid replacement therapy. However, replacement medication does not restore the natural circadian rhythm of cortisol and, despite adherence, patients experience sub/supra physiological cortisol concentrations, particularly during the night. Patients with AD report and experience both poor-quality sleep and cognitive difficulties –8. One pThis review aims to summarize and integrate the literature on the relationships between cortisol concentrations, sleep disruption, and cognitive functioning in patients with AD. This review is needed because despite expanding scientific evidence suggesting that sleep is a critical biological process and its functional value extends well beyond simple physical and mental restoration, very few published studies have investigated whether disrupted sleep is a possible mechanism that underlies the memory deficits experienced by patients with AD.Human sleep is a natural state of reduced responsiveness accompanied by a partial loss of consciousness. Sleep is regulated by three different processes: the homeostatic process, which determines its need, the circadian process that influences its timing, and the ultradian process that determines its organization , 10.Sleep is cyclical in nature, alternating between 4 and 6 repeated cycles of rapid eye movement (REM) and non-rapid eye movement (NREM) sleep, with each cycle lasting approximately 90–120 120 minutes –13. HumaThe release of nearly all hormones follows daily oscillations, which result from an interaction between 24-hour circadian rhythmicity and the sleep-wake cycle , 14–16. In healthy people, cortisol has a robust diurnal secretory pattern. The highest concentrations occur in the early hours of the morning, with a peak just after waking. Concentrations then decrease slowly throughout the day, with troughs in the mid-afternoon and at midnight; the daily nadir typically happens several hours after initiation of nocturnal sleep. Concentrations then begin to rise from 02h00 to 03h00 and continue to rise until awakening. The nocturnal rise in cortisol is thought be in response to the greater energy demands of the brain as the night ends –26. The The HPA axis plays an important role in maintaining alertness and modulating sleep Regarding sleep deprivation, several studies report that elevated cortisol concentrations are present during both the sleep deprivation period and the subsequent day and evening , 62–66. However, sleep disruptions do more than just impact the circadian rhythm of HPA-axis hormones. Disrupted sleep has detrimental effects on health, quality of life, mood and cognition, which is not surprising given the central role of sleep in physiological restorative processes, emotion regulation and memory consolidation , 24, 67.memory consolidation involves strengthening of memory traces, which represent information of our experiences, and the parallel integration of these experiences with previously acquired knowledge (The ability to effectively remember relies upon three broad cognitive processes: encoding (the transformation of new information into a form that can be stored in memory), consolidation (the stabilization of new memories in the brain), and retrieval , 69. Onenowledge .Whereas encoding of environmental events  and retrieval of those memories  takes place during waking hours, the process of memory consolidation is incompatible with waking consciousness . Hence, Evidence for sleep-dependent memory consolidation is provided by numerous studies indicating that sleep enhances retention of information learned during waking hours, and that a sleep-filled delay enhances performance on a variety of declarative and non-declarative memory tasks , 80–89. Adequate concentrations of cortisol are essential for optimal cognitive functioning –97. The Studies have consistently demonstrated that chronically elevated glucocorticoids impair hippocampal-dependent memory –1341. ThAlthough hippocampal-dependent forms of memory are impaired by increased cortisol concentrations, non-hippocampal forms of memory , appear unaffected e.g., , 164. FoRegarding the PFC’s involvement in memory processing, this brain structure plays an important role in the encoding and retrieval of declarative memories . SpecifiChronically elevated cortisol concentrations lead to dendritic atrophy in the PFC , and steGlucocorticoids affect the human brain by their interaction with two intracellular receptors . GlucocoMRs are found predominantly in the hippocampus, whereas GRs are distributed throughout the brain. Both play important roles in cognitive function, however , 177. MRelevated cortisol levels on cognitive functioning. The negative effects of supra-physiological cortisol levels on brain structure and cognitive functioning is well known and evident in both healthy individuals and in patients known to experience chronically elevated cortisol levels [e.g., Cushing’s syndrome, depression, Alzheimer’s disease; , found that a 10mg/m2 daily dose of CSHI normalized cortisol and ACTH levels in the morning, and patients 24-hour cortisol curves approached normal circadian variation compared with conventional oral replacement. The 24-hour area under the curve (AUC) did not differ between infusion and conventional oral therapy, but daytime AUC (8am-midnight) was higher for oral replacement therapy, and night-time AUC (midnight-8am) was higher for CSHI. Infusion improved vitality and physical functioning (N = 10 patients with AD) assessed whether CSHI improved QoL and fatigue, compared to standard GC therapy  self-reported abnormal fatigue; 61% reported severe fatigue. Researchers postulate that reports of increased daytime fatigue may be due to reduced quality of sleep in patients with AD and that relatively increased doses of HC may contribute to these sleep disruptions  experience less time in SWS, shortened REM latency, increased REM sleep and density, and sleep discontinuity , 241–244Because of the central role the HPA axis plays in sleep regulation , 35, eitDespite replacement therapy, patients with AD frequently present with both subjective cognitive complaints and objective cognitive impairments, including poor memory and impaired concentration , 221. DuKlement et al.  reportedImpaired declarative memory performance likely emerges from two main sources. First, indirectly, disrupted cortisol secretion patterns impact circadian rhythms and lead to sleep disturbances. Second, directly, due to supra-physiological cortisol levels experienced by patients taking short-acting hydrocortisone . Supra-pAnother neurobiological mechanism that may explain