Epilepsy is a neurological disorder affecting around 1%–2% of population worldwide and its treatment includes use of antiepileptic drugs to control seizures. Failure to respond to antiepileptic drug therapy is a major clinical problem and over expression of ATP-binding cassette transporters is considered one of the major reasons for pharmacoresistance. In this review, we have summarized the regulation of ABC transporters in response to oxidative stress due to disease and antiepileptic drugs. Further, ketogenic diet and antioxidants were examined for their role in pharmacoresistance. The understanding of signalling pathways and mechanism involved may help in identifying potential therapeutic targets and improving drug response. Epilepsy is a neurological brain disorder, affecting around 1%–2% of the population worldwide , alteredIt is worth noting that the abnormal neuronal discharge occurring in epilepsy consumes massive amounts of energy, accounting for extensive oxidative stress observed in the disease. Hence, oxidative stress has become an emerging event in the pathophysiology of epilepsy. The disturbed pro-oxidant antioxidant balance creates an accumulation of free radicals, which are toxic and can damage lipids, proteins, or nucleic acids and cause mutation and cell death. Therefore, our first goal was to review the contribution of disease and AEDs to oxidative stress. Since ABC transporters are known to be critically involved in influencing drug pharmacokinetics in epilepsy, it becomes important to review the studies showing alteration in ABC transporters in response to oxidative stress, so that we can exploit these studies to understand and comprehend how oxidative stress caused due to disease and drugs can affect ABC transporters. Furthermore, the importance of non-pharmacological treatments like ketogenic diet and antioxidants as an adjunct therapy to the available treatment to target epilepsy is discussed in the review and emphasis on drug-diet and diet-transporter interaction as an essential parameter is also argued.Oxidative stress has been implicated in a variety of disorders, including cardiovascular diseases, diabetes, and cancer, but the brain being a most demanding organ for oxygen makes it highly susceptible to oxidative stress. Hence, any pathological condition in brain requiring increased energy consumption will result in elevated reactive oxygen species (ROS) levels . Epileps2−) were significantly higher in the patient group. Moreover, activity of catalase which occurs in response to scavenge free radicals was also elevated. Since patients were on AEDs in both of these studies, it cannot be concluded that the increase was solely the consequence of epilepsy [Menon et al. performed a study to investigate that increased oxidative stress levels in patients with epilepsy is the result of the disease itself and not due to any of the AED medication. Most studied markers of oxidative stress, i.e., nitric oxide levels; lipid peroxidation; and protein carbonylation (PC) were checked in serum. The results showed a significant increase in levels of malondialdehyde  and PC in patients with epilepsy as compared to controls. However, AED treatment revealed no difference . In a stepilepsy .2− ions are also produced extracellularly as a result of seizure-induced hippocampal damage, possibly through activation of brain NADPH oxidase activity [Kainic acid, which is well known to induce seizures in vivo, was administered to Sprague-Dawley adult rats. Increase in activity of superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx) was observed within five days of exposure. Effect on lipid and protein oxidation was also seen as early as 8 h . Anotheractivity . Anotheractivity . Similaractivity , pilocaractivity , etc., s1 oxidoreductase (complex I) and cytochrome c oxidase (complex IV) were measured. Complex 1 activity was found to be decreased, which was the possible reason for enhanced neuronal cell loss and vulnerability to seizures [−/− mice, lacking an important mitochondrial antioxidant superoxide dismutase 2. EEG monitoring revealed an increased frequency of motor seizure activity in these mice with elevated brain levels of oxidative stress as confirmed by the levels of aconitase, coenzyme A (CoASH), and its disulphide (CoASSG) and 3-nitrotyrosine. This observation was reversed when endogenous ROS generation inhibitor AEOL 11207  was administered to SOD2 deficient rats [Epilepsy can also be a consequence of oxidative stress. Since the maximal contribution of cellular ROS comes from a leaky electron transport chain of oxidative phosphorylation in mitochondria , defectsseizures . Also, aseizures . Again, ent rats .There are a number of indications which reveal that, apart from contribution of disease, AEDs can also modulate pro-oxidant/antioxidant balance. Experimental investigations for the effect of AEDs on oxidative stress has been done both at in vitro and in vivo levels.Willmore et al. (1984), reported that phenytoin (PHT) treatment in rats prevented the occurrence of convulsive and EEG seizures; however, lipid peroxidation was unaffected. This revealed PHT masked convulsive seizures without preventing peroxidation causing biochemical brain injury . Mahle aStudies with second line AEDs have also investigated their role in oxidative stress. Reduced antioxidant capacity and toxic liver dysfunction have been observed in rats on topiramate for three months . However2+ in 1-Methyl-4-phenylpyridinium (MPP+) model of Parkinson’s in neuronal PC12 cells [Hepatotoxicity with aromatic AED viz. CBZ, PHT, and phenobarbital in rat liver microsomes was reported and it was suggested that it might be mediated by the oxidative stress induced by the drug metabolites . A group12 cells  were obsThe generated free radicals from AEDs cause toxicity by binding to fundamental biomolecules of cells and causing cell injury and death rather than having a neuroprotective effect on brain cells, aggravating the disease state. Thus, it has been observed from literature that conventional AEDs cause more oxidative stress and free radical generation than newer AEDs.ABC transporters have evolved to protect against oxidative stress generated from various reactive oxygen species. Toxic compounds generated are eliminated by ABC transporters after they are detoxified by conjugation to GSH, glucuronide, and sulphate. However, the protective function of ABC transporters may interfere with drug retention leading to pharmacoresistance through their efflux.P-gp, MRPs and BCRP transporters have been associated with AED resistance. P-gp is the extensively studied transporter in epilepsy followed by multidrug resistance related proteins  and breast cancer related protein . A first study by Tishler et al. that led to the formulation of multidrug transporter hypothesis showed increased expression of P-gp in capillary endothelial cells of patients with medically intractable epilepsy. They also reported decrease in steady state intracellular concentrations of PHT in P-gp expressing neuroectodermal cells compared with P-gp negative cells . FurtherThe efflux transporters remove their substrate drugs and restrict brain uptake. So, it is important to understand the substrate relationship of AEDs with ABC transporters. Lamotrigine, oxacarbamazepine, phenobarbital, and PHT are definite substrates of P-gp . EvidencThere are also in vivo studies to study substrate relationships. By using in vivo microdialysis in rats, Potschka et al. (2001) found enhanced concentration of