Motor neuron diseases (MNDs) are a heterogeneous group of disorders that affect the cranial and/or spinal motor neurons (spMNs), spinal sensory neurons and the muscular system. Although they have been investigated for decades, we still lack a comprehensive understanding of the underlying molecular mechanisms; and therefore, efficacious therapies are scarce. Model organisms and relatively simple two-dimensional cell culture systems have been instrumental in our current knowledge of neuromuscular disease pathology; however, in the recent years, human 3D in vitro models have transformed the disease-modeling landscape. While cerebral organoids have been pursued the most, interest in spinal cord organoids (SCOs) is now also increasing. Pluripotent stem cell (PSC)-based protocols to generate SpC-like structures, sometimes including the adjacent mesoderm and derived skeletal muscle, are constantly being refined and applied to study early human neuromuscular development and disease. In this review, we outline the evolution of human PSC-derived models for generating spMN and recapitulating SpC development. We also discuss how these models have been applied to exploring the basis of human neurodevelopmental and neurodegenerative diseases. Finally, we provide an overview of the main challenges to overcome in order to generate more physiologically relevant human SpC models and propose some exciting new perspectives. The spinal cord (SpC) plays the crucial role of transmitting signals between the brain and the peripheral body, including the relay of sensory information and motor instructions, reflex actions and the generation of motor activity . A varieMost of our knowledge on spMN diversity and biology as well the SpC development was generated from in vivo studies in model organisms. However, the advancement in the last decade of in vitro models to study human development and disease is enabling scientists to tackle questions that were difficult to address in vivo. In vitro-generated three-dimensional tissue-like models are pluripotent stem cell (PSC)-derived complex systems arising from the self-organization of multiple cell types, with distinct cytoarchitecture and that partially recapitulate the functional features of an organ. These tissue-like structures are classified under the umbrella term organoids (ORG) ,5. SpherDespite our extensive understanding of the anatomy of the SpC, its cellular composition, neuronal circuitry and embryological development, many fundamental questions remain to be resolved. How do extracellular signals regulate the expression of lineage-allocating transcription factors (TFs) during spMN development and instruct the signaling state of regulatory mechanisms that maintain this developmental fate? How can we manipulate these signals to direct the differentiation of specific MN subtypes? How is the layered organization of the SpC achieved on a molecular level? Can abnormalities in human SpC development underlie or contribute to the emergence of neurodegenerative diseases (NDs)? To address these and other questions, in the last decade, the scientific community has made use of stem cell (SC)-derived in vitro approaches as a valuable complementary asset to in vivo studies. While an extensive number of reports have kept optimizing protocols for the generation and study of cortical organoids, SCOs have been significantly less pursued. However, SCOs have emerged as a useful resource for studying human SpC development in recent years. In this review, we will outline the SpC and spMN development and summarize the methods used to produce such cultures, their evolution and the current state-of-the-art approaches that have significantly contributed to the study of SpC development and the modeling of the most common neuromuscular disorders such as spinal muscular atrophy (SMA) and amyotrophic lateral sclerosis (ALS). Furthermore, we will discuss how closely these approaches recapitulate human physiology and pathology and what recent advances and challenges exist in the field to improve the formation of human SpC-like structures in vitro.TBXT and SOX2 [By the time of a late gastrulation, germ layer separation in the vertebrate embryo is nearly complete, and multipotent cells in the epiblast have started to differentiate into lineage-restricted progenitor cells. Concomitantly, neural induction occurs and neuroepithelial cells form a sheet-like neural plate, which undergoes a series of rapid morphological changes (convergence–extension–elevation–fusion) to become the primitive neural tube. This process occurs in two modules, whereby primary neurulation forms the brain and rostral SpC, while secondary neurulation contributes to the caudal SpC A. Moreovand SOX2 ,11. A tiand SOX2 ,13. The and SOX2 ,15,16. Land SOX2 ,18. It rand SOX2 . One of the most intriguing questions about the development of the vertebrate SpC is by which mechanisms the correct size, proportion and anatomical architecture are established from a primitive tissue layer, the neural tube. Over the past thirty years, studies have shown that several morphogens diffuse from the dorsal and ventral poles of the developing SpC and seemingly instruct this process. Per definition, such morphogens are diffusible molecules that can form concentration gradients within a tissue. Cells can sense their position within these gradients to determine their developmental fate by precisely regulating their gene expression in a spatially delimited area . The traPAX6 and NKX6.1. Within this domain, the pMN marker OLIG2 is induced by NKX6.1, and specifies a pan-spMN fate [OLIG2 represses HES TFs (such as HES1 and HES5), which are NOTCH pathway effectors and act as neurogenesis antagonists. Ultimately, high OLIG2 and PAX6 levels induce the expression of the proneural TF NEUROG2, which dictates the timing of differentiation by marking progenitor cells for cell cycle exit and further development into immature, postmitotic spMNs [HB9 shortly after exiting the cell cycle [ISL1 and specify into different subtypes along the RC axis [LHX3 and LIM1, contributing to their molecular identity [ISL1/2 and HB9 and appearance of filamentous, cytoplasmic maturity markers  or nuclear antigens such as NeuN, allows for the identification of spMNs. Recent studies have investigated the spatial and temporal TFs expression dynamics during mouse SpC embryogenesis at single-cell resolution [Downstream of Shh signaling, the progenitor MN (pMN) domain is established and initially defined by the co-expression of the neuroectodermal TFs pMN fate ,28. Receic spMNs . Newly dll cycle . As diff RC axis . Other Tidentity ,33. The solution . Additiosolution ,36,37.HOX) genes [HOX genes, which are expressed in overlapping patterns along the RC axis of various developing tissues, is to sequentially provide an anterior–posterior identity within the developing body column, precisely encoded on a genetic level [HOX gene expression boundaries and inactivation studies in mice. The former manipulation led to segmental identity alterations and homeotic transformations [HOXA10 and HOXD10 genes resulted in a significant reduction in the number of medial and lateral spMNs in the lumbar SpC [HOX gene expression. Mechanistically, the expression of HOX genes is regulated by gradients of WNT and FGF signaling during the anterior spreading of the primitive streak [HOX genes expressed in more rostral parts of the SpC are induced by lower amounts of FGF, whereas the HOX expressed in a more caudal part are induced by higher amounts of FGF [HOX genes [HOXox genes [HOX genes play a role in regulating components of RA signaling, which support feedback loops that strengthen the crosstalk between HOX gene expression and RA signaling [At the molecular level, the axial identity of NPCs is heavily influenced by caudalizing morphogens that trigger the expression of a group of TFs called homeobox (X) genes ,39. ThesX) genes . The maiic level . Often, ic level . The imprmations . Taking mbar SpC . Intensee streak ,46. Specs of FGF . Importas of FGF ,48,49. EOX genes ,51,52  and human-induced pluripotent stem cells (hiPSCs)-derived MN cultures have been widely used in the last two decades for investigating spMN biology in health and disease. Whereas ESCs are derived from the inner cell mass of the mammalian blastocyst, iPSCs are created by genetically reprogramming somatic cells, such as fibroblasts. This is achieved by overexpressing the “Yamanaka TFs”, nd C-MYC . These Pnd C-MYC   and FP/notochord (SHH) during neural tube development in vivo . In the nal fate . While enal fate , Wichternal fate ,72. Imponal fate . Later snal fate . Extensinal fate ,76,77. Notably, there is some controversy regarding the importance of RA-mediated signaling to induce spMN differentiation from PSCs. Patani and colleagues showed that inhibiting TGFβ/Activin/Nodal signaling with SB and later adding a SHH agonist (SAG) was able to specify PSCs into spMN precursors even in the presence of RA pathway antagonists . This meISL1 expression by more than 5-fold [In addition to TGFß/BMP/RA and SHH signaling pathways, the activity of NOTCH is often modulated to accelerate the differentiation of NPCs into specific neural sub-lineages, such as spMNs. γ-secretase-mediated inhibition of the NOTCH signaling pathway through DAPT during early NPC emergence from msESCs led to the increased formation of OLIG2 + pMNs and 20% more HB9+; SMI32 + spMNs . Importan 5-fold . Based on 5-fold ,81. SOX1 and OLIG2 TFs, which raises concerns with regard to the fidelity of modeling embryological development in vitro when utilizing these approaches [An alternative approach to these developmentally inspired guided differentiation protocols relies on the induction of specific TFs to directly convert somatic cells into MNs or to transcriptionally program PSCs into MNs or bypassing developmental stages. Although this approach was intensively explored in the past, and proved advantageous especially to model late-onset diseases, given that the epigenetic clock of the donor cells does not reset during cell reprograming, its limited efficiency and reduced scalability turned many researchers to the second alternative for directed differentiation (reviewed in ). It is proaches . Additioproaches . Howeverproaches . A potenproaches ,86. HOXC4 gene expression and a spatial arrangement of ISL1 + MNs, ventral and dorsal interneurons along the pseudo-DV axis, positioned in relation to the FP-like structure. A more precise recapitulation of the SpC DV domains was later recreated in hiPSC-derived spheres by dual SMAD inhibition with SB/LDN, followed by treatment with BMP4 or SAG to induce dorsalization of spinal progenitors or to trigger a developmental shift toward ventral fates, respectively, in combination with RA [In a pioneering study, Meinhardt and colleagues demonstrated the formation of neural tube-like structures embedding mESCs suspensions directly into an exogenous extracellular matrix (Matrigel), which generated NESTIN+ neuroepithelial spheroids. Notably, these neuroepithelial EBs displayed a homogeneous, anterior axial identity of GBX2 and HOXA2 , charact with RA . A simil with RA . In this with RA . They fu with RA . When ex with RA . This su with RA .spMNs exhibit a preferential degeneration pattern along the SpC RC axis in neurodegenerative diseases such as SMA or ALS . In ALS,HOX genes in the hindbrain and SpC plays a crucial role in diversifying and assigning neural phenotypes to specific anatomical domains along the RC axis [HOX gene clusters, thus generating spMNs with a