the memory deficits observed in patients with AD is the differential activation of the two types of receptors discussed earlier, MRs and GRs. Cortisol’s effects on the hippocampus and PFC are mediated by the interaction of glucocorticoids with MRs and GRs . ActivatPrevious studies have shown that, in healthy adults across the lifespan, elevated cortisol levels impair cognitive functioning in ways that are predictable and that can be explained neurobiologically , 252. InThe orderly night-time sequence and transition between SWS and REM sleep provides optimal conditions for memory consolidation . Consoliversus controls) or between-condition (Sleep versus Wake) were found on a test of procedural memory. These results may have emerged because declarative memory tasks are hippocampal-dependent, whereas procedural tasks are not. Since hydrocortisone affects hippocampal integrity but not areas typically associated with response-based sequence learning , it is possible that procedural memory performance of patients with AD is unimpaired. No prior study had investigated procedural memory in patients with AD, and hence this suggestion that procedural memory is not impaired in patients with AD is a novel finding.Henry and colleagues  obtainedWhile it is well established that sleep plays a crucial role in various aspects of health, and cognition, sleep also plays an important role in the processing and regulation of emotion , 79, 271Previously published studies in patients with AD have consistently shown that, despite being on replacement therapy, these individuals still report and experience depression and anxiety, as well as reduced stress tolerance and reduced ability to cope with daily demands , 281. ReGenerally depressed patients self-report difficulty falling and staying asleep, and early morning awakenings; , and expIn addition to the wealth of knowledge linking sleep and affect regulation, numerous studies illustrate that affect and cognition are interrelated , 284, anIn this article, we have summarised the current knowledge on sleep, cognition, and the association between the two in patients with AD. Numerous studies indicate that (i) healthy sleep benefits memory consolidation, (ii) alterations in cortisol activity has negative effects on sleep architecture, and (iii) sleep disruptions  might impede the beneficial effects of sleep on memory consolidation. Sub- and supra-physiological cortisol concentrations resulting from immediate release hydrocortisone replacement therapy can have negative effects on sleep architecture and sleep-dependent memory consolidation processes. Therefore, disrupted circadian rhythms are suspected to be a major cause of sleep disturbances and cognitive impairment in patients with AD. It is well established that cortisol plays a key role in maintaining the integrity of sleep architecture and that sleep plays an important role in cognitive functioning, emphasizing the interrelationship between sleep, cognition and intact cortisol secretion.The literature suggests that patients with AD experience disruptions to cognition, primarily in the domain of declarative memory , but also extending to executive functioning . Procedural memory does not appear to be impaired in these patients . They also experience a reduced quality of sleep and altered sleep architecture. Hydrocortisone immediate release may lead to disrupted sleep patterns which impair optimal consolidation of learned information. Moreover, general fatigue may contribute to the presence of cognitive deficits in patients with AD. Furthermore, prolonged replacement therapy may have deleterious effects on brain regions required for optimal cognitive functioning . However, studies using brain scans are needed to confirm this hypothesis.Although prior research suggests that both cognitive and sleep complaints are frequently reported by patients with AD, only a few have used objective measures to assess either sleep patterns or memory impairments experienced by patients. Patients with AD encounter sub- and supra-physiological cortisol concentrations due to imperfect replacement therapy, ultimately altering sleep architecture and impairing cognition. It is conceivable that through modifying the pharmacokinetics of replacement therapy that these modalities in patients with AD may be improved. From a broader neuroscientific perspective, patients with AD provide a unique opportunity to simultaneously study the effects of hyper- and hypo-cortisolism on sleep quality, memory performance, and sleep-dependent memory consolidation. Careful study of these patients can help unravel the distinct roles that sub- and supra-physiological GC concentrations play in sleep regulation/structure and in sleep-dependent memory consolidation.Although current replacement therapy aims to mimic the natural circadian rhythm of cortisol, periods of sub- and supra-physiological cortisol concentration are experienced. Both low and high cortisol concentrations can negatively impact cognition and sleep. More research is needed on the effects of dosage, duration and type of GC therapy used in patients with AD and how these impact cortisol concentrations, sleep and cognition.Food and caffeine intake, smoking, intense exercise, and encountering stressful situations may all influence cortisol concentrations, sleep, and cognitive performance . StudiesMore studies are needed to characterize the relationship between sleep and memory, using objective measures to examine the hypothesis that poor sleep is a biological mechanism underlying memory impairment in patients with AD. More polysomnographic studies are needed to comprehensively investigate sleep architecture in patients with AD. Such studies may help explain for instance, memory consolidation in not enhanced by sleep in patients as in healthy controls. Intervention studies and clinical trials might seek to confirm this association and investigate whether the same pattern of sleep and memory deficits are present in patients, using modified-release or dual-release hydrocortisone. If it is confirmed that disrupted sleep is a vital mechanism underlying the impaired consolidation of previously learnt information, clinicians should prioritize treatment of disrupted sleep in patients with AD.Review written by MH and IR and edited by KT. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Precision nutrition aims to translate individual molecular signatures into applicable personalized dietary and nutritional recommendations and ultimately a personalized dietary plan. Some endeavors have been made to customize macronutrient intake for individual predispositions, through the implementation of different dietary regimes, such as the Mediterranean diet with optimized fat intake , or a keSLC5A5 (rs775249401) gene locus might modulate transportation of iodine into breast milk, with A-allele carrier mothers being more efficient with iodine transportation to breast milk when exposed to inadequate iodine intake . The results have been demonstrated in women of African descent and warrant more research in the race- and ethnic-specific context. On the other hand, a genome-wide association study across 7 million single nucleotide polymorphisms in Asian populations of Malay, Indian, and Chinese women, revealed that genetic variation (rs4588) in GC gene encoding for vitamin D binding protein was associated with low vitamin D status in mothers and cord blood, while the variation in CYP2J2 (rs10789082) was associated with low vitamin D in the antenatal analysis only . Precision nutrition tailored strategies based on adequate vitamin D supplementation during pre- and peri-conception periods could largely improve vitamin D deficiencies in both women and babies, potentially associated with immunological benefits and musculoskeletal health.Early development largely depends on maternal nutritional competence, which primarily relies on intake but could also be modulated by endogenous factors such as the genetic background of a mother and even the developing fetus, both factors influencing the adequate nutritional supply of an offspring. The first 1,000 days concept requires appropriate delivery of essential nutrients, otherwise, a set of metabolic derangements may occur in malnourished children . In addiMilošević et al.On the other side of the lifespan continuum, adequate supplementation of bioactives such as polyphenols and microelements from fruits and medicinal plants might improve healthy aging and prevent neurodegenerative disease through a panel of nutri(epi)genetic mechanisms, as well as gut microbiota-brain axis, as reviewed in Milutinović et al.).A body of research has recently been directed toward gut microbiota different organ axes, with gut microbiota eubiosis playing an essential role in immunological balance and prevention of a leaky gut through sustained intestinal integrity and low permeability. Fine modulation of gut microbiota profiles remains an outstanding goal for future personalized strategies, and a recent paper has shown that polyphenols from medicinal plants might have growth-stimulating effects on probiotic bacterial and yeast strains (DHCR7/NADSYN rs12785878 and CYP2R1 rs10741657 variants) were linked with severe COVID-19 disease , implicating the potential of vitamin D-based precision supplementation strategies in boosting immunological response toward more efficient COVID-19 prevention and suppression.The importance of microelements in immunological response has also been demonstrated in the burning topic of COVID-19 disease, with unprecedented effects on public health globally. In adult Serbian subjects, but not in a pediatric population, variations in genes involved in vitamin D metabolism . In this study, biomarkers of iron status, such as ferritin and transferrin, were shown to be linked with fibrinogen, fibrin formation, and fibrinogen lysis, implicating a role of circulating iron in hemostasis.Precision nutrition supplementation strategies of iron might also depend on the genetic variation coding for fibrinogen and FXIII molecules, as indicated in the recent epidemiological cohort of black African descent . The necessity of zinc supplementation has also been established in reportedly zinc-deficient hemodialysis patients, who also presented with an inadequate long-chain omega-3 fatty acid intake , indicating potential interaction between fatty acid and micronutrient metabolism. Furthermore, the interaction between dietary bioactives i.e., polyphenols from Aronia berry and polyunsaturated fatty acid metabolism, has also been reported in dyslipidemic women, with those consuming polyphenol-rich berry juice having a lower inflammatory arachidonic acid/eicosapentaenoic acid ratio . The same study demonstrated that habitual polyphenol intake also induced decreases in Long Interspersed Nucleotide Element-1 methylation levels in peripheral blood leukocytes, which was dependent on MTHFR variant allele (C677T), indicating nutri(epi)genetic forces elicited by polyphenol consumption. Aside from microelements and bioactives, fatty acid profiles are influenced by the quality of a diet. In obese subjects, FADS2 rs174583 variant, involved in dietary fatty acid conversion, interacted with the level of adherence to either Dietary Approach to Stop Hypertension or Mediterranean diet, finally affecting triglyceride concentration/diastolic blood pressure in women/men and glucose serum levels, respectively .Zinc is involved in the inflammatory response and disturbed zinc homeostasis is an early feature of cardiovascular disease. Zinc status is essential for optimal cellular and tissue proliferation, hormonal and immunological balance, and randomized controlled zinc interventions to alleviate cardiovascular disease, as well as nutrigenetic implications of zinc transporter proteins and metallothionein, are much needed .Finally, precision nutrition strategies are of special importance in populations with specific nutritional and dietary needs, which was demonstrated in a recent study in underground coal miners, where unexpected direct correlations between serum vitamin D levels and anthropometric and biochemical indicators were demonstrated, the latter commonly indicative of obesity, metabolic syndrome, and fatty liver disease (In order to implement precision nutrition postulates in practice, further race-, ethnicity-, and population-specific randomized controlled studies are needed to validate responsiveness to a particular nutrient and dietary intervention depending on the holistic interpretation of individual genetic and molecular biomarker profiles. Further research should put additional attention on population groups with specific nutritional and dietary needs, such as occupational groups and athletes.MMZ wrote the manuscript and IK, LZ, and CMS reviewed the manuscript. All authors approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The approach to reperfusion therapies in stroke patients is rapidly evolving, but there is still no explanation why a substantial proportion of patients have a poor clinical prognosis despite successful flow restoration. This issue of futile recanalization is explained here by three clinical cases, which, despite complete recanalization, have very different outcomes. Preclinical research is particularly suited to characterize the highly dynamic changes in acute ischemic stroke and identify potential treatment targets useful for clinical translation. This review surveys the efforts taken so far to achieve mouse models capable of investigating the neurovascular underpinnings of futile recanalization. We highlight the translational potential of targeting tissue reperfusion in fully recanalized mouse models and of investigating the underlying pathophysiological mechanisms from subcellular to tissue scale. We suggest that stroke preclinical research should increasingly drive forward a continuous and circular dialogue with clinical research. When the preclinical and the clinical stroke research are consistent, translational success will follow. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are established treatments proven to reduce disability after acute ischemic stroke by salvaging the brain. Even in the case of complete vessel recanalization, some patients remain functional dependent, which is thus called “futile recanalization” (FR) ,2,3. MorHT encompasses a broad spectrum of severity grades ranging from small areas of petechial hemorrhage to massive space-occupying hematomas. From the clinical point of view, HT has been divided into symptomatic and asymptomatic, a distinction that is important while evaluating the overall risk-to-benefit ratio of revascularization treatments.CE is a severe complication of acute ischemic stroke and is the cause of death in 5% of all patients with cerebral infarction ,5. EdemaA critical role in the molecular mechanisms determining HT and CE is the disruption of the neurovascular unit (NVU), a dynamic terminal structure configuring an elaborate vascular network. The NVU is composed of an arteriole and its endothelial cells, basal lamina matrix, astrocyte end-feet, pericytes, astrocytes, neurons and their axons, and supporting cells (microglia and oligodendroglia) ,11, and During the ischemic insult, NVU participates in the reperfusion battleground occurring between the ischemic core and the surrounding salvageable tissue. Endothelial basal lamina dissolution starts as soon as 2 h after the onset of ischemia and is rapidly followed by an increase in Blood–Brain Barrier (BBB) permeability . The earAge, stroke severity ,18, and Notably, the problem of selection for reperfusion therapies also persists after the introduction of multiparametric imaging techniques, such as multimodal Computed Tomography (CT) protocol and magnetic resonance (MR) imaging. These widely used techniques include: 1—non-contrast CT (NCCT) to detect intracerebral hemorrhage and early ischemic changes, quantified by a semiquantitative method known as ASPECTS (Alberta Stroke Program Early CT Score); 2—CT Angiography (CTA) to identify the occlusion site and to assess collateral circulation with a single-phase (sCTA) or, better, multiphase (mCTA) techniques; 3—CT perfusion (CTP) to define the size of infarct core and ischemic penumbra and consequently their mismatch using its capability to discriminate the different functional components of the ischemic area ,22,23,24To better explain the aim of this review, we present three real-world LVO stroke patients with similar risk profiles and fully reperfused by combined IVT and MT, as paradigmatic examples capable of stimulating stroke clinician’s specific questions to preclinical research. All patients’ data and imaging were obtained under informed consent.Case 1: A 73-year-old man with a history of hypertension, dyslipidemia, and prior myocardial infarction presented to the emergency department after the sudden onset of right-sided weakness and difficulty speaking. NCCT showed early ischemic changes in the left insular territory with an ASPECT score of 9 A. The mCCase 2: A 71-year-old woman presented to a local emergency department 1 h after the sudden onset of speech difficulties and hemiparesis involving the right face, arm, and leg. She had a history of poorly controlled cardiovascular risk factors. NCCT showed a left MCA hyperdense sign E. The mCCase 3: A 70-year-old man had a sudden onset of left hemiplegia and forced eye deviation to the right. His medical comorbidities included hypertension, dyslipidemia, type 2 diabetes mellitus, and coronary artery disease. On neurological examination, he was awake, unable to communicate or follow commands. He had forced right gaze deviation, left hemianopsia, moderate left arm and leg weakness. NCCT identified hyperdense right MCA sign. The ASPECT score was 10 I. The mCThe three cases presented here show rather different clinical–functional outcomes despite similar neurological severity, neuroimaging at onset, and recanalization degree. Different treatment delays and clinical parameters might only partially account for differences in outcomes. The potential causes underlying this phenomenon are probably multifactorial but poorly understood. Ischemic changes at the tissue level appear to play a critical role and include reperfusion injury and ischemia-related microcirculatory dysfunction. It is of paramount importance to understand in depth what is there inside the hypoperfused tissue in order to find new predictors of clinical deterioration/FR and, consequently, specific prevention strategies.In the past few decades, the development of animal stroke models helped dissect the mechanism of neurovascular disruption as the main factor in determining the clinical outcome.Interestingly, rodent stroke models and study designs revealed numerous potential targets for novel stroke therapies; yet subsequent clinical stroke trials failed to confirm promising preclinical findings. In the past, the National Institute of Neurological Disorders and Stroke (NINDS) tried to address these gaps, searching for new “vision and opportunities” in translational stroke research . In line(1)Are there experimental animal models capable of reproducing human LVO stroke and subsequent recanalization? Are there animal models for age, sex, and comorbid human conditions?(2)Can animal stroke models assess early endpoints, such as hemorrhagic transformation or cerebral edema?