CBZ in the extracellular fluid of the cerebral cortex in the presence of P-gp and MRP inhibitor verapamil and probenecid respectively. The data indicated that both P-gp and MRP participate in the regulation of extracellular brain concentrations of the CBZ . There aAs discussed earlier, wherein reactive oxygen species are involved in cytotoxicity, they can also play important role in signal transduction  through 2O2 generating system. Surprisingly, MRP1 protein expression increased 2.5-fold after 90 min of exposure, along with the increase in its functional activity [Ronaldson et al. in an attempt to demonstrate the role of MRPs in regulating oxidative stress observed in brains of HIV-1 infected patients found that these MRPs are also in turn regulated by these molecules. Primary rat cultured astrocytes were treated with HIV-1 gp120. Significant increase in cellular ROS and GSSH/GSH ratio was found at 24 h, which was indicative of oxidative stress. Besides, MRP1 mRNA and protein expression also showed a significant increase. To elucidate that oxidative stress is involved in this increase, the same cells were exposed to an Hactivity .Upregulation of P-gp and other ABC transporters including MRP1, 2, 4, and BCRP protein expression by an air pollutant diesel exhaust particle (DEP), affecting CNS pathology, provides another compelling indicator of oxidative stress mediated regulation of ABC transporters. DEP is shown to generate ROS through NADPH oxidase activation. Blockage of NADPH oxidase prevented DEP mediated increase in P-gp in isolated rat brain capillaries. When tissue culture medium was supplemented with SOD and catalase as ROS scavengers, again P-gp activity decreased. This suggests the role of oxidative molecules in transporter regulation . AmmoniaN-acetylcysteine (NAC). As previously mentioned, again NF-κB was established to be the mediator [Seebacher et al. 2015, in its study depicted how increased ROS levels contribute to MDR phenotype. Lung carcinoma cell lines as a tumor model were used to validate this. When the cells were exposed to varying glucose conditions, ROS generation increased in response to high glucose as well as glucose deprived conditions. Both these cases were also accompanied with simultaneous increase in P-gp activity. ROS induced P-gp activity was confirmed by reversal of increased P-gp activity after treatment with antioxidant mediator . Butylatmediator . Thus, iThe literature on the direct involvement of oxidative stress and ABC transporters in epilepsy is scarce. Zhang et al. reported increased P-gp expression in astrocytes of the hippocampus in rats after intracerebroventricular kainate injections and concluded that the increase in expression could be part of a cellular stress response program in these cells induced after neuronal injury . FurtherThere are other studies linking inflammation (which is elicited in response to oxidative damage) with ABC transporters ,78,79. MManaging patients with pharmacoresistance epilepsy is a challenge and requires a structural multidisciplinary approach. Treatment is limited to surgery and aggressive combination treatment with available AEDs. Non-pharmacological alternative treatments like implementation of ketogenic diet and antioxidants, for the symptomatic treatment of epilepsy have been very promising in recent times.Ketogenic diet is a medically regimented, high-fat, low protein/carbohydrate diet, used to treat pediatric and refractory epilepsy. The ketogenic diet is also an important coadjuvant treatment for most refractory and generalized epilepsies—such as Dravet, Doose, Lennox-Gastaut and West syndromes —and is oIn addition, it has been speculated that PUFA exert their diverse effects on ion channels and by activating nuclear receptors such as peroxisome proliferator-activated receptor-alpha (PPARα) ,92 that The burgeoning evidence from recent research studies has considerably highlighted the key role of the antioxidant/oxidative system in the pathogenesis of epilepsy. Antioxidants, endogenously formed and exogenously administered such as lipoic acid, mexidol, tocopherol, melatonin, resveratrol, vitamin C, and vitamin E have been evaluated for their efficacy in various models of seizures and shown to protect the brain against seizure induced damage as well ,49,50. TThough dietary supplements can have neuroprotective effects, concomitant treatment with AEDs can result in drug-diet interactions, further resulting in change in pharmacokinetic and pharmacodynamic parameters. Induction of CYP3A4 has been observed with Vitamin E  treatmenReports suggest that epilepsy is well-associated with oxidative stress levels in brain causing extensive neuronal damage. There is an extensive antioxidant imbalance and increased production of reactive species in epilepsy patients. Older generation AEDs cause oxidative stress and impact life quality of patients with epilepsy as compared to newer AEDs. Moreover, even after the development of new generation AEDs, 30% of the patients still remain refractory. There is a considerable gap in understanding this pharmacoresistance. Since overexpression of ABC efflux transporters plays a critical role in limiting access to AEDs and epilepsy drug resistance, the fact that oxidative stress generated during the course of the disease or due to AED treatment alters transporter expression at the blood-brain barrier. This may result in further worsening situation of patient with epilepsy. The alteration may result in either overexpression of transporters contributing to efflux of AEDs or downregulation culminating in increased cellular toxicity due to reduced efflux of oxidative molecules. From the above studies, we can conclude that oxidative stress activates a series of downstream factors or proteins—including Nrf2 and NF-κB—to finally regulate ABC transporters, thus reducing the brain drug efficacy . Identif


Both stroke and falls are common conditions affecting the older adult. Despite stroke being considered a well-established major risk factor for falls, there remains no evidence for effective prevention strategies for falls specifically for stroke survivors. Previous observational studies evaluating falls risk factors in stroke have mainly been uncontrolled and found similar risk factors for stroke populations compared to general older populations. Specific risk factors, however, are likely to play a greater role in stroke survivors including unilateral weakness, hemisensory or visual neglect, impaired coordination, visual field defects, perceptual difficulties and cognitive issues. In addition, individuals with stroke are also more likely to have other associated risk factors for falls including diabetes, falls risk increasing drugs, atrial fibrillation, and other cardiovascular risk factors. While anticoagulation is associated with increased risk of intracranial bleeding after a fall, the risk of suffering a further stroke due to atrial fibrillation outweigh the risk of bleeding from a recurrent fall. Similarly, while blood pressure lowering medications may be linked to orthostatic hypotension which in turn increases the risk of falls, the benefit of good blood pressure control in terms of secondary stroke prevention outweighs the risk of falls. Until better evidence is available, the suggested management approach should then be based on local resources, and published evidence for fall prevention. Multicomponent exercise and individually tailored multifactorial interventions should still be considered as published evidence