specific axial fate [During vertebrate embryogenesis, colinear expression of  RC axis . If the ial fate ,96. It hThe rationale followed by most protocols for achieving spMN differentiation is based on the activation–transformation model, whereby PSCs are first patterned toward neuroectoderm and afterward treated with RA or other caudalizing molecules to force them to commit to a hindbrain/SpC fate. However, recent evidence suggests that a different rationale has to be adopted to induce the acquisition of thoracic–lumbar spMN identity. Such a “primary regionalization model”, proposed by Metzis and colleagues, highlights that progenitor cells need to acquire an axial identity prior to committing to a neural fate ,63. It fHOX gene clusters and then inducing NPC specification. Lippmann and colleagues developed an optimized approach culturing with WNT agonist CHIR99021, FGF-8 and GDF11, followed by a stimulation of RA signaling [HOX genes and therefore promoting pMNs caudalization [HOX genes was more progressed and a stark reduction in cervical/hindbrain allocated HOXB4 expression was observed [HOXC9 and HOXD11, and not the cervical HOXC6. After 6 days of exposure to the NOTCH pathway inhibitor Compound E, caudal pMN progenitors derived from NMPs fully differentiated to HB9+; ISL1 + spMNs that retained their caudal identity [Numerous studies have accomplished the generation of hindbrain/cervical or thoracic PSC-derived spMNs, following adherent or EB/SCO cultures. These protocols mainly applied the activation–transformation model of treating PSCs with TGFß/BMP inhibitors, followed by SHH-mediated ventralization and RA-induced caudalization. In contrast, only a limited number of studies focused on refining guided differentiation protocols to generate lumbar spMNs from NMPs, which can be achieved by firstly stimulating the HOX clock to express caudal ignaling . The addlization . They obobserved . Concludobserved . Lastly,Building on the NMPs’ potential to generate and elongate caudal SpC and the adjacent paraxial mesoderm, Gouti’s group recently developed the first neuromuscular organoid (NMO) protocol, composed by SpC-like tissue and skeletal muscle in approximately even proportions . After bIn conclusion, in the last 5 years, an impressive advance in SCO modeling has been made. There are still, however, unanswered questions regarding the optimal selection, concentration, timing and combination of signaling molecules for the optimal differentiation of PSCs into SpC-like tissue. Efforts to develop protocols for patterning hiPSCs into organoids that contain spMNs with mixed axial identities have encountered various challenges. Reduced yields of spMNs, a persistence of immature progenitors, strong rostral or caudal regional identity bias, or loss of entire spMN subpopulations are common examples. This is partially due to the lack of systematic studies on how mechanistically each morphogenetic signal contributes to the patterning of each type of neural progenitor and their specification into different spMN subtypes. Further research on this end will surely propel the generation of the SCO that best resembles human physiology.HOX genes in organoids grown with and without WNT signaling activation. Organoids cultured without WNT induction expressed anterior HOX transcripts and adopted a hindbrain identity, while WNT activation caused the spheroids to express hindbrain and cervical HOX transcripts. Interestingly, thoracic HOX genes started to emerge as the gastruloids were kept longer in culture, mimicking the progression of axial elongation during embryonic development in vivo. While N-cadherin and β III-tubulin expression was observed in the organoids, indicating the emergence of maturing populations of neurons, the (motor) neuronal character of the gastruloids was not further characterized. In summary, gastruloids in vitro constitute highly promising assets to study the mechanisms of neural tube formation and elongation, a process that has been partially recapitulated in murine cultures [One could argue that an ideal human SpC in vitro model should be generated by the expansion of NMPs and their progressive differentiation into neural progenitors with different rostro-caudal segmentation commitment that additionally undergoes periodic elongation. Recent studies have discovered that generating gastruloids from hPSCs constitutes an effective in vitro model for studying axial specification during the earliest stages of post-implantation embryonic development ,102. Thecultures ,101, andcultures . By usinEthical and technical reasons confined research on developmental biology to various animal models such as chicken, frog, zebrafish and mice. Although they are valuable systems that have contributed immensely to discovering conserved principles of SpC development with ease of observation and manipulation, TFs and epigenetic regulators can function differently in human development. Moreover, the human genome contains many types of non-coding regulatory elements that could be essential for human embryos and structures to develop . For theAmong these models, a very interesting one described previously was recently developed by Gouti’s group, neuromuscular organoids (NMOs) . NMOs weAn organoid system highly promising for studying the earliest phases of SpC formation and the molecular basis of developmental abnormalities in vitro was developed by Martinez-Arias’ group using mouse ESCs. These 3D aggregates, termed gastruloids, contained the three germ layers, underwent symmetry breaking and were able to elongate in an axis resembling gastrulation in vitro ,117. In In 2019, around 300,000 people worldwide were diagnosed with a MND . Motor nSOD1, TARDBP, FUS and C9orf72. Several impaired pathways such as RNA metabolism, vesicle trafficking, cytoskeletal dynamics and axonal transport as well as the accumulation of misfolded protein aggregates have been reported being contributors to the disease. However, the precise order of events contributing to neuronal death remains elusive. Extensive research on these four genes, and many others, is ongoing worldwide to elucidate common and mutation-specific altered pathways that could uncover the disease origin, the contribution of each of them to the initiation and progression of the pathology and the interplay between MN intrinsic and cell non-autonomous alterations [Approximately 10% of ALS cases are familial (fALS) while 90% are sporadic (sALS) ,128. So erations . A valuaerations . In addierations . SOD1 mutation and differentiate these into MNs [LHX3, ISL1, NGN2 and SOX11 overexpression in FUS-mutated fibroblasts generated lineage-converted MNs that showed soma shrinkage, hypoactivity and inability to form NMJs [Eggan’s group was the first to generate hiPSCs from a patient carrying a familial into MNs . As moreinto MNs . Large-sinto MNs . This lainto MNs , in partinto MNs ,135. Thiinto MNs . MNs coninto MNs . This storm NMJs . C9orf72 or FUS with respect to organoids generated from healthy individuals, supporting a NMJ dysfunction in ALS. To conduct a detailed analysis of NMJ structure and composition, they switched to isogenic hiPSC lines engineered by introducing SOD1, TARDBP or PFN1 mutations into a healthy control line. Experiments revealed a reduced number of NMJs in the SOD1 and PFN1 mutant organoids and defective innervation in the established NMJs in TDP43 mutant organoids. Since no changes were found in axonal growth or skeletal muscle area across the different genotypes, they concluded that the ALS mutations lead to a structural inability to form NMJs that needs to be explored further to determine if this disease phenotype has a degenerative or developmental nature [Even though the use of patient-derived iPSCs for ALS research has exponentially grown in the last decade, only a few studies have utilized complex 3D-based differentiation protocols. As described above, using more physiologically relevant, tunable, and tractable 3D models should not only recapitulate more closely the human disease but also uncover disease mechanisms that might remain otherwise masked in more simplified 2D models. A recent study by Pereira et al. established sensorimotor organoids that contained microglia, endothelial cells and skeletal muscle fibers in addition to MNs by generating NMPs from hiPSCs and allowing them to differentiate into mesodermal and neuronal lineages . The autl nature . ImportaThe next generation 3D approach to model MNDs is organ-on-chip, in which different cell types can be cultured in separate compartments by combining the use of hydrogels and microfluidic devices. This strategy guides cells to ensemble in 3D structures while precisely controlling their microenvironment  to better simulate human physiological conditions . An inteSMN1 gene, which codes for survival of motor neuron (SMN) protein. The complete lack of SMN is incompatible with life, and homozygous deletion of Smn in mice results in death at the gastrulate stage [SMN2, only present in humans, allows patient survival and partially compensates for SMN1 loss. Importantly, a translationally silent point mutation in SMN2 exon 7 results in the skipping of this exon in most of the SMN2 transcripts during mRNA splicing, resulting in a truncated and unstable form of the protein. Approximately 10% of the SMN2 transcripts retain exon 7, and thus code for the full-length functional SMN protein [SMN2 gene copies varies across individuals (zero to six copies) and determines the onset and severity of the disease (type 0–4). Higher SMN2 copy numbers translate into higher levels of full-length SMN and a milder course of the disease and a longer life expectancy, while lower copy numbers result in severe forms and death, often occurring during infancy [SMA is an autosomal recessive neuromuscular disease and the leading genetic cause of infant death. It is caused by mutations or a full deletion of the te stage . A paral protein ,142. The infancy . SMN is  infancy .SMN2 gene [Smn. These in vivo SMA models replicate major disease hallmarks such as spMN loss, NMJ degeneration, muscle wasting and a shortened lifespan [SMN2 exon 7 or by an AAV-mediated SMN1 gene [To investigate the spMN degeneration caused by SMN deficiency scientists initially relied on murine models, generated by introducing a different version of the human MN2 gene ,146 whillifespan . These aMN1 gene . DespiteMN1 gene . AdditioSOX2 and NESTIN brought forth developmental alterations in NSCs/NPCs as potential initial drivers of SMA pathology [A pioneering hiPSC-based study on SMA was conducted by Ebert and colleagues, where they reprogrammed fibroblasts from a patient affected by a severe SMA form and from his healthy mother into hiPSCs and differentiated them into MNs using a EB-based method . Soon, hathology  , hematopoietic stem cells  and NSCs . ALS has been the MNDs for which the highest number of cell therapy-based clinical trials have been approved in the past two decades to test for safety, tolerability and early efficacy. Although the vast majority of the completed trials have proven safe, regardless of the type and number of cells transplanted and the delivery route, the functional improvement of the patients has been modest, with a mild reduction in the slope decline or diminished levels of pro-inflammatory cytokines being the most common positive outcomes ,160. MosIn ALS animal models, besides BM-MSC, HSCs and ESC-derived NSCs, hiPSC-derived NPCs have been delivered systemically and via intracerebroventricular, intrathecal or intra-SpC parenchyma injection with