(3)Which mechanistic insight could be given by preclinical research to explain the different evolution of hypoperfused tissue?With reference to the clinical cases presented, we aim to investigate to what extent preclinical research can answer the following questions:.In order to answer these questions, we have reviewed (A) the main preclinical models of stroke, highlighting both the similarities with human LVO stroke and subsequent recanalization, and possible limitations on the use of animal models; (B) how preclinical research assesses the most frequent clinical complication ; (C) how novel optical imaging techniques can provide high resolution structural and functional investigations thus help explain reperfusion consequencesExperimental stroke models are widely used to investigate the events associated with both the cellular response within the ischemic or healthy cortical area and the mechanisms of recovery in the peri-infarct regions. In particular, animal models of focal cerebral ischemia allow identifying the critical cerebral blood flow thresholds responsible for cell death, electrical failure, inhibition of protein synthesis, energy depletion, and thereby the lifespan of the potentially salvageable penumbra .Very common rodent models of ischemic stroke include the middle cerebral artery occlusion (MCAO), endothelin, and photothrombosis. Each of those partially recapitulates substantial features of human LVO stroke and recanalization, as described below.The intraluminal suture of the middle cerebral artery MCA,  developeThough this model highly reproduces the reperfusion by endovascular thrombectomy, it has several drawbacks, such as low reproducibility due to the variability of the infarct volume depending on the size of the sutures. Another drawback of this model is that considering the nature of blood flow interruption, it is not suitable to mimic thromboembolism .The endothelin-1 model of focal stroke  is basedIn the photothrombotic model , a photoThough many efforts have been made to develop animal stroke models resembling human ischemia , biologiFinally, several complications can occur after the surgery requiring careful and more frequent post-surgery monitoring  and incrNevertheless, preclinical research makes great efforts to develop animal models that better resemble the multifaceted scenario of stroke patients by exploiting aging animals ,75,76, gAfter cerebral vascular occlusion, many events occur as a direct consequence of the blood flow reduction, such as energy failure, excitotoxicity, increase in intracellular calcium levels, and generation of free radicals. Taken together, all these are potential causes of BBB disruption, which leads to vasogenic CE, inflammation, and possibly HT after stroke . While iNevertheless, many Ex Vivo and In Vivo experimental methods have been proposed for assessing the disruption of the BBB in animal models ,83. MoreIn many studies, hemorrhage assessment is performed through ex vivo evaluation exploiting staining that differentiates between metabolically active and inactive tissue  or the dTo overcome this significant limitation, different imaging techniques are applied to perform in vivo evaluations of post-stroke hemorrhage and edema with different resolutions and scales. Among all, MRI technology represents a methodological link between clinical and preclinical research. The main advantage of high-resolution preclinical MRI is that it provides a direct display of morphological changes in cerebral architecture linked to HT and CE with high precision and non-invasiveness in the entire brain. Xiong and collaborators investigate cortical inflammatory edema in a rat model of stroke , exploitAssessing the extension and progression of the CE and HT may not be sufficient to understand the reasons for the discrepancies in the clinical cases reported above. As described before, the entire NVU is involved in the degradation process triggered by cerebral ischemia. In turn, this cascade of events affects brain organization at all levels, from single synapses to neuronal networks to whole-brain activity. More in-depth understanding of the ischemic progression that leads to neuronal survival or massive degeneration in the penumbral tissue with cellular and subcellular detail is necessary. Preclinical research, though it is still not always able to reproduce the complexity and the variety of human clinical cases, presents the great advantage of dissecting neuronal structure and function over multi-scale. In the last decades, the development of 2PFM , coupledIn line with these preclinical studies, a similar system-level measure of functional connectivity in humans through fMRI observed a consistent decrease in brain modularity indicating a reduction in integration within functional areas and segregation between brain systems during a subacute phase after store .The limited knowledge on the molecular, cellular, and network level that can be offered by common clinical practice hinders the understanding of the mechanism underlying a specific clinical outcome. Within this review, we discussed the potentials and limits of preclinical research to answer clinical questions raised by the reported exemplary cases. Among others, the two major questions that this review tried to address were: (1) why does MT not improve stroke outcome in all patients, despite full recanalization? (2) how can stroke reperfusion treatments be further improved? Preclinical researchers are thrilled to bring their contribution to stroke care in a way that works alongside stroke clinicians and helps get the right patient to the right treatment (precision medicine), but there is still plenty of work to be done.Stroke is most prevalent in elderly men and women, whereas preclinical models mostly test young animals.Stroke is more devastating in patients with multiple comorbidities not often captured by preclinical models.The last two decades have witnessed a remarkable increase in the number, breadth, and depth of preclinical research studies on acute ischemic stroke , but mosHowever, exploratory research aimed at investigating potential new therapeutic targets or theoretical understanding of pathophysiological mechanisms does not necessarily need to perform experiments on an extensive range of age and comorbid models. Furthermore, since the incidence of stroke in young adults has increased in the last decades ,113, preUnlike clinics, where HT and CE are used to define the prognosis of stroke patients, preclinical studies usually characterize the severity of the insult with behavioral tests in vivo or through the evaluation of the lesion volume ex-vivo. Nevertheless, since cerebral hemorrhage and edema are the most frequent clinical complication in the acute phase after an ischemic stroke, we illustrated that preclinical research had developed a multifaceted array of techniques to investigate these pathological processes. Another emerging topic that is catching the attention of preclinical research is the understanding of the role of cortical depolarization waves in the acute phase after stroke. Many studies ,117,118,To this aim, neuroscientists are making a great effort in order to optimize animal models of stroke with reperfusion to investigate HT and CE in parallel with neuronal functionality and structural plasticity of synaptic contact, better resembling clinic progression observed in humans.In conclusion, the ongoing technological development of cutting-edge investigation approaches will offer the capability to realize a more specific and detailed investigation of the pathophysiological mechanisms underlying ischemic progression. Undoubtedly, the bi-directional collaborative approach between preclinical and clinical researchers represents a propulsive thrust to improve stroke treatments.