evaluating the above have included stroke patients in their study population. The risk of stroke and falls both increase with age. In addition, stroke is an established risk factor for falls with up to 37% of all stroke survivors reporting at least one fall in the preceding six months . A recenThis clinical review presents published evidence for the epidemiology, risk factors, prevention and management of post-stroke falls. We will also propose a rational approach to the evaluation for falls risk and complications, as well as suggested topics for future research. Contentious issues such as anticoagulation and antihypertensive treatment will also be addressed.We searched PubMed and Google Scholar for English Language articles published after 2006, with titles, abstracts and keywords containing the words: (“stroke” OR “cerebrovascular disease”) AND . Additional articles were also obtained through the authors’ personal archives and cross-referencing.The incidence of falls after stroke reported in the literature varies with patient selection, geographical location and duration after stroke. A recently published community-based study involving 567 individuals with acute stroke in North Dublin established an incidence of 1.50 per 1000 person-years, with 23.5% of their stroke population reporting at least one fall in two years . Recent While recent studies now raise doubts about the previously reported increased incidence of falls after stroke over shorter terms of two years or less, published studies do suggest that stroke is associated with increased falls frequency or increased risk of recurrent falls ,9. JorgeStudies evaluating risk factors for falls in stroke have mainly been conducted exclusively among stroke survivors with few studies embarking on comparisons between risk factors among stroke and non-stroke populations to identify potential differences. The risk factors identified for falls in stroke are similar to those of falls in the general population ,11. FallIt is common practice to assume that motor weakness would be the primary reason why the stroke survivors should fall. While muscular weakness is a major risk factor for falls, the deficits associated with stroke are highly variable between each patient and stroke event, and highly dependent on the underlying stroke etiology and severity of stroke . While mCallaly et al. found that persons with a Modified Rankin Scale (MRS) of 2–3 at 90 days were at highest risk of falling two years post-stroke, whereas those with a MRS of 4–5 were at intermediate risk compared to stroke patients who could mobilize independently [Sensory deficits are often overlooked in stroke, and the role of this in falls post-stroke remains unclear. It is expected that as sensation plays a vital role in maintaining postural stability, sensory deficits will indeed lead to an increase in risk of falls post-stroke. Hemi-sensory neglect is also a common feature of anterior circulation strokes, particularly those with non-dominant hemisphere strokes. The associated anosognosia or lack of awareness of their physical weakness as well as potential dangers in their physician surroundings is a particular danger ,15. IndiVisual field defects, visual hemi-inattention, diplopia and cortical blindness may all occur as a result of stroke, all of which will require different management strategies .Cortical strokes affecting relatively silent areas of brain may also lead to delayed presentation, with falls or acute confusional state. Loss of sequencing or problem solving abilities will lead to difficulties in negotiating physical obstacles or performing daily tasks in a safe and effective manner ,18. LittCognitive function is often affected, and tend not to be regularly evaluated after stroke, with the main focus of management being on restoring function. However, even mild cognitive loss is likely to lead to impaired judgment, gait disorders and reduced ability to dual-task . A studyPosterior circulation strokes may lead to either cerebellar or vestibular deficits. The associated symptoms of vertigo are often distressing and difficult to control pharmacologically. Position sense and coordination, both essential components of balance, if impaired leads to compromised ability to maintain the upright posture, despite preservation of motor control .An increasing proportion of strokes are now being attributed to atrial fibrillation (AF) . The preAs both stroke and syncope are age-related disorders, falls related to syncope can co-exist with stroke-related falls. Little is currently known about the potential interactions between stroke and syncope. In addition to CSH, hypotensive disorders such as vasovagal syncope (VVS) and orthostatic hypotension (OH) may be more common following stroke due to primary autonomic nervous system involvement , the advDepression is a common complication of stroke as well as a well-established risk factor for falls in the general older population . The mecFear of falling, commonly assigned the term post-fall syndrome, had been considered a common and devastating consequence of falls leading to activity avoidance, social isolation and physical and psychological deterioration. However, in stroke, fear-of-falling is found to be highly prevalent regardless of the prevalence of falls. It is not entirely clear whether fear-of-falling is linked to increased risk of falls in stroke ,33.Blood pressure (BP) lowering therapy is now routinely prescribed post-stroke to those with at least Grade 1 hypertension (systolic BP > 140 mmHg and diastolic BP > 90 mmHg) . ConversRecent evidence has linked anticholinergic properties of both prescribed and over-the-counter pharmacotherapy with increased risk of both stroke and falls ,39,40,41The list of falls risk increasing drugs include medications commonly prescribed in the management of stroke and stroke complications, namely antidepressants and antiepileptics . The cavWhile the use of anticoagulants per se do not influence falls risk, anticoagulants are commonly discontinued after falls to avoid potential bleeding complications after falls including subdural hematoma, intra-abdominal bleeding and uncontrollable bleeding from fracture and soft tissue injury . HoweverIndividuals with post-stroke epilepsy occasionally present with falls, which are often unwitnessed . The posA recent systematic review has identified several published prediction models for falls which mostly included hemi-inattention for in-patient falls, and history of falls and balance measures for community studies . These iThere is currently inadequate published evidence to support specific recommendations for the investigations of falls for stroke survivors. However, as previous literature have highlighted similar risk factors in stroke and general adult populations, the investigative strategy barring a few exceptions should not differ from that of general older adult populations . A detaiAll stroke survivors who present immediately after a fall should first of all be evaluated for the presence of injury and other complications such as pneumonia. In addition, falls may also be precipitated by acute intercurrent illness such as acute gastrointestinal bleeding, urinary tract infection, myocardial infarction and decompensated heart failure, which could be life-threatening. All fallers should be investigated with a 12-lead electrocardiogram and postural blood pressure measurements. Postural BP measurements should be measured with non-invasive continuous beat-to-beat digital blood pressure measurements