different efficacy outcomes. Most studies have reported some beneficial effects, including: delayed onset or disease progression, temporarily improved motor function, reduced reactive gliosis or inflammation, and in some cases, preserved NMJ, MN survival and prolonged lifespan, irrespective of the cell-type source, the number of cells transplanted or the delivery route and number of interventions ,160. TheSMN2 into a SMN1-like gene, into the SpC of newborn SMA mice modestly ameliorated disease phenotype and increased the mouse lifespan [Despite the tumorigenicity potential of hiPSCs if the cells or organoids derived from them are not fully differentiated, using hiPSCs as the cell source offers the critical clinical advantage of no immune rejection with the possibility of autologous cell transplant. With this scope in mind, numerous preclinical studies have reported survival, functional integration, axonal elongation and muscle preservation after hiPSC-derived NSCs/NPCs transplantation in ALS  and SMA lifespan . The rapRecently, hiPSC-derived organoids as entire entities have arisen as another potential source for transplantation, providing advantages over former approaches using the suspension of dissociated cells. Daviaud et al. showed that hiPSC-derived cerebral organoids transplanted into an injured mouse cortex survived better and displayed a more robust host vascularization, resulting in a better engrafting than transplanted NPCs differentiated from the same iPSC lines . The autThe transplantation of hiPSC-derived brain organoids has recently been proven valuable to reveal neuronal connectivity phenotypes in rare neurological disorders that were masked in the limited maturation stage of the current in vitro models. By transplanting genetically engineered human cortical organoids derived from individuals with Timothy syndrome into the somatosensory cortex of newborn rats, Pasca’s group demonstrated that the transplanted cortical neurons not only matured further and functionally engaged into the host neuronal circuitry, but also uncovered abnormal electrophysiological properties in the patient-derived neurons . StructuC9orf72 mutations were shown to have strong immunomodulatory activity in vitro [Other cells aside from NPCs or pMN differentiated from iPSCs have been transplanted into rodent models of neuromuscular disorders as an attempt to slow down disease progression, for example, muscle progenitors. Because of the MN degeneration, their muscle targets denervate and eventually deteriorate as well. Initially, efforts were placed at generating and expanding in vitro muscle stem cells (satellite cells) from hiPSCs. However, their very limited proliferation capacity has not resulted in satisfactory clinical outcomes yet. Research into generating other muscle progenitors using hiPSC-derived muscle organoids, such as mesoangioblasts and pericytes, as well as at increasing their migration potential  once engin vitro . Therefoin vitro , neurotrin vitro , neurotrin vitro  and/or aAlthough brain and SCOs and/or their derivatives hold great promise as a form of cell replacement therapy that could be used alone or in combination with other more standardized approaches, such as target-specific drugs or gene therapy, a long path ahead is expected before they are to become a real therapeutic alternative. Critical biological features of the organoids, such as cell type(s) to be transplanted, cell suspension or organized structures, proliferation/differentiation stage, number, location and delivery route, as well as the host, such as the degree of damage at transplantation, cell loss, reactive gliosis, inflammation and the functionality of neuronal circuitry, will need to be fully understood to ensure the safety and efficacy of the engraftment. Even though SCOs hold great promise for understanding human SpC development and MND biology, they are so far only able to rudimentarily represent the complexity of the SpC. Several studies have started to evaluate how accurately the emerging cell populations in these models reflect the in vivo counterparts ,102. A pAs discussed previously, SCOs can be derived from hiPSC through the formation of EBs and subsequent guided differentiation. As hiPSCs/hESCs are used as the “starting point” of the SCO culture, it is fundamental to consider potential pitfalls concerning their handling and their internal properties. Differences in epigenetic marks, chromatin modifications, mRNA and protein synthesis dynamics can vary greatly between hiPSC lines generated from different donor cells or even lines generated from the same donor but by different groups ,184. FurDespite intense efforts to reproduce the cell-type-specific gene expression patterns observed in the SpC in vivo, we are still far from precisely replicating development in vitro. Certain marker genes that define specific cell clusters may be absent or decreased, which indicates a different ratio of distinct neural and non-neuronal cell populations, a common issue in current neural organoid models ,188. TheETV2)  D. When tTranscriptomic studies have raised questions regarding the maturity of hiPSC-derived cortical and spMNs in vitro, indicating that their global transcriptome electrophysiological profiles resembled more closely to that of fetal neurons. This constitutes a limitation for modeling late-onset MNDs such as ALS ,206. ProIn conclusion, despite the significant progress made in the last decade in optimizing guided differentiation organoid protocols to mimic the developmental cues that orchestrate SpC formation, notable challenges remain. Achieving robust SCO cultures that accurately replicate the anatomical regionalization, cytoarchitecture and cell-type specification of the SpC constitutes an ambitious task. However the continuous refinement of protocols —perhaps by applying microfluidic-based morphogen gradients and next generation functionalized matrices—as well as standardization approaches for hiPSC quality control and the same genetic background should push this endeavor. A major determinant for the success of 3D cell cultures in terms of modeling complex tissues lies in the choice of extracellular matrix (ECM) F. PhysioPolyethylene glycol (PEG)-based hydrogels have emerged as chemically defined, scalable and customizable alternatives, with almost half-cost and ease of scalability without batch variability that, in some cases, have proven to have an equal or superior performance in cell culture systems with respect to Matrigel . HoweverAn interesting approach to polarize SCOs has been reported by culturing hiPSCs in 2D in a geometrical confinement, analogous to symmetry breaking during development . This meMicrofluidic devices are a more reliable alternative to generate multiple morphogen gradients simultaneously in an automized and highly controlled manner. They have the capacity to manage the abundance of proteins and small molecules released into the culture media in picoliter to milliliter volumes , demonstAs described above, the maturation and connectivity of neural circuits are key aspects of brain organoid technology that are still intensively researched to improve their resemblance of an in vivo scenario. The combination of organ-on-a-chip systems compatible with multielectrode recording are starting to be used to measure advances at this front, as well as to model electrophysiological aspects of NDs and test drug candidates. An example of the applicability of this technology can be found in a recent study where dorsal SCOs generated by following traditional small-molecule-based patterning, were transferred to a multiple electrode array chip to investigate nociceptive circuitry, and an increased electrophysiological activity was detected upon treatment with pain evoking reagents . ApplyinDespite decades of research and thousands of studies, the scarcity of efficacious treatments for MNDs is obvious. This is in part due to our incomplete understanding of the molecular and cellular basis of these human diseases or the development of the human neuromuscular system. While human in vitro 2D cultures have been highly revealing to identify cell-intrinsic pathogenic factors and their response to external modulation, the numerous non-cell autonomous contributors to MND pathology are not well recapitulated in those simplified systems. More complex and controllable 3D models overcome that important limitation and enable exploring the crosstalk between the affected neurons with their muscle targets, the immunomodulatory role of glial cells or the nurturing and tissue homeostasis support provided by the vascular system. While cortical organoids have been most evolved and used to study human cortical development, in recent years, numerous SpC-like tissue models have emerged, advancing our understanding on how the SpC develops and how the neuromuscular system functions and deteriorates in pathological situations. These models include gastruloids to study the earliest phases of neural tube formation, trunk-like structures to study neural tube elongation and somitogenesis and more mature SCOs, in some cases including the muscular and cortical components of the corticomotor system, to study MNDs. Most likely, only after fully understanding the embryonic development of the human SpC, we could then explain how diseases surface. The continuous refinement of these 3D in vitro models, and the advantages they introduce to study human-specific processes in an experimentally tractable manner, hold great promise to elucidate the spatiotemporal mechanisms of SpC morphogenesis and the molecular and cellular contributors to MNDs. Constant conceptual and technological progress  make SCOs a powerful system to fill those knowledge gaps . These m


A review article summarizing recent findings related to totipotency in mammals, encompassing topics such as the epigenome and gene regulation in early embryos, in vitro totipotent-like cells, and somatic nuclear transfer. Numerous efforts to understand pluripotency in mammals, using pluripotent stem cells in culture, have enabled the generation of artificially induced pluripotent stem cells, which serve as a valuable source for regenerative medicine and the creation of disease models. In contrast to these tremendous successes in the pluripotency field in the past few decades, our understanding of totipotency, which is highlighted by its broader plasticity than pluripotency, is still limited. This is largely attributable to the scarcity of available materials and the lack of in vitro models. However, recent technological advances have unveiled molecular features that characterize totipotent cells. Single-cell or low-input sequencing technologies allow the dissection of pre- and post-fertilization developmental processes at the molecular level with high resolution. In this review, we describe some of the key findings in understanding totipotency and discuss how totipotency is acquired at the beginning of life. Pluripotency is defined as the cellular ability to differentiate into all three germ layers of the embryo. In contrast, totipotency can be defined as the ability of a cell to contribute to all lineages in an organism . AccordiIn stem cell research, totipotent-like cells often refer to cells with broader plasticity than pluripotent stem cells. As mouse embryonic stem cells (mESCs) have limited differentiation capacity toward extraembryonic lineages, mouse cells that can differentiate into both embryonic and extraembryonic lineages are generally recognized as totipotent-like . HoweverThe