Pediatric urology has been developed by many pediatric urologists and pediatric surgeons from all over the world. Congenital urinary tract malformations are the main field of interest of urology in pediatrics. Obstructive uropathies and vesicoureteral reflux are the most frequent urinary tract congenital anomalies requiring urological consultation. Antenatal and perinatal diagnosis allows early management of these anomalies, before the onset of symptoms, such as urinary tract infections and pyelonephritis. Considering surgical treatments, the most noteworthy advance in pediatric urology has been the development of minimally invasive surgery including endourology, laparoscopy, retroperitoneoscopy and robotic surgery, which have the advantages of reducing postoperative pain, improving the cosmetic results and reducing the time of postoperative hospitalization. The Special Issue “Urology in Pediatrics” mainly focused on the surgical management of urogenital pathology in children, including conservative treatments and minimally invasive and open surgery.Regarding the conservative management of urinary tract malformations, antibiotic prophylaxis is the basis of treatment of uropathic patients, in order to prevent urinary tract infections and consequent possible renal scarring. Pyelonephritis (PN) is the most serious complication in urophathic patients. Giovanni Parente and colleagues carried out a retrospective study on pyelonephritis (PN) in pediatric uropathic patients. They found that pathogens of PN in uropathic patients, with vesicoureteral reflux (83% Gram-negative bacteria vs. 17% Gram-positive bacteria), are different from those of community-acquired PN (99.1% Gram-negative bacteria vs. 0.9% Gram-positive bacteria), and considering this finding, clinicians should be aware of their peculiar antibiotic susceptibility .Endourology is the most minimally invasive approach for treatment of congenital uropathies, such as vesicoureteral reflux and ureterocele. Raffaella Cocomazzi and colleagues performed a retrospective study on the long-term follow-up of the endoscopic treatment for vesicoureteral reflux using two bulking agents, polymethylsiloxane (PDS) and hyaluronic acid/dextranomer (Ha/dx). The reported persistence rate was significantly higher in patients treated with absorbable bulking agents, such as Ha/dx 43%), compared to PDS (25%), and in patients with bladder dysfunctions [%, comparMinimally invasive surgery is largely applied in pediatric urology. Laparoscopy, retroperitoneoscopy and, more recently, robotic surgery are the approaches which have been developed in children. Hydronephrosis secondary to uretero-pelvic obstruction is one of the main indications for minimally invasive surgery in children. Anderson–Hynes dismembered pyeloplasty, first described in 1949, remains the gold standard technique. Robotic pyeloplasty seems to be particularly indicated in children more than one year of age, but there is no consensus about the timing of surgical intervention and the appropriate technique for asymptomatic neonates and infants. Mario Lima and colleagues reported a retrospective study comparing patients who underwent an early pyeloplasty, in the first 90 days of life (group 1), with patients who underwent a delayed pyeloplasty, between 3 and 12 months (group 2). They used one-trocar-assisted pyeloplasty (OTAP), which is a video-assisted retroperitoneoscopic technique particularly feasible in small children. They found no significant differences in terms of intraoperative data and early postoperative outcomes, between the two groups. Moreover, they interestingly registered a significant improvement in those patients with an impaired split renal function (SRF) that underwent an early surgical correction, especially in terms of urinary flow, evaluating the hydronephrosis severity score  one year after surgery .Another important topic reported in the Special Issue “Urology in Pediatrics” is surgery of genital acquired pathology. Circumcision is one of the most common urologic procedures performed in children. Laura E. Gilberston and colleagues reported a study on the utilization of an opioid-free anesthetic for circumcision in an ambulatory surgery center. They reported a substantial decrease in in-room and postoperative recovery time with the utilization of this anesthetic approach . VaricocFinally, Edoardo Bindi and colleagues published a case report on continent urinary diversion in children. They reported a girl who was affected by a bladder rhabdomyosarcoma and a girl born with bladder exstrophy and treated at birth. In both patients, a complete cystectomy was performed and a continent neo-bladder was created by detubularized ureterosigmoidostomy using, respectively, Mainz pouch II and Cologne pouch techniques. They concluded that these procedures are safe with good long-term outcomes and, interestingly, are particularly suitable for patients from poor countries because they require no device (bags or catheters) .In conclusion, this Special Issue reports articles regarding different important topics in urology in pediatrics, ranging from the conservative and minimally invasive treatment of urogenital pathologies in children and adolescents, to open approaches for ambulatory and major traditional surgeries in children.