if available. Supine measurements should be recorded after at least 5 min of supine rest . If autoThe assessment of gait and balance is of vital importance. Visual observation of gait will reveal gait abnormalities associated with stroke such as the high-stepping gait or the broad-based gait. To improve objectivity, and to aid future monitoring of progress, validated physical assessment tools should be used. The Functional Ambulation Category is a commonly used measurement of walking ability post-stroke . MeasureHome hazards assessments should be performed by trained occupational therapists (OT) if possible, but non-OT tools are a trade-off in settings where OT services are not available . EnvironIn individuals with unexplained falls the presence of cardiac or neurocardiogenic syncope should be considered. An abnormal ECG and history of heart disease should raise the suspicion of cardiac syncope. Ambulatory ECG measurements should then be obtained . While 2In individuals with unexplained falls, carotid sinus massage or tilt-table testing should be considered to determine the presence of CSH or vasovagal syncope. Previous reports have warned against a small risk of stroke with carotid sinus massage used to diagnose CSH, but a recent multi-center study involving 1401 patients has reported no stroke complications with carotid sinus massage . These iThe role of brain imaging in post-stroke falls is often a source of potentially avoidable healthcare expenditure, with recurrent fallers sometimes subject to several CT scans within a year. The main reason for conducting brain CT scans after a fall is to detect subdural hematomas. Therefore, brain scans should be conducted should there be a history of head injury with loss of consciousness, reduced consciousness, signs of raised intracranial pressure, seizures or new focal neurological deficits on presentation . Many clThere is no established role for carotid Doppler ultrasound in the investigation of post-stroke falls. Transient ischemic attacks present with transient unilateral symptoms and signs with complete recovery, rather than falls. However, in individuals who are investigated with Doppler ultrasound as part of their post-stroke work-up, the presence of bilateral tight stenosis may discourage the physician from tight blood pressure control, though there is currently no evidence to support the concerns with regards to cerebral perfusion and subsequent falls. The role of EEG is only limited to those we suspect epilepsy. However, the inter-ictal EEGs may offer no additional diagnostic information above a good history from both the patient and a witness. Nevertheless, the sensitivity and specificity of EEG are unchanged among older adults compared to younger individuals .There is to date, no published evidence for effective prevention strategies for falls in stroke . The recSeveral potential approaches could be adopted in addressing falls prevention strategies. In the management of falls in the general population, clear distinctions are often drawn between primary and secondary prevention. If we were to base our recommendations on the body of evidence suggesting that stroke and cerebrovascular disease are established risk factors for falls, then the boundaries between primary and secondary prevention should be blurred in the stroke population, instead adopting blanket strategies for falls prevention measures regardless of falls history. However, with the recent publications suggesting that falls occurrence in stroke may not necessarily be as high as previously reported, perhaps an alternative approach of adopting published falls risk predictors to identify those most at risk and to concentrate resources on falls prevention in these individuals. In the absence of any clear evidence, we would recommend that the approach individual centers choose to adopt, i.e. universal vs. targeted approach, should be based on local availability of resources.Stroke survivors should receive individualized physical therapy as part of their stroke rehabilitative process. The handful of published studies involving intervention studies, some of which were non-randomized, had evaluated sit-to-stand training, early mobilization, standing and sit-to-stand training, exercise training, and balance training, mostly showed no actual reduction in falls recurrence or fall frequency, with the two studies reporting statistical significance containing small samples sizes and hence requiring cautious interpretation . There iThe benefits of medication review in falls reduction remains unclear even for the general older population. While numerous studies have linked falls risk increasing medications, potentially inappropriate prescribing and anticholinergic burden with falls, there is limited evidence that withdrawal subsequently reduces falls . In addiEnvironmental or home modification should very much be part of the long-term rehabilitation process following a stroke and falls prevention measures should always be incorporated into this discharge process in those who are ambulatory. In addition to removal of loose mats and walkway clutter, installation of grab rails, appropriate lighting, etc., the use of assistive technology for fall detection and prevention should also be considered. These could take the form of bed or chair monitors, wearable devices, infrared monitors, alarm button, and the list goes on . The latHypotensive disorders including CSH, VVS and OH are often drug related, and can be treated by optimization of medications as well as conservative measures including avoiding potential precipitants, ensuring adequate hydration and taking immediate abortive actions. Occasionally, the implantation of permanent cardiac pacemakers may be necessary in those with evidence of bradyarrhythmia on the ECG recording, CSM or tilt-table . Less frApart from early first cataract surgery, other studies on visual interventions in the general older population for the prevention of falls have yielded disappointing results . A previIn the two systematic reviews on falls interventions in stroke published so far including 13 and 10 studies, only studies involving Vitamin D supplementation and osteoporosis treatment improved falls outcomes in stroke survivors ,69. DailIndividualized multifactorial inventions have not been found to benefit individuals with stroke. Batchelor et al. evaluated the benefits of the modified Otago exercises in combination with falls education, falls risk minimization strategies and fracture minimization strategies in a randomized controlled study, and demonstrated no significant benefit with their multifactorial interventions . HoweverFalls in stroke survivors specifically remains an understudied area with no evidence of effective therapy for primary or secondary prevention of falls after stroke. Although the incidence of stroke appears to be reducing in developed nations despite population ageing, the absolute numbers of new strokes per year will continue to rise worldwide. With the burden of stroke and falls set to increase rapidly, more research in this area is now desperately needed. Nevertheless, published evidence so far suggests that risk factors for stroke are similar to that of falls in the general older population. Therefore, investigatory and management approaches for falls among stroke survivors should be similar to existing strategies adopted for general populations. Concerns with regards to blood pressure lowering therapy and anticoagulation among fallers with stroke appear unfounded.