transcriptome of totipotent zygotes shows a profile highly similar to that of unfertilized eggs . This isMacfarlan et al identified two-cell-like cells (2CLCs) that express the MERVL retrotransposon and other two-cell-specific transcripts as a minority subpopulation in mESC cultures . A similIn humans, ZGA occurs around the four-cell and eight-cell stages. Recently, similar to the concept of 2CLCs, eight-cell-like cells (8CLCs) were identified in naïve hESC cultures . DUX4, tIn contrast to the transcription mode in other cell types, the positional selection of transcription start sites is ambiguous in minor ZGA. In addition, splicing activity is extremely low during minor ZGA . RelatedEarly mouse embryos displayed unique epigenetic landscapes that were largely different from those of other cell types, which led to the hypothesis that they might be required for totipotency. Recent technical advances have greatly facilitated the understanding of epigenetic status in early embryos . For exaDNA methylation status in early embryos has also been extensively investigated . The patOne of the epigenetic features of totipotent zygotes is the inheritance of epigenetic marks from gametes. As a result, the zygote is characterized by the establishment of an asymmetric epigenome between male and female pronuclei . These cWhereas maternal epigenetic status tends to be inherited by the zygote, paternal chromatin undergoes extensive remodeling upon fertilization. This is because sperm protamines incorporated during spermiogenesis need to be replaced by histones after fertilization . HoweverSCNT, which involves the injection of a somatic nucleus into an enucleated oocyte, gives rise to a complete organism in several species . Thus, SSCNT embryos are generated in several steps  Fig 1)..Fig 1). Experimental techniques applicable to mammalian early embryos have been limited until recently. However, recent technical advances, including single-cell or low-input sequencing technology, have made considerable progress toward understanding the molecular basis underlying mammalian early development and how much zygotes or early embryos differ from other cell types. Using these technologies, we can accumulate knowledge to describe the specific features of totipotent cells. The next question that comes up is, “What is necessary and sufficient for the acquisition of totipotency?” For this understanding, finely controlled loss-of-function experiments, such as a degron-mediated acute protein degradation system , would b


Systemic autoimmune diseases are characteristically associated with aberrant autoreactive innate and adaptive immune responses that lead to tissue damage and increased morbidity and mortality. Autoimmunity has been linked to alterations in the metabolic functions of immune cells (immunometabolism) and, more specifically, to mitochondrial dysfunction. Much has been written about immunometabolism in autoimmunity in general, so this Essay focuses on recent research into the role of mitochondrial dysfunction in the dysregulation of innate and adaptive immunity that is characteristic of systemic autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Enhancing the understanding of mitochondrial dysregulation in autoimmunity will hopefully contribute to accelerating the development of immunomodulatory treatments for these challenging diseases. Systemic autoimmune diseases are linked to alterations in the metabolic functions of immune cells. This Essay addresses key aspects of the current knowledge on how mitochondrial dysfunction in particular affects human autoimmune diseases. The main function of the human immune system is to protect us against microbes, cancer cells, and other threats through its 2 arms: the innate and adaptive immune systems . The immIn this Essay, we discuss recent findings related to changes in the metabolic functions of immune cells (immunometabolism), particularly mitochondrial dysfunction, in innate and adaptive immune cells and their contribution to the generation of autoimmunity, with emphasis on systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) as examples of systemic autoimmune conditions .The body’s first line of defense, quick in its responses and generally nonspecific. The main cellular components are myeloid cells, including granulocytes , monocytes, macrophages, and dendritic cells (DCs), but other cells such as gamma delta T cells, innate lymphoid cells (ILCs), and mast cells can be considered part of the innate immune system. Innate immune cells are the first in line to directly detect and effectively destroy threats: endowed with a powerful broad range of antimicrobial molecules and functions, including phagocytic capacity, antigen presentation, synthesis of enzymes, vasoactive factors, pore-forming proteins, chemokines, and cytokines.Mostly consists of B cells and T cells, which have powerful and specific mechanisms to destroy and remember pathogens for future encounters, making them essential for vaccine effectivity and immunity against pathogens.A series of chemical modifications of nucleic acids and/or histones to modulate gene expression without changing the genetic code. Some of the modifications include methylation, acetylation, and the recently described lactylation.An active process of the immune system that deals with preventing or reverting antigen-specific autoreactive responses.An autoimmune syndrome characterized by multi-organ damage due to inflammation. Systemic lupus erythematosus (SLE) is characterized by the presence of circulating autoantibodies that recognize double-stranded DNA, histones, and a variety of RNA–protein complexes, among other autoantigens. The formation of immune complexes leads to proinflammatory and pro-oxidative environments and tissue damage.Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the synovial joints are targeted by autoantibodies and autoreactive immune cells. In severe cases, the inflammation can also affect other tissues including the heart, lungs, eyes, nerves, and skin.A complex intracellular structure formed by diverse components that assemble together in response to inflammation, oxidative stress, and infectious triggers.Required to avoid self-recognition and the development of autoreactive immune responses, and to generate enduring protective immunological memory. Antigen-presenting cells (APCs) internalize and process microbes and antigens. Upon processing, the ingested antigens are transformed into peptides. Peptides are presented at the APCs’ membrane by major histocompatibility complex (MHC) class II molecules. Specific T cells recognize the presented MHC–peptide complex, becoming activated. Activated T cells proliferate and engage through their T-cell receptor with the respective antigen-specific B cell (which present the correct membrane-associated MHC–peptide complex) promoting their transition into plasma cells, which synthetize specific antibodies.The mechanisms by which innate immune cells promote autoimmune responses have become significantly clearer over the past few decades. Overactive innate immune cells responding to microbial triggers or other danger signals might cause tissue damage and undergo or promote inflammatory cell death, generating and modifying endogenous danger-associated molecular patterns (DAMPs), autoantigens or neoantigens . This au➢ Genetic propensity, environmental stimuli, and stochastic events trigger the generation of proinflammatory and pro-oxidative pathways.➢ In this milieu, inflammatory cell death and improper clearance of dead cells can trigger and perpetuate neoantigen generation and inflammation.➢ Dysfunctional mitochondrial function is prevalent and perpetuates in inflammatory conditions and under hypoxia.➢ Mitochondrial dysfunction affects cells’ metabolism, perturbing regulatory networks, fueling proinflammatory responses, and interfering with immune system homeostasis.reg) cells and regulatory B (Breg) cells, key in the development of immunologic tolerance  , where tolerance , may alsThe development of these opposing (inflammatory versus tolerogenic) immune responses and cellular networks requires specific metabolic responses. Effective immune responses entail heightened cellular metabolism, biosynthetic potential, and cellular division. A shared feature of both inflammatory and cancer cells is a metabolic reprograming activity required for actively dividing cells. This metabolic reprograming in cancer cells, known as the “Warburg effect,” in which cells increase the rate of glucose uptake and preferential production of lactate, takes place in cells that are actively dividing and that have increased demand for biosynthetic molecular precursors and enzyme cofactors .+) coenzyme, leading to activation of alternative cellular metabolic cycles such as glycolysis to provide both ATP and NAD+ [Another shared feature between inflammatory and cancer cells is that they function in hypoxic microenvironments in the tissues they infiltrate. Hypoxia development is frequently observed in inflamed tissues in autoimmune diseases  and is aand NAD+ . Due to It is important to consider that these metabolic pathway adjustments are essential for the survival of cells and to effectively fight infections; therefore, they cannot be completely blunted. As such, it is imperative to learn in more detail how to harmonize the balance among these pathways to avoid aberrant inflammatory responses while mounting an adequate antimicrobial response .The genetic factors involved in the common susceptibility to both autoimmune diseases and mitochondrial dysfunction remain incompletely characterized. Potentially highlighting a critical role for enhanced mROS, and common to both RA and SLE, are genetic variants in major histocompatibility complex (MHC) class II molecules that can lead to enhanced mROS production in antigen-presenting cells (APCs). Through a noncanonical mechanism that seems to be independent on specific antigen–T cell interactions, but which relies on the recognition of certain inflammation-derived DAMPs by specific sequences (epitopes) on MHC class II molecules, a signaling pathway is activated that promotes enhanced mROS activity and mitochondrial dysfunction in the APCs . AdditiocGAS)–stimulator of interferon genes (STING) pathway and/or through endosomal TLRs [Neutrophils are the most abundant cells in human blood and can act as important sources of extracellular mitochondrial and nuclear-derived proinflammatory nucleic acids/autoantigens. This externalization is driven in part by the ability of these cells to form neutrophil extracellular traps (NETs). NET formation is triggered by a variety of infectious and sterile proinflammatory stimuli and leads to the externalization of nuclear and mitochondrial DNA (mDNA) and various RNAs bound to histones and other proteins –20. Whilmal TLRs ,19,24. Omal TLRs .Importantly, other cell death mechanisms besides NET formation have recently been identified as putative contributors to SLE pathogenesis . FerroptMyeloid APCs, including macrophages, monocytes, and dendritic cells (DCs), are considered important contributors to autoimmunity, and their metabolism is also reprogramed in inflammatory conditions. Indeed, mitochondrial quality control in myeloid cells is a key anti-inflammatory mechanism . MitophaAnother mechanism of mROS-triggered myeloid cell death during infection and inflammation is pyroptosis, which is a lytic process induced in inflammasome-activated cells to counteract inflammatory processes. Once activated, the inflammasome  leads thOverall, disruptions in mitochondrial function and immunometabolism seem to be a driving factor that affects the function of myeloid cells, promoting proinflammatory and autoimmune responses in SLE, RA, and other conditions. Promising preclinical evidence  indicates that targeting dysfunctional immunometabolism may have therapeutic benefits in these diseases.+ essential coenzyme, which blunts the secretion of lipopolysaccharide-induced type I IFN in activated healthy control or SLE monocytes [Autophagy is a self-degradative process that allows recycling of damaged/old organelles. It is critical for the proper balance of energy sources during conditions of starvation and nutrient stress. While considered a survival mechanism, it has also been linked to non-apoptotic cell death. Autophagy can also promote antigen presentation  and the onocytes  Fig 3A)+ essentiThe role of disruptions of autophagy in autoimmunity is complex, cell-dependent, incompletely characterized, and has potentially important implications if systemic modulation is considered. For example, contrary to the nicotinamide riboside beneficial effect in SLE monocytes, inhibition of autophagy can promote the generation of inflammatory DCs that are able to prime the autoreactive T cells that perpetuate autoimmunity. Inhibition of autophagy in this case allows mDNA to reach and remain in the DC cytoplasm, thereby promoting type I IFN responses  Fig 3B)Fig 3B). Adaptive immune cells are essential for producing strong, specific, and long-lasting immune responses. These cells and the defensive responses triggered are powerful and, as such, there are specific regulatory mechanisms both to induce their activity and to mitigate it. The relevant role of mitochondria functionality both in the normal and pathological physiology of B cells and T cells has been recently reported for a variety of diseases including SLE and RA.B cells have crucial roles in the pathogenesis of systemic autoimmune diseases. Increased mitochondrial activity in SLE has been linked to enhanced differentiation of B cells into plasmablasts, with putative undesired effects linked to autoantibody production . For theT cells have a primordial role in the development of autoimmunity. T-cell activation is triggered following the recognition of antigen presented on MHC class II molecules in the membrane of APCs. T-cell activation promotes differentiation of various subclasses of T cells depending on the secondary signals received from the APCs and other innate immune cells. Once activated, T cells secrete various proinflammatory cytokines, proliferate, assist the transition of specific B cells into plasma cells and, for certain T-cell subsets, deploy cytotoxic effects onto specific cellular targets. All these activities heavily rely on their metabolic and mitochondrial activity, and various perturbations of these processes have been recently described for autoimmune conditions. For example, oligomerization of mitochondrial antiviral signaling protein (MAVS) occurs in response to viral infections and leads to type I IFN-driven antiviral responses; however, this process is perturbed in patients with SLE as a consequence of mitochondrial dysfunction, whereby enhanced mROS synthesis can directly trigger spontaneous MAVS oligomerization in lymphocytes, leading to downstream induction of the type I IFN pathway  Fig 4B)Fig 4B). + coenzyme. RA inflammatory T cells have deficient tricarboxylic acid (TCA) cycle aspartate production by dysfunctional mitochondria. Proinflammatory T cells populate the RA synovium and promote tissue damage [In RA, proinflammatory T cells are generated in part due to an inability to renew the pool of NADe damage  Fig 4B)+ coenzyme damage .The mitochondrial translation process is also important for T-cell function. When mitochondrial translation is deficient, the mitochondrial respiration machinery lacks essential proteins required for proper functioning of the electron transport chain, eventually leading to general dysfunction and enhanced mROS synthesis . Of notereg and Breg cells, which are crucial for the tolerance process and long-term control of autoimmunity [Esrrg) spontaneously develop autoimmune diseases in association with dysfunctional Treg cells and mitochondrial defects [reg cells. TFEB has a critical role in this Treg cell differentiation and function by improving mitochondrial fitness [Global inhibition of mitochondrial physiology is not always helpful in autoimmune diseases and can be deleterious for the function and maintenance of Timmunity ,51. Mice defects . Further defects . AutophaGiven the link between mitochondrial dysfunction and type I IFN synthesis, it has been hypothesized that modulating or improving aberrant neutrophil mitochondrial dysfunction and myeloid bioenergetics could have beneficial effects in SLE. Indeed, mROS scavengers and inhibitors of VDAC oligomerization can attenuate lupus features in mice and normalize dysregulated neutrophil responses ,28. AdmiDespite all the caveats related to global modulation of immunometabolism in autoimmunity, there is also promising data in which systemic treatment with metformin  together with 2-deoxyglucose (to reduce exacerbated glycolysis) displayed beneficial effects in murine lupus models and in vitro experiments with T cells from patients with SLE ,60. HoweSignificant advances in understanding mitochondrial physiology and metabolism in immune cells highlight that targeting abnormalities in these pathways could benefit the treatment of autoimmune diseases. Indeed, future research should focus on developing strategies to generate effective immune tolerance, mitigate mitochondrial dysfunction, and enhance mitochondrial functionality. More research into metabolic dysfunction in various immune cell subsets in autoimmunity, its triggers, and cell-specific versus systemic effects will be needed before more targeted approaches can be designed. Efforts toward modifying aberrant mitochondrial physiology may help prevent or revert tissue damage in systemic inflammatory conditions. Given the complex effects of immune metabolism in homeostasis and disease, it remains unclear whether these approaches could also promote significant deleterious effects. It is expected that the next decade, with the significant advances in multi-omic approaches and disease pathophysiology will clarify the benefit, risks, and feasibility of targeting mitochondrial dysfunction in chronic autoimmune diseases.


Microbial symbionts could intervene with the physiological processes of insect chemoreception, such as changing the processing, transmission, and integration of olfactory or gustatory signals and thereby improve or reduce insect sensitivity to semiochemicals, which in turn adjusts insect behavior. The influence of microbial symbionts on insect chemical communication facilitates the spread of symbionts but could be beneficial or detrimental to insects, which provides the impetus for the co-evolution of symbiotic systems. The association between microbial symbionts and insect chemoreception could be exploited to develop new insect control strategies.Chemical communication is widespread among insects and exploited to adjust their behavior, such as food and habitat seeking and preferences, recruitment, defense, and mate attraction. Recently, many studies have revealed that microbial symbionts could regulate host chemical communication by affecting the synthesis and perception of insect semiochemicals. In this paper, we review recent studies of the influence of microbial symbionts on insect chemoreception. Microbial symbionts may influence insect sensitivity to semiochemicals by regulating the synthesis of odorant-binding proteins or chemosensory proteins and olfactory or gustatory receptors and regulating host neurotransmission, thereby adjusting insect behavior. The manipulation of insect chemosensory behavior by microbial symbionts is conducive to their proliferation and dispersal and provides the impetus for insects to change their feeding habits and aggregation and dispersal behavior, which contributes to population differentiation in insects. Future research is necessary to reveal the material and information exchange between both partners to improve our comprehension of the evolution of chemoreception in insects. Manipulating insect chemoreception physiology by inoculating them with microbes could be utilized as a potential approach to managing insect populations. Chemical communication is widespread among insects and exploited to adjust their behavior, such as food and habitat seeking and preferences, recruitment, defense, and mate attraction . During Dengue virus (DENV) infection increases the gene expression in the mosquito’s head and leads to a reduction in olfactory preferences, potentially altering the preference of oviposition sites in female mosquitoes [Recently, mounting evidence suggests that microbial symbionts play essential roles in insect chemical communication. Many of these roles are usually regulated by microbe-produced chemical signals ,6. For isquitoes . HoweverThroughout their long-time evolution, insects have developed close associations with microbial symbionts, and both partners interact with and depend on each other while co-evolving simultaneously . Thus, aInsect olfaction is a complex process in which the peripheral olfactory nervous system transforms volatile molecules into electrophysiological signals, which are transported to primary olfactory centers and then integrated and processed in higher nerve centers, ultimately eliciting corresponding behavioral responses in insects . The senInsects possess a sophisticated gustatory system. The main gustatory organs known as gustatory sensilla are predominantly located on their legs and wings. Each sensillum contains multiple gustatory receptor neurons (GRNs) that express gustatory receptors (GRs), the pickpocket, IRs, or transient receptor potential receptors in their dendrites . The GR Nasonia giraulti, the male-to-female transfer of the endosymbiont Wolbachia pipientis to uninfected females increases the load of W. pipientis in the brain or sensory organs of the head region of females, which leads to the increased acceptance of females to interspecific mates [Apis mellifera, deformed wing virus (DWV) infection in the antennae reduces the olfactory sensitivity of middle- and forager-age honeybees to the odor of the essential oils of Eucalyptus globulus and Mentha piperita, and the increment in the viral load is negatively correlated with the olfaction of honeybees [Beauveria bassiana or Metarhizium acridum reduces host-seeking responses and olfactory neuron responsiveness tuned specifically to 1-octen-3-ol in the Asian malaria mosquito Anopheles stephensi [The association between symbionts and insect chemoreception is mostly found in the symbiosis of insects with endosymbionts or pathogens . Some miic mates . In the oneybees . Exposurtephensi .Drosophila melanogaster, larvae fed with antibiotics have a lower gut microbial load and exhibit a decreased chemotaxis reaction toward odorants, and this phenomenon is partially rescued in larvae treated with probiotics that results in the partial recovery of the microbial load [Wolbachia could enhance host olfactory responsiveness, and Wolbachia-infected Drosophila simulans is more sensitive to ethyl acetate odor than uninfected controls [Bemisia tabaci prefers to feed on healthy plants after the acquisition of Tomato chlorosis virus (ToCV), while healthy whiteflies have a feeding preference for ToCV-infected plants [As the insect host needs energy partitioning between immune reaction and normal physiological activity , extremeial load . This incontrols . Similard plants . These fGrammia geneura, with lethal parasites results in the altered taste perception of specific phytochemicals in the caterpillars. Compared with unparasitized caterpillars, the taste cells of parasitized individuals increase their firing rates when exposed to pyrrolizidine alkaloids and iridoid glycosides that are toxic to parasitoids but reduce their firing rates in response to deterrent caffeine, which drives the caterpillar to ingest normally unpalatable plants. It was also found that there are no differences in the response of caterpillars to sucrose, a phagostimulatory nutrient. As the sucrose sensitivity is mediated by the same gustatory neuron as iridoid sensitivity, it implies that the modification of sensory neurons does not influence the whole cell but rather certain receptor proteins or their second messengers [The association between microbial symbionts and insect gustatory perception is rarely mentioned in existing studies. By comparing the proboscis extension response of germ-free honeybees and normal honeybees, it was found that the gut microbiota significantly elevates host sucrose sensitivity, and normal honeybees respond to lower concentrations of sucrose . Howeverssengers . It alsoMicrobial symbionts could intervene with the physiological processes of insect chemoreception, such as changing the processing, transmission, and integration of olfactory or gustatory signals  Figure .OBP3 expression in whiteflies [A. mellifera is upregulated by gut Lactobacillus Firm4 and Firm5 [B. bassiana stimulates the expression of SiCSPs and SiOBPs in the fire ant Solenopsis invicta [Microbial symbionts, such as viruses, gut bacteria, and entomopathogenic fungi, can enhance insect sensitivity to chemical signals by regulating the expression of OBPs. DENV infection leads to an increased AeOBP22 expression within the mosquito salivary gland , and ToCiteflies . Obp14 end Firm5 . Infecti invicta . Obvious invicta .Drosophila larvae [D. melanogaster with the picorna-like Drosophila C virus. Phk-3 is also expressed in macrophage-like S2 cells, and its expression is enhanced when treated with LPS, suggesting that Pherokines might participate in the immune reaction [OBPs share structural similarities with other proteins involved in the binding and transportation of other signals, such as RYA3, that displays critical sequence homology to the lipopolysaccharide (LPS)-binding protein . This raa larvae . Pherokireaction .Glossina morsitans morsitans, the obligate symbiont Wigglesworthia upregulates obp6 expression in the gut of intrauterine tsetse larvae. This process is essential and sufficient to trigger the systemic expression of the hematopoietic RUNX transcription factor lozenge, leading to the subsequent generation of crystal cells (a type of hemocyte) that could activate a melanotic immune reaction in adult tsetse [There are other mechanisms for the symbiont-induced overexpression of OBPs to enhance the host immune capacity. In the tsetse fly t tsetse .Locusta migratoria. The pathogenic fungus Metarhizium anisopliae generates phenylethyl alcohol (PEA), which induces behavioral repellence in locusts. LmOBP11 participates in the insect detection of PEA and aversion of food contaminated with PEA, but the upregulation of LmOBP11 expression upon M. anisopliae infection has a negative impact on insect immune reactions. Furthermore, the expression of an extracellular serine protease that is involved in generating the Drosophila Toll ligand Spätzle is markedly upregulated in locusts co-treated with LmOBP11 dsRNA and M. anisopliae infection, suggesting that LmOBP11 acts as a negative regulator modulating immune-protease-related functions [Overall, multiple functions of pathogen-induced OBP overexpression in host chemoreception and immunity will elicit host immune priming, where earlier experience with a low dosage of pathogen infection affords defense against subsequent infection with the same pathogen . A countunctions . This fiNosema ceranae induces a downregulation of OBP expression in A. mellifera, which could then lead to a reduction in host olfactory sensitivity [Anopheles gambiae, OBPd-1, is downregulated by the Salmonella typhimurium infection [Aedes aegypti with a double subgenomic Sindbis virus leads to a significant reduction in AaegObp1 and AaegObp2 mRNA levels in olfactory tissues compared with controls, suggesting that this virus expression system can be utilized to effectively suppress OBP expression [Infection with certain microbes could also suppress host OBP expression. A high load of DWV or parasitism by a microsporidian parasite sitivity ,33. One nfection . The inopression .Wolbachia increases the sensitivity of D. simulans to food odors by enhancing the host transcript levels of the odorant receptor co-receptor gene or83b [Spodoptera exigua multiple nucleopolyhedrovirus (SeMNPV) is an entomopathogenic double-stranded DNA virus that mainly infects the beet armyworm Spodoptera exigua. OR35 is upregulated in larvae infected with SeMNPV, which renders S. exigua to recognize a broader spectrum of odor molecules with diverse chemical structures [Rice stripe virus significantly upregulates olfactory receptor co-receptor transcripts in the small brown planthopper Laodelphax striatellus, resulting in enhanced olfactory sensitivities and improved seeking abilities to the odor of rice plants compared with healthy insects [Microbial symbionts can alter insect olfactory perception by manipulating the expression of ORs. Infection with ne or83b . Spodoptructures . In the  insects .The gut microbiota may modulate host taste preferences by regulating the expression of GRs. While associations between gut microbiota and host gustatory functions have not been systematically illustrated in insects, a possible mechanism of receptor manipulation by gut bacteria has been found in the studies of germ-free murine. For example, germ-free mice possess a larger number of sweet receptors and higher preferences for sweet compared with normal mice, which may subsequently influence the structure of the gut microbial community and increase the risk of metabolic disorders ,52. ThisThe metabolism of signal molecules by ODEs is essential to maintaining the sensitivity and specificity of chemoreception in different insects, and several specific esterases, cytochrome P450s (CYP450s), glutathione S-transferases (GSTs), and UDP-glycosyltransferases (UGTs), are involved in this process . At presBacillus subtilis, Escherichia coli, and Lactobacillus plantarum, are known to generate neurotransmitters such as dopamine, acetylcholine, serotonin, noradrenaline, and gamma-aminobutyric acid (GABA) [Caenorhabditis elegans, the neuromodulator tyramine generated by commensal Providencia bacteria is probably transformed to octopamine by the tyramine β-hydroxylase enzyme of the host. Octopamine subsequently targets the OCTR-1 octopamine receptor on ASH nociceptive neurons to regulate a repellent olfactory response [It has been proposed that elevated amounts of microbiota-produced chemical messengers may be a crucial intermediate for crosstalk between bacteria and host neurons . Severald (GABA) . GABA prd (GABA) . Furtherresponse .Pale and Ddc, are upregulated in Wolbachia-infected D. melanogaster [Wolbachia-infected A. aegypti has higher dopamine levels in their heads [Toxoplasma gondii compared with uninfected cells and, consequently, the aversion of mice to cat odor is changed into attraction [Microbial symbionts can also regulate host chemical messenger biosynthesis. Dopaminergic signaling plays a pivotal role in regulating insect activity. Two essential genes in the dopamine biosynthesis pathway, nogaster . Similarir heads . Dopaminir heads . This phtraction .D. melanogaster and Erwinia carotovora carotovora 15 (Ecc15) is a typical example to explain how microbial symbionts regulate the host nervous system [Ecc15. However, flies infected with Ecc15 show significant aversion to food containing Ecc15, indicating that Ecc15 infection increases host olfactory discrimination. It is further found that Ecc15 infection can regulate fly olfaction via the metabolic reprogramming of ensheathing glia of the antennal lobe. Gut-derived inflammatory cytokines induced by Ecc15 modulate glia/neuron metabolic coupling in the fly brain, which increases lactate and lipid transport between olfactory neurons and glia and consequently results in lipid droplets accumulation and the upregulation of mitochondrial β-oxidation in glia. Increased oxidative stress from β-oxidation results in the age-related dysfunction of cholinergic projection neurons within the olfactory circuit, thus inducing an adaptive temporary halt of olfactory discrimination upon gut infection. Such alterations in the olfactory system help to enhance the avoidance of flies to bacteria-laced food and promote fly survival [The symbiotic system of s system . Flies wsurvival .Wolbachia infection shortens the memory duration of the wasp Trichogramma brassicae compared with uninfected individuals and thus stimulates the dispersal of the endosymbiont by manipulating hosts to forget the information of prior environments [A. mellifera, which are less able to associate an odor with a reward [N. ceranae could modulate the immune system of honeybees by enhancing oxidative responses or altering the expression of antimicrobial peptides [N. ceranae is due to an activation of the immune reaction [N. ceranae also disturbs the serotonin metabolism by, for instance, suppressing the expression of the dopa decarboxylase-encoding gene [Drosophila [Microbial symbionts also affect olfactory sensitivity via interference with the host olfactory memory. ronments . The stia reward . N. cerapeptides . It is treaction . Moreoveing gene , a biogeosophila .Drosophila displays a moderate decline in memory performance during olfactory appetitive conditioning compared with normal flies [D. melanogaster is a neural circuit that plays a crucial role in the formation and storage of memories [Ecc on the olfactory nervous system of Drosophila, and it is assumed that the ingestion of Ecc strengthens synaptic connections between the neurons that transport unconditioned stimulus information and the mushroom body Kenyon cells, thereby enhancing olfactory-conditioned stimulus information in insects [Lactobacillus is required for olfactory learning and memory abilities. Aromatic amino acid aminotransferase (ArAT) converts tryptophan to serotonin, kynurenine (Kyn), and indolic compounds, which exert a profound influence on gut–brain interaction. ArAT produced by gut Lactobacillus strains could upregulate tryptophan metabolism, thus improving the learning and memory performance of honeybees [Conversely, sterile al flies . The musmemories . Numerou insects . Using loneybees .Drosophila paulistorum mating with the ‘wrong’ partner (belonging to another incompatible semi-species) is harmful for both the symbiont and the host . Therefore, this symbiotic relationship has developed delicate modalities to recognize the infection type of the latent mate before mating by active mate avoidance [The manipulation of insect chemosensory behavior by microbial symbionts is conducive to their proliferation and dispersal. If such an association is beneficial to both partners, it can promote the co-evolution of the symbiotic relationship. Leafcutter ants are polyphagous herbivores that possess the ability to avoid plants containing chemicals detrimental to their symbiotic fungi. Therefore, the preference of leafcutter ants for plants is partly driven by the demand for fungi, which protects mutually symbiotic fungi from harmful compounds . Drosophvoidance .G. geneura larvae. Considering that these compounds are toxic to parasites and present in plants eaten by caterpillars, their altered taste may stimulate parasitized individuals to ingest more plants that offer a biochemical defense against parasites [Infection with parasites or pathogens adversely affects the host, and insects can change their feeding habits by enhancing their chemical sensing to meet the demand of their own survival and reproduction. Infection with lethal parasites changes the taste of specific phytochemicals, such as pyrrolizidine alkaloids and iridoid glycosides, in arasites . Furtherarasites . This maParanosema locustae suppresses the aggregation of solitary Locusta migratoria manilensis and causes gregarious individuals to shift back to solitary behavior. Healthy locusts exposed to olfactory stimuli from parasite-infected conspecifics exhibit a significant reduction in serotonin levels, leading to decreased gregariousness [Erynia neoaphidis decreases the sensitivity of the pea aphid Acyrthosiphon pisum to alarm pheromone, and the percentage of nonresponding aphids increases as the disease progresses [The suppression of host chemosensitivity induced by parasite or pathogen infection will affect host aggregation and dispersal behavior, which facilitates population segregation. Infection with the microsporidian parasite iousness . This triousness . Infectiogresses . AlthougSymbiotic associations between insects and microbial symbionts are universal in nature. Symbiosis offers a chance for microbial symbionts to live together through a mutual or one-way benefit with insects. Insect chemoreception system perceives volatiles, and microbial symbionts can cause alterations occurring at any point in the process from recognizing the signal to transmitting it to the brain to elicit a response. Symbionts not only impact insect chemoreception through interference with the expression of host OBPs/CSPs, ORs/GRs, and ODEs but also fine-tune host chemosensory neurotransmission, thus regulating insect behavior. Microbial symbiont-mediated chemoreception facilitates the spread of symbionts but could be beneficial or detrimental to the hosts, which provides an impetus for the co-evolution of symbiotic systems.Although insect-symbiont interactions have always been a research hotspot in the insect ecological field, the molecular mechanisms by which gut microbes modulate host physiology, however, remain largely unknown . Future Sindbis virus expression system can suppress OBP gene expression in the olfactory organs of mosquitoes [Sogatella furcifera to Southern rice black-streaked dwarf virus-infected rice plants switches from preference to non-preference after M. anisopliae infection. Interestingly, the OR23 and OR43 are downregulated after pathogenic fungal infection and could be used as targets to develop strategies  to suppress the capability of S. furcifera to transmit this virus [Manipulating insect physiology by inoculating them with microbes is a potential method to reduce the application of insecticides in pest management. The double subgenomic squitoes , which pis virus .


Zea mays L.) crops. Concerns about the negative consequences of chemical pesticide use on people’s health and the environment, as well as the emergence of insecticide resistance, have accelerated attempts to discover alternatives that are effective, low-risk, and cost-effective. Maize-legume intercropping systems are known to have multiple benefits to agroecosystem functioning, including pest regulation. This review focuses on the influence of maize-legume intercropping systems on insect diversity and abundance as a mechanism for insect pest regulation in maize crops. First, this review combines knowledge of maize-legume intercrops, with a particular emphasis on the mechanism by which this practice attracts beneficial insects  to reduce pest damage in intercropping systems. In addition, the pairings of specific legume species with the greatest potential to attract more beneficial insects and therefore reduce maize pests are also discussed. Finally, future research needs are also recommended. Findings are reviewed in the context of looking for long-term management strategies that can increase the adoption of integrated pest management programs in maize-based production systems.In many parts of the world, chemical pesticides are the primary method of pest control in maize ( Although intercropping is a widespread traditional agricultural practice world-wide, to the best of our knowledge, few studies have conclusively demonstrated how maize intercropped with legumes increases the population of beneficial insects, resulting in less phytophagous damage in maize plants.This work is significant as in tropical areas, intercropping is widely used by small-scale farmers. It is also relevant for researchers due to the lack of information about the mechanism used by this practice to control major pests in the main crop  that cause crop damage, as well as beneficial insect species  capable of suppressing phytophagous species populations. In cereal-legume agroecosystems, maize-legume intercrops are a good model system that can help us better understand the behavior of insects and their associated natural enemies in such cropping systems (S. frugiperda (J. E. Smith), a Lepidopteran pest attributed to up to 60% yield damage in some maize-producing regions globally  (Lepidoptera)), which damages ears by feeding initially on silk tissue and then on the ear tip and kernels , soybean (Glycine max L.), and cotton Gossypium hirsutum L.  (Diptera: Agromyzidae)), ootheca (Ootheca benigeni (Coleoptera: Chrysomelidae)), bruchids (Acanthoscelides obtectus and Zabrotes subfasciatus (Coleoptera: Chrysomelidae)), and aphids (Aphis fabae (Hemiptera: Aphididae)) cause 37% to 100% yield loss in common bean. Additionally, pests such as corn rootworms or cucumber beetles (Diabrotica spp.) pose a significant threat to maize crops as they feed on the roots of young plants. Other pests that affect maize production include the European corn borer (Ostrinia nubillais), the corn leaf aphid , and cutworms (Agrotis ipsilon).These species also consume a variety of economically important crops like cowpea, lima beans, common bean, soybean, maize, and peanuts (Arachis hypogaea L.) (The larvae of and ears . Young land ears . Corn eaand ears . This inand ears . Variatiand ears . Other pgaea L.) . In the gaea L.) . This dagaea L.) . These aAphis fabae) was considerably lower when beans were intercropped with older and taller maize plants (A. evuncifer and C. sjostedti) have been reported as highly damaging species to maize  revealed that natural enemies were more numerous and diversified in monocultures than in stands of mixed crop species  as the arrangement of the crops may affect directly the predator insects attraction , which actively limit the number of herbivorous insects  attracts entomopathogenic nematodes in maize plants (For the control of he world . Harrisoasitoids . For exae plants . Increase plants . In maize plants .S. frugiperda by Trichogramma sp. (Hymenoptera: Trichogrammatidae) were recorded in maize/broad bean intercrops compared to the monocrop of maize   , crop disitoids) . In ordes) e.g., .Cotesia icipe (Hymenoptera: Braconidae) and Coccygidum luteum, two major larval parasitoids of S. frugiperda, were attracted to the volatiles of all three companion plant species (The increase in parasitoid species number can be linked to multiple causes in intercropping systems. Some of these insects use plant scents or visual cues to locate their hosts by locating the plants on which they are located . In such species . DespiteIncluding legume plant species in maize-based intercropping systems is regarded as a highly effective and dynamic insect pest control tactic. Nevertheless, the selection of legume species with sufficient mass-flowering must be considered to assure the effectiveness of maize-legume intercrops to attract more beneficial insects and therefore reduce the pest population in maize. It is vital to comprehend the process by which maize-legume interactions increase insect diversity and abundance in order to develop effective pest management techniques for maize-legume intercropping systems around the world. Extremely sophisticated phytophagous insect defenses against beneficial insects have impeded the selection of insect-resistant legumes for intercropping with maize-based planting strategies; however, this is not always the case as suggested by the “resource concentration” hypothesis. This review demonstrated that maize-legume relationships boosted the diversity and abundance of beneficial insects, consequently decreasing the number of phytophagous insects.Although maize-legume intercropping systems have been identified as a promising approach to reduce pest infestation in maize, there is a lack of specialized research on how parasitoids and predators interact with various resistant phytophagous insects in these systems. Future research should focus on discovering how insect pests have co-evolved to resist the abilities of beneficial insects to reduce them. Identifying the mechanism of phytophagous insect counter-adaptations to natural enemies would allow us to comprehend the rate at which maize insects adapt to natural enemies and set new objectives for the development of sustainable pest control programs in maize-based legume intercropping systems. Further, the discovery of legume species that attract particular predators and parasitoids may play a crucial role in boosting the sustainability of pest management programs in maize-based intercropping systems. For example, Sekamatte et al.  discoverThe findings of this review demonstrate that intercropping maize and legumes may increase insect diversity and abundance and that beneficial insects preferred maize-legume intercropped habitat by altering the population dynamics of insects in the cropping system. In addition to volatile compounds emitted by partner crops in intercropping, the maize-legume intercropping system enhances the number of beneficial insects by providing pollen, nectar, alternate prey, shelter, and overwintering places. Thus, the maize-legume intercropping system promotes an environment suitable for the optimal delivery of ecosystem services, which may contribute to agricultural sustainability. Nevertheless, there is ample room for additional research on interactions between phytophagous insects and beneficial insects in maize-based intercropping systems, particularly identifying which legume species is more likely to attract more effective beneficial insects that can harm maize phytophagous pests. Even though maize-legume intercropping is one of the most effective ways to eliminate maize pests, little is known about how generalist predators can have a negative effect on the diversity of other predators and how phytophagous insects in maize-legume intercropping systems protect themselves from predators and parasitoids. This opens the door for additional research on the influence of maize-legume intercropping on the interaction between insect-plant relationships. Overall, intercropping maize with legumes can be used to effectively control pests in maize production systems, hence reducing the requirement for chemical insecticides.


Poorly differentiated thyroid carcinoma (PDTC) is a rare entity of thyroid cancer with an intermediate clinical behavior between differentiated and anaplastic thyroid cancer. Here we present a patient who was referred to the endocrinology clinic for evaluation of hyperthyroidism and multinodular goiter. Due to presence of right toxic thyroid nodules and compressive symptoms, the patient underwent right lobectomy and isthmectomy, where surgical pathology revealed PDTC in the right thyroid lobe. Based on this unusual case of malignancy within a toxic nodule, we propose further evaluation of hot nodules with concerning features such as growth rate. Furthermore, exploration of relative sodium iodine symporter (NIS) expression in PDTC may help us better understand how iodine uptake changes as PDTC develops, which may impact our approach to assessing and treating PDTC in the future. Poorly differentiated thyroid carcinoma (PDTC) accounts for about 6% of thyroid cancers and is thought to have an intermediate clinical behavior between differentiated and anaplastic thyroid cancer . AlthougPDTC tend to present late clinically . Thus, aA 66-year-old male with a urothelial carcinoma and history of metastatic transitional cell carcinoma to the lung, with a history of left upper lobectomy, presented to the endocrinology clinic for evaluation and management of hyperthyroidism and multinodular goiter. Upon evaluation, he endorsed right-sided neck discomfort, but denied dysphagia, odynophagia, voice changes, heat intolerance, palpitations, tremors, diarrhea, unexplained anxiety, or weight loss. There was no history of neck irradiation or family history of thyroid cancer. On physical examination, he was found to have an asymmetric thyroid gland with right lobe enlargement, firm and nontender. He had no proptosis, exophthalmos, lid lag, or fine tremors. Six months prior to his endocrinology office visit, the patient was evaluated by otolaryngology  for an enlarged right thyroid lobe with calcifications seen on computed tomography (CT) of the chest without intravenous contrast and diffuse hypermetabolic activity in right thyroid lobe on positron emission tomography (PET) CT. An in-office thyroid ultrasound was performed, followed by ultrasound-guided FNA of the right isoechoic solid thyroid nodule. It was unclear why the right hypoechoic solid thyroid nodule was not biopsied at that time. The patient was concerned about palpable right thyroid lobe enlargement and right lobectomy was discussed but not pursued immediately. A thyroid function test was performed, revealing a suppressed thyroid-stimulating hormone (TSH) level with elevated free thyroxine (T4) which prompted referral to the endocrinology office. When taking the previous findings into consideration, along with the presence of hyperthyroidism, the decision was made to obtain an iodine-123 (I-123) thyroid uptake scan in addition to checking thyroid-stimulating immunoglobulins and TSH receptor antibodies to rule out Graves disease.The thyroid ultrasound performed in the ENT office prior to the endocrinology office visit shown in , revealeIn view of the compressive symptoms and enlarged right thyroid lobe, the patient underwent right lobectomy and isthmectomy.Surgical pathology shown in  showed aOur patient's case presents multiple interesting findings. First, the presence of discordance in results of the negative FNA and the surgical pathology results showing PDTC. FNA is considered the gold standard for diagnosis of thyroid nodules >1 cm with suspicious features . There aAs PDTC has significantly lower 5, 10, and 15 year-survival rates than well-differentiated thyroid cancers , the impAnother interesting feature of our case presentation was the I-123 uptake pattern demonstrated. It is generally accepted that thyroid nodules that have avid uptake of I-123 (“hot nodules”) are less likely to harbor a malignancy compared with a nodule that is not iodine-avid. Some clinicians think of PDTC as thyroid cancer that does not trap iodine on radioiodine scans and mention that the ATA recommends CT/PET scans for initial staging and monitoring of patients with PDTC . AlthougPDTC is thought to arise from either de-differentiation of a well-differentiated thyroid cancer or a de novo mutation of benign thyroid follicular cells with both early and late driver mutations . In a puThe exact mechanism of iodine uptake in a patient with PDTC is unclear, although the variation in ability to uptake iodine might be related to variation in sodium iodine symporter (NIS) expression in different subtypes of PDTC. Nikitski et al suggested that there may be unique subtypes of PDTC with variation of NIS expression . In thisWe recommend consideration of nodule growth in determining treatment/intervention rather than FNA alone.Examination of NIS expression may lend keen insights into the variation in iodine uptake among different subtypes/stages of PDTC, and this should be further explored in humans .All authors made individual contributions to authorship. A.C. was involved in the diagnosis and management of this patient. A.C., H.A., and K.Y. were involved in manuscript writing and submission. All authors reviewed and approved the final draft.


The poorest 50% of the global population live in countries with access to only 1% of the annually distributed morphine-equivalent opioid stock.2 Such inadequate access to evidence-based pain and symptom management is a substantial barrier for patients living in LMICs.1 These inequities are compounded by the paucity of formalised programmes for palliative care training in LMICs, with few exceptions.1 In some cases, surgeons are the only available health-care professionals treating patients with health-related suffering in LMICs given the shortages of a workforce specialised in palliative care.4 Thus, interdisciplinary approaches between surgery and palliative care are crucial to improving a streamlined, cross-team partnership with a range of health-care professionals, such as nurses, who comprise nearly 60% of the global health-care workforce and have the numeric power and clinical competency to effectively implement point-of-care and system-wide practice changes in palliative care access and delivery.7Surgeons and multidisciplinary surgical teams are vital contributors to fully integrated palliative care services throughout the care continuum—from serious illness diagnosis to surgical intervention , and during end-of-life care. These teams are often a unique point of contact between patients and health-care systems. Surgeons can make substantive contributions to palliative care provision through expert clinical decision making and technical skills, as well as person-centred and family-centred communication and building relationships to ensure goal-concordant services and optimal quality of life for the patient.8 A palliative care approach in these circumstances would empower surgical teams to identify the underlying causes of distress and partner across specialties to recommend and deliver improved support. In robust, global academic–practice partnerships, such as in Ethiopia,9 there is a need for surgical–palliative care collaborations to strengthen the quality of service and overall care delivery, and to promote the reintegration of patients into the community after treatment interventions. For example, strategic surgical-palliative care interventions that emphasise early and ongoing symptom management and long-term, whole-person needs assessments could help to narrow the disparities in 2-year post-surgical survival rates in patients with breast cancer in urban (74%) and rural (46%) areas, which might be partly attributed to stigmas associated with the disease and treatments .9 In India—with longstanding governmental and non-governmental palliative care provision10—multidisciplinary palliative care specialists can provide general and targeted palliative care training that can be adapted by surgical teams to meet their unique service and patient needs. Additionally, palliative care specialists and surgeons in these settings can merge resources to advocate for balanced, controlled, and essential access to medicines  while identifying regulatory pathways needed to mitigate opioid misuse and diversion.There are ample opportunities to involve surgical care teams in providing palliative care services in LMICs, thereby alleviating the experience of suffering for patients, family caregivers, and communities. In Chile, almost half of the 727 362 surgeries done in 2021 were for patients with conditions requiring ambulatory surgical procedures and placed on waiting lists that often delay the relief of suffering.There should be international and multi-stakeholder commitment to embed competencies in primary palliative care throughout surgical curricula and global health research endeavours. Such skills will equip surgical teams to foster relationship-based care with patients, caregivers, and communities; optimise pain and symptom management; elicit patients’ core values; provide psychosocial screening and care; and participate in iterative advance care planning in the face of unpredictable serious illness and perioperative courses. Increased investments in palliative care will also empower investigators to ensure research is designed and implemented from a community-based and people-centred stance.Several recommendations for surgical teams and palliative care specialists are provided (panel). We recognise the substantive resource constraints facing surgical teams and do not suggest formalised palliative care delivery as another task shifting expectation. Rather, our suggestions are about task integration. Ultimately, learning to integrate palliative care principles in everyday surgical practice will improve perioperative quality, person-centredness, and physical and psychosocial outcomes through holistic assessment and intervention. Data are needed to understand the perspectives of surgical teams on how best to increase the knowledge of palliative care in surgical training, practice, and research.11 capable of grasping patients’ narratives, values, preferences, and goals, while using empathic communication skills to measurably inform outcomes. The capacity of surgical teams to build on palliative care practices prepares them to facilitate encounters that transcend disease-focused or transactional interventions. Palliative care provision at the surgical–generalist level will move us towards care models that honour patients’ personhood and wellbeing while enabling health systems in LMICs to make universal health coverage  a societal reality.Arguably, all surgical teams should be palliative care oriented,