Approximately one-third of individuals in a major depressive episode will not achieve sustained remission despite multiple, well-delivered treatments. These patients experience prolonged suffering and disproportionately utilize mental and general health care resources. The recently proposed clinical heuristic of ‘difficult-to-treat depression’ (DTD) aims to broaden our understanding and focus attention on the identification, clinical management, treatment selection, and outcomes of such individuals. Clinical trial methodologies developed to detect short-term therapeutic effects in treatment-responsive populations may not be appropriate in DTD. This report reviews three essential challenges for clinical intervention research in DTD: (1) how to define and subtype this heterogeneous group of patients; (2) how, when, and by what methods to select, acquire, compile, and interpret clinically meaningful outcome metrics; and (3) how to choose among alternative clinical trial design options to promote causal inference and generalizability. The boundaries of DTD are uncertain, and an evidence-based taxonomy and reliable assessment tools are preconditions for clinical research and subtyping. Traditional outcome metrics in treatment-responsive depression may not apply to DTD, as they largely reflect the only short-term symptomatic change and do not incorporate durability of benefit, side effect burden, or sustained impact on quality of life or daily function. The trial methodology will also require modification as trials will likely be of longer duration to examine the sustained impact, raising complex issues regarding control group selection, blinding and its integrity, and concomitant treatments. Over one-third of persons with major depressive disorder (MDD) will not achieve sustained symptom remission after several treatment trials , These and other findings formed the basis for the heuristic, treatment-resistant depression (TRD), which is typically defined by the number of previously failed acute phase treatment trials, based on lack of short-term improvement in overall depressive symptom severity Fava, . VariousFavoring the concept of TRD is the fact that the degree of resistance seems to be easily assessed ? Must all the failed trials occur in the current episode or do failed treatments in prior episodes also count, especially since a treatment that failed in the past is expected to fail again if tried in a new episode? All of these questions can be operationalized and attempts have been made to do this on the basis of a Delphi consensus approach , has been proposed to stimulate the timely identification and personalized management of patients for whom our current treatments – even if well-delivered and tolerated – are unlikely to either initiate or sustain symptomatic remission  trials in ‘treatment-responsive’ populations when developing therapeutics for major depressive episodes (MDEs). These trials typically compare an antidepressant against a placebo, sham, or active comparator, and a statistically and clinically meaningful acute antidepressant effect is potentially identified. Subsequently, continuation or maintenance phase trials address prevention of relapse or recurrence , environmental circumstances, and anticipated risks and benefits of untried and sometimes minimally evaluated treatments, as well as other factors. This problem of when to change targets from sustained symptom remission to optimal patient and disease management is implicit in managing every depressed patient who is struggling despite multiple treatment attempts. The designation of DTD promotes a more deliberate, transparent and shared decision-making process. Further, it implicitly promotes the use of evidence-based interventions before embarking on less rigorously evidenced treatments.There is a great need for clinical and service researchers to develop and evaluate patient-level clinical interventions for DTD, such as novel medications or combinations, psychotherapies, and neuro-stimulatory methods, as well as administrative/programmatic innovations such as intensive outpatient programs, peer-supported self-help programs aimed at promoting wellbeing, or substance use reduction programs.To facilitate DTD intervention research, this report reviews three fundamental challenges: participant selection, outcome assessment, and study design. Participant selection is especially challenging because DTD is likely heterogeneous in etiology, course, pathobiology, and intervention responsiveness. The development of a DTD taxonomy could facilitate the identification of more homogeneous subgroups, thereby enhancing trial efficiency and, potentially, intervention targeting and staging Sackeim, . OutcomeThe consensus report recommended that a broad set of evaluations be considered when DTD is suspected . In addition, when remission was achieved, relapse/recurrence rates during follow-up increased progressively with more previously failed acute phase treatments  or specific treatment sequences [e.g. cognitive behavioral therapy to SSRI to atypical antipsychotic augmentation to monoamine oxidase inhibitor to electroconvulsive therapy (ECT)]. Even with this approach, the introduction of a new treatment will change sample definitions. Further, such staging approaches focus only on treatment history rather than the broader clinical context and course.This dilemma could be addressed, in part, by staging the ‘level of resistance’  . This effort could begin by evaluating whether specific features distinguish DTD from non-DTD patient groups  . For many DTD patients, treatments effective earlier in their illness subsequently lose benefit, suggesting a developmental change in key neurobiological substrates Katz, . This obKnowledge about the nature and results of prior depression treatments is crucial to informing a taxonomy. This information  will be key in distinguishing among patients who do not receive ‘adequate’ therapeutic trials due to intolerance, those who show only minimal acute benefit despite ‘adequate’ treatment, and those who have greater acute responsivity but cannot sustain the benefit. At a practical level, such knowledge could also inform investigators as to which patients have already benefited or not from the intervention under study. In theory, a national electronic health record (EHR) would be optimal in providing universal and uniform data collection  compared to control conditions. However, depressive symptoms may not necessarily be the most critical outcome. Some modest, but valuable, degree of symptom control has often already been achieved, and further meaningful symptomatic reduction is not expected, given the history of responsivity to prior treatments. Aside from symptom control, DTD treatments/interventions may aim to improve other factors, such as managing concurrent psychiatric and general medical conditions, minimizing treatment burden, enhancing daily function, QoL, or overall mental and physical wellness, mitigating symptomatic worsening, or otherwise reducing mood instability  can be targets for DTD interventions . ResearcSelecting a primary outcome would be far simpler had we an analog in DTD of the hemoglobin (Hgb) A1C measure in diabetes. This measure reflects the average glucose level in the bloodstream over the prior 2–3 months (thereby taking into account complex effects of multiple determinants). Hgb A1C is a strong indicator of disease process/control, with established benchmarks for normal, moderately severe, and severe dysregulation. It informs management decisions, and assessment of disease outcomes and complications  being addressed and the specific DTD subgroup under study. A reduction in symptomatic variability (waxing and waning) may be especially important in the management of the difficult-to-treat bipolar disorder, while addressing treatment burden and adherence may be key outcomes in another subgroup. We recognize that bipolar depressions are also often difficult-to-treat and the research and clinical challenges posed by bipolar DTD deserve separate in-depth discussion.To enhance day-to-day function and QoL in DTD, optimizing control of medical and psychiatric co-morbidities may also be prioritized. This imposing number of potential primary and secondary outcomes in DTD presents challenges in selecting assessment domains and specific measures, and in determining assessment frequency. Therefore, it is essential that studies are based on specific hypotheses that determine the outcome measures chosen.The multifaceted outcomes in DTD raise the possibility of approximating a ‘Hgb A1C-like’ outcome metric by forming a composite or multidimensional outcome measure from the assessment of several diverse outcomes. Composite outcomes typically combine various aspects of a particular single construct, such as speed and extent of symptom change, or likelihood and persistence of such change. Multidimensional outcomes assess diverse domains that cannot be easily reflected in a single construct, such as the benefits and costs of an intervention  may be attempted, stakeholders will want to know what incremental changes are likely to be achieved in which groups of patients. Such a multidimensional/combinatorial model for DTD will require consensus as to what represents positive clinical outcomes.Typically, longitudinal outcome data address three aspects of change: (1) average change in the population; (2) individual differences in the degree of change; and (3) individual within-person change over different temporal intervals ketamine may be observed within hours of the first infusion and, unless treatment is continued at regular intervals, usually wanes over the next 5–7 days  with potentially multiple averaged measures to establish a true baseline in DTD. Thus, the frequency of outcome assessments and the duration of the baseline period may be especially critical considerations when designing DTD intervention studies.In typical acute-phase antidepressant trials with pharmacotherapy, psychotherapy, or ECT, there is a relatively moderate correlation between baseline self-report and clinician-ratings of symptom severity, often on the order of only 25% shared variance  choosing among alternative treatments for a specific patient ; (2) estimating the likelihood of benefit of a single treatment ; and (3) identifying mediators of treatment outcome .For example, consider a treatment aimed at enhancing psychological abilities to promote resilience-enhancing skills in everyday life, which in turn is expected to improve daily function or QoL. The measurement of resilience  is essential to determine whether the treatment outcomes achieved actually depend on enhanced resilience in those who benefit.The identification of mediators, moderators, or prognostic predictors is especially important in DTD due to its etiological and treatment response heterogeneity. Any intervention will likely be useful for only a subset of DTD patients. Some outcomes may entail different mediators, moderators or prognostic predictors than others. From a cost-efficiency perspective, it is less expensive to select candidate measures as potential predictors and mediators early in the conduct of trials, whether observational or randomized, given the overall cost of conducting the trial  and other forms of artificial intelligence (AI), remote real-world sampling of outcomes  has become cost-effective and potentially may provide more valid outcomes.This section discusses three trial design challenges presented by DTD: sample sourcing, trial execution, and intervention study designs that preserve causal inference.DTD and TRD are heterogeneous in clinical presentation, course of illness, biology, treatment responsivity, and other factors. Recruiting DTD intervention research participants from representative real-world treatment settings (as opposed to research clinics) would help ensure a representative sample which enhances the generalizability of findings and may reduce costs of recruitment, treatment delivery, and trial management costs. Large care systems, whether governmental (e.g. VA) or private commercial systems, can lower costs by providing much of the information on the prior treatment of mental health and general medical conditions.Access to large numbers of representative participants helps to address the heterogeneity issue. Large numbers enable the identification of subgroups within the DTD patient population, especially those responsive or unresponsive to a particular intervention. This enables post-hoc secondary analyses to generate hypotheses for subsequent studies. Larger patient populations also increase the certainty of findings which, when obtained in real-world settings, enable rapid real-world implementation.However, due to the heterogeneity of DTD and our current lack of taxonomy, there are risks in being too inclusive. Inclusion criteria must ensure that people with the targeted problem are included with few others, while the exclusion criteria might best be minimal to enhance generalizability. For example, a treatment targeting anhedonia in DTD might include depressed patients with sufficient baseline anhedonia to show the intended effect. In addition to the heterogeneity of DTD, potential efficacy-confounding aspects of DTD  are often not easily identifiable by standard review of diagnoses/medication exposure in large EHR databases. This is particularly challenging as concomitant personality disorder and substance addiction significantly impact depression outcomes  may not readily apply to DTD (Frank et al.,