With the aging of the world’s population, there has been a parallel growth of valvularheart disease. The development and establishment of less-invasive transcatheter aorticvalve replacement (TAVR) has provided a different framework to approach these patientsthrough a multi-disciplinary heart team for planning and treatment. Thismulti-disciplinary heart team allows the sharing of different expertise and knowledge inorder to improve patient care. Although TAVR is one example, many other transcatheterstructural heart interventions for the mitral valve, left atrial appendage, paravalvularleak closure, and tricuspid valve, will continue to expand the armamentarium ofless-invasive therapies for these typically high-risk patients.Within this context of continued expansion of devices and procedures, there has beenincreased demand for physicians with specific procedural-based skills and advancedcardiac imaging training in both echocardiography and cardiac computed tomography (CCT).However, the relative novelty of this subspecialty, brings many challenges. In thepresence of poorly defined training requisites and skill-sets and lack of appropriateprocedural reimbursement and recognition of the advanced level of peri-proceduralimaging and medical care provided, there are many barriers to sustainability andexpansion of this unique subspecialty.1 there are no specific trainingguidelines and/or requirements for SHD imagers as demonstrated by the results of arecent European survey.2 Some ofthe challenges currently faced by cardiology fellows who look for SHD imagingtraining include finding training centers with enough high-risk clinical volume andexposure to a variety of high-risk procedures so they can train beyond traditionalTAVR procedures. This brings an inevitable question of whether adequate SHD imagingtraining should therefore be reserved to a small number of centers with sufficientknowledge and experience in these procedures. What should constitute the minimalportfolio of procedures, their degree of complexity, the number of cases performedfor procedural planning and for intraprocedural guidance to achieve adequateproficiency are some of the questions whose answers remain unclear.Although training in multi-modality imaging has been well outlined,The majority of high-volume programs can provide comprehensive exposure for adequatetraining, particularly in TAVR, Atrial Septal Defect (ASD) and Left Atrial Appendage(LAA) closure procedures. Transcatheter mitral valve repair with MitraClip system is also becoming increasingly more commonlyperformed and should become a standard part of the SHD imager training. On the otherhand, transcatheter procedures such as paravalvular leak closure, transcathetermitral valve replacement and percutaneous tricuspid interventions are more complexand less frequently performed, and therefore should involve different expectationsfor what is considered the minimal requirement to achieve proficiency.3 One of the keycomponents is to have exquisite understanding of and training in these imagingmodalities so the imager can integrate and succinctly present information to theheart team, as well as provide value for further recommendations in diagnostictesting and interpretation of data, particularly when there are conflictingreports.We have recently provided a brief outline including some of the main characteristicsand attributes necessary for the success of Structural Heart Disease (SHD)imagers.In pre-procedural planning, review and synthesis of serial imaging studies isrequired to evaluate for progressive changes in cardiac function, chamber size, andseverity of valvular pathology. This is particularly important when multi-valvulardisease is present, which can pose a challenge in both diagnostic and therapeuticdecisions. More often than not, using multi-modality imaging and hemodynamicevaluation can be necessary to clarify the clinical question(s).During intraprocedural guidance, SHD imagers learn to be agile, focused, mindful andable to protect themselves from radiation exposure. The ability to applymulti-modality critical thinking to integrate and combine clinical information andimaging findings (fluoroscopy and TEE) implies a physician trained skill-set thatimagers can develop overtime. Interventional imaging physician drivingcritical-thinking imaging becomes invaluable to procedural success, much more thanany form of imaging overlay or fusion. In-depth knowledge of particular devices andprocedural steps, as well as clear, succinct and timely communication with theinterventional cardiologist and other team members are critical attributes of asuccessful SHD Imager, thus implying solid knowledge of the timing and importance ofhis/her role.Post-procedurally, SHD imagers must be able to correlate imaging findings withintraprocedural results and potential device complications. Exposure to a variety ofSHD interventions is required in order to generate sufficient imaging experience, toallow the mitigation of complications and to promote safety during high-risktranscatheter procedures. A SHD imager who has developed these unique skill setswill be an indispensable asset to a SHD heart team and a key component to achieveexcellent procedure safety and outcomes.Given the dynamic nature of this field, continued changes are expected on thestandard training curriculum, reflecting important updates in the medicalliterature, device iterations and procedural changes. This can be done by attendingannual meetings and industry-sponsored seminars, participating in online CMEopportunities and structural imaging workshops, all of which can help refresh andenhance imaging skills.4,5 it certainly represents one of the most important job hazardsfor the SHD imager. Both publications4,5confirm that the SHD imager can be subject to very high levels of radiation exposurein structural cases.Although the issue of radiation exposure was not adequately studied until relativelyrecently,5,6Therefore, given the increased complexity of these procedures, which demand morefluoroscopic and imaging guidance, one can only hope that it remains an importantarea for future research and technological development. At present time, a number ofsimple measures, such as the use of protective lead apron, portableceiling-suspended lead shield and distancing from the X-ray source, can provideimportant strategies to minimize exposure and the potential risk associated withit.Work environments and hospital management teams need to be supportive of andaccomodating to providing the necessary resources that can minimize the potentialconsequences of excessive radiation exposure outlined by the authors.At the majority of programs in the United States, the SHD Interventional Imager isconsidered part of the non-invasive general cardiologist group. This occurs atprivate-practice groups, hospital-employed group-practices or at major academiccenters. This creates a significant mismatch between the amount of time that isrequired to plan and guide complex SHD procedures, and the reimbursement currentlyallocated to the SHD imager. In the current model, the amount of work relative valueunits (wRVU) dictates the metrics for purposes of reimbursement and final wages.Simply put, the more procedures a physician does, the more studies he/she reads, themore he/she can charge.http://asecho.org/2018-medicare-physician-fee-schedule-final-rule].The current model does not reflect the time spent on procedural planning, therequired skill-set to successfully guide complex SHD interventions, nor does itaccount for the potential adverse health-effects on the SHD imager, such asradiation exposure. Let’s take, for example, an uncomplicated MitraClip procedure.This Mitraclip procedure is dependent on intraprocedural transesophageal (TEE)guidance, and requires 90+ mins of uninterrupted real-time TEE 3D imaging proceduralguidance. This is billed as one umbrella SHD intraprocedural TEE code (93355), withan associated wRVU measure of 4.66, therefore amounting to a $230 charge. Within thesame time frame, another “non-invasive” cardiologist could have read 10-15transthoracic echocardiograms  or 3-4 TEEs , which demonstrates, by traditional productivity metrics, morevalue to an institution than the Interventional Imaging physician functioning as asecond operator in the Mitraclip procedure who is additionally getting radiationexposure. [source: SHD imagers must continue to advocate recognition for the unique requirements tothrive in this emerging subspecialty. Sustainability within a SHD imaging careertrack is directly dependent upon fair productivity metrics. Many graduating fellowsshow a clear interest in pursuing further SHD Interventional Imaging training.However, current reimbursement practice models will deter potential trainees fromembracing this new subspecialty field of medicine. A salary-based model is morelikely to facilitate a successful SHD imaging career, as opposed to the traditionalwRVU productivity model. Until societal guidelines are established for this emergingfield, differential procedural codes will continue to fall short on allocating andcompensating SHD imaging time properly.7 emphasize theopportunity for a multi-societal level discussion. In order to allow sustainablegrowth and continue to provide the imaging support necessary for patient safety andthe success of these high-risk transcatheter procedures, it is necessary to revisethe current structural and payment model which provides insignificantacknowledgement to the SHD imager; a Co-operator who is absolutely necessary tosuccessfully execute this procedure.The presence of a skilled SHD imager is critical to the growth and success of anyhigh-volume SHD program. The recent, strongly positive results of the COAPTtrialTogether, these findings emphasize the critical need for and the opportunity torecognize SHD interventional imaging as a subspecialty within Cardiology and CardiacImaging and importantly, to legitimize the SHD imager as the second procedureoperator, equally dedicated to exceptional patient care.


To effectively address elder mistreatment (EM) in the emergency department (ED) hospitals must have mechanisms that promote and, to the extent possible, ensure patient safety post-discharge. However, the realities of working within busy hospitals--limited staff time, financial resources, and EM-specific expertise--prevent many EDs from being able to dedicate staff for patient follow up or develop EM multi-disciplinary teams. The fourth core element of the NCAEM’s ED Care Model aims to address this need with a roadmap for leveraging existing community resources. The roadmap provides streamlined tools to help hospitals assess their needs, identify existing teams and resources in their community, and connect with Adult Protective Services and other organizations. In this presentation we will present these tools and share case examples from beginning stages of feasibility testing in hospitals across the US. We will discuss specific strategies for implementing the model in hospitals of differing types, sizes, and resource levels.


Development of organ dysfunction discriminates sepsis from uncomplicated infection. The paradigm shift implicated by the new sepsis-3 definition holds that initial impairment of any organ can pave the way for multiple organ dysfunction and death. Moreover, the role of the systemic inflammatory response, central element in previous sepsis definitions, has been questioned. Most strikingly, a so far largely underestimated defense mechanism of the host, i.e., “disease tolerance,” which aims at maintaining host vitality without reducing pathogen load, has gained increasing attention. Here, we summarize evidence that a dysregulation of critical cellular signaling events, also in non-immune cells, might provide a conceptual framework for sepsis-induced dysfunction of parenchymal organs in the absence of significant cell death. We suggest that key signaling mediators, such as phosphoinositide 3-kinase, mechanistic target of rapamycin, and AMP-activated protein kinase, control the balance of damage and repair processes and thus determine the fate of affected organs and ultimately the host. Therapeutic targeting of these multifunctional signaling mediators requires cell-, tissue-, or organ-specific approaches. These novel strategies might allow stopping the domino-like damage to further organ systems and offer alternatives beyond the currently available strictly supportive therapeutic options. In this “perspective,” we summarize evidence that substantial changes in these signaling pathways during sepsis occur not only in the immune system but also in parenchymal cells. To target  cellular metabolic and signaling dysfunctions will open new avenues for therapeutic interventions.Severe metabolic dysregulation and circulatory failure are central to the definition of septic shock , 3 and sA paradigmatic example of sepsis-related organ failure is excretory dysfunction of the liver. Sepsis accounts for approximately 20% of admissions for jaundice, a rate that is only surpassed by malignant compression of the bile duct . WhereasLiver dysfunction also strongly challenges overall metabolic and immunological homeostasis in the critically ill and frequently promotes progression to multi-organ failure. Prolonged hepatic dysfunction interferes with the adaptive immune system . Accordivia two distinct strategies: resistance and disease tolerance  effects. Hence, before signaling mediators can be used therapeutically, it will be necessary to overcome the significant hurdles posed by these multifunctional signaling molecules. Nanoparticle-based targeted drug-delivery , 22, 59 The manipulation of key signaling pathways can be expected to significantly add to armamentarium of sepsis therapy, in particular, in the light of increasing antibiotic resistance.MB, SC, ML, SW, BL, and RW wrote sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.MB declares that he is co-founder and share-holder of a company aiming to develop PI3K inhibitors for target-specific treatment of organ dysfunction. RW holds patents related to the therapeutic use of PI3K inhibitors. All other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The central goal of medical genomics is to understand the inherited basis of sequence variation that underlies human physiology, evolution, and disease. Functional association studies currently ignore millions of bases that span each centromeric region and acrocentric short arm. These regions are enriched in long arrays of tandem repeats, or satellite DNAs, that are known to vary extensively in copy number and repeat structure in the human population. Satellite sequence variation in the human genome is often so large that it is detected cytogenetically, yet due to the lack of a reference assembly and informatics tools to measure this variability, contemporary high-resolution disease association studies are unable to detect causal variants in these regions. Nevertheless, recently uncovered associations between satellite DNA variation and human disease support that these regions present a substantial and biologically important fraction of human sequence variation. Therefore, there is a pressing and unmet need to detect and incorporate this uncharacterized sequence variation into broad studies of human evolution and medical genomics. Here I discuss the current knowledge of satellite DNA variation in the human genome, focusing on centromeric satellites and their potential implications for disease. Genome-scale initiatives, such as the Human Genome Project and the 1000 Genome (1KG) consortium ,3, have Centromeric satellite DNA arrays are known to vary extensively in the human population, yet few genomic tools have been developed to study the full extent of this sequence variation, thereby ignoring a fraction of the human genome expected to contribute directly to cancer and human disease ,9,10. ThAcknowledging the differences between the satellite arrays, there is limited utility in restricting studies to the use of a single genomic map. Rather, it is important to extend our survey of satellite DNA genomics to large panels of diverse individuals, thus enabling high-resolution maps of human sequence diversity in these regions. Such sampling efforts would be the foundation for a modern era of satellite DNA genomics: establishing allelic frequencies for satellite variants necessary to expand disease-association studies. Here I discuss our current understanding of satellite DNA variation as determined from whole-genome sequencing projects, with a focus on the largest families in the human genome and their association with disease.The largest arrays of satellite DNAs in the human genome are organized within centromeric and pericentromeric regions ,3,16. AlGenome-wide estimates of alpha satellite and HSat2,3 content have relied on constructing comprehensive sequence databases using raw read data from each satellite DNA family, thereby avoiding underestimates due to assembly collapse of identical/near-identical repeats ,31. AlphProper representation of satellite DNAs in human reference assemblies will be critical to ensure faithful short read mapping and accurate assessments of satellite family variability in the future. Notably, the addition of millions of bases of alpha satellite “reference models” with the release of the GRCh38 reference genome has provided initial short read mapping targets ,40. ThisThe variation of satellite DNAs genome-wide abundance is driven by repeat expansion and contraction, commonly attributed to mechanisms of non-homologous crossover and/or conversion ,47. GenoThe relationship between repeat units from different alpha satellite arrays would suggest that the rate of intra-chromosomal exchange  is higher than inter-homologue exchange . As a reThis ever-changing genomic landscape guides our understanding of centromere function and chromosome stability. For example, the repeat structure and array length are expected to change the frequency of and spacing of the 17-bp centromere protein B binding motif, or CENP-B box. The functional role of CENP-B at human centromeres is not yet fully understood ,55, yet Previous methods have used unassembled reads from whole-genome sequencing projects to evaluate chromosome-specific satellite overall abundance, or copy number, and the frequency of variants ) within the array ,31,68. SUse of error-corrected long reads  prior to assembly provide an automated method to identify larger structural variation (SV) in satellite arrays, such as: HOR rearrangement (insertion and/or deletion), inversions, and interruption by transposons . In addiEntire multi-megabase-sized centromeric regions, including the heterochromatic regions in the pericentromere, suppress meiotic recombination and are commonly observed as a single haplotype block, or ‘cenhap’ a 74]. L. L74]. LThese immense linkage blocks encompass satellite DNAs, segmental duplications , and a cIn addition to studies that involve the cenhap associated regions, extensive sequence variation within the satellite array is expected to contribute to our understanding of centromere instability and disease. Cytogenetic staining has revealed the constitutive heterochromatin in human centromeric regions has a highly heteromorphic structure. Given the critical importance of centromeres in ensuring proper chromosome segregation, such genomic variation is hypothesized to drive genome stability, and have been linked with human disease and cancers (reviewed ). NevertIn conclusion, human satellite DNAs provide a new, largely uncharted source of sequence variation in the human population. Chromosome-specific satellite arrays are expected to vary considerably in the human population, and measuring the overall range in the abundance and frequencies of repeat variants will contribute to ongoing studies of centromere biology and genome instability. Efforts to identify and study these variants will rely on improved, comprehensive genomic methods capable of mapping the full extent of satellite sequence heterogeneity that cannot be captured using a single reference genome. Such maps are necessary to direct future biomedical research to variants that are associated with disease, rather than natural sequence variation, which may have little or no clinical consequence.


Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary. Screening represents a cornerstone of preventive medicine. Its rationale is to identify disease during an early and pre-symptomatic stage . With apHowever, screening is not entirely risk-free and usually represents an immediate economic burden for systems with tight budget constraints. Some screening tools are associated with direct health risks (X-rays and radiation), and others might not provide a real additional value if, for instance, no follow-up treatment is available . AdditioRecognizing opportunity costs, healthcare systems may require that health interventions are both clinically and cost-effective to be considered for implementation . Cost-efA systematic review was conducted to identify the latest cost-effectiveness analyses (CEAs) of screening tools. Review and reporting followed the PRISMA  guidelines . Only reWe searched the online databases of EMBASE and MEDLINE. Search terms included Medical Subject Headings (MeSH), Emtree, and keywords for “mass screening” or screening, economic evaluation, and cost-effectiveness analysis. The last search was run on August 17, 2017. The search strategies can be found in We extracted the study characteristics and findings including the population, disease/condition, screening tools (strategies), comparators, perspective, time horizon, discounting, outcome or effectiveness measures , and incremental cost-effectiveness ratios (ICERs). A description of the findings was portrayed in a narrative synthesis. Results were compared to an economic evaluation focused on the early diagnosis and treatment of psoriatic arthritis (PsA) that is currently being developed by the authors (NI and ES).A total of 1059 records were found after 109 duplicates were removed. Two hundred nineteen articles were included for full-text assessment after 840 were excluded during the abstract screening stage  explicitly reported challenges regarding screening test accuracy –43. One To understand the implications of screening on patients’ health, it is important to model the outcomes of any follow-up diagnostic tests. However, one common difficulty is that there is usually no information on the accuracy of the diagnostic test in the screen-positive population. A few assumptions were made to account for this uncertainty. A study in Thailand for non-alcoholic fatty liver disease used pooled estimates of diagnostic accuracy from a meta-analysis assuming independence between the screening and diagnostic accuracy . ChowersScreening and diagnostic accuracy determines the proportion of patients who will continue to receive treatment or further follow-up. It is important to understand the health outcomes of all patients screened. Patients identified as false positive or false negative are particularly difficult to consider in cost-effectiveness analysis given the lack of data on these patients. Costs and outcomes for patients who followed incorrect screening and treatment pathways were included in 22 (32.3%) of the studies , 45–54. Screening pathways are greatly altered by different rates of participation and compliance. Screening is only effective if the target population and healthcare providers are engaged. Twenty-nine evaluations (42.6%) identified patient participation and compliance as an important model parameter , 55–62. Disease prognosis and patient evolution from pre-symptomatic stages of disease were modeled in most cases to estimate aggregate costs and outcomes. All included studies but 2 (3%) , 64 explScreening models often focus on at-risk populations. Incidence rates are used to determine the proportion of patients who enter the models at pre-symptomatic stages. This is useful for scenarios with repeated screening procedures, as a dynamic model can be developed to evaluate repeated screening processes while taking into account new at-risk patients . On the Once an at-risk population is identified, some cost-effectiveness analyses focused on modeling the pre-symptomatic stages of disease. There is a time interval before clinical symptoms appear and after disease onset where disease is identifiable by screening tools. This timeframe, also called sojourn time, is a major challenge for CEA since progression of pre-symptomatic disease if often unknown Table . UncertaModeling patient progression during the sojourn time, i.e., through pre-symptomatic health states, remains a challenge. Three studies extrapolated progression rates from symptomatic disease stages to pre-symptomatic disease , 56, 68.According to the WHO, screening interventions are expected to provide treatment alternatives for those patients with identified cases of disease . HoweverSome studies reported uncertainty around treatment efficacy inputs , 66, 75.CEAs take into account the costs and outcomes of specific interventions and compare them to determine if they provide enough benefits relative to the cost compared to the next best alternative. However, not all potential benefits and costs are necessarily health related. The perspective of a CEA determines what kind of effects and costs will be included. A healthcare perspective seeks to compare costs and consequences that directly pertain to the healthcare sector. They generally focus on health-related outcomes . AlternaOne concern of adopting a societal perspective is the implicit assumptions on how resources should be distributed; for example, including productivity costs  generally benefits treatments of the working age population at the cost of children and seniors . Prusa eThis study reviewed the latest CEAs of screening tools and provided a thorough breakdown of challenges and suggestions to overcome them. The included studies mentioned several assumptions and methodological alternatives that were grouped in four major categories: the screening pathway, pre-symptomatic disease, treatment outcomes, and spillovers and externalities. To capture all important costs and outcomes of a screening tool, screening pathways should be modeled through the treatment of the patient. Also, false positive and false negative patients are likely to have important costs and benefits and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. Many assumptions are needed when modeling screening tools. It is important that these assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses. These include the assumptions such as the independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times, i.e., the time between when a patient can be identified by screening test and when they would have been identified due to symptoms. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary. Not surprisingly, different scenarios concluded that longer sojourn times were likely to result in improved health outcomes. This becomes one of the main drivers of the effectiveness of a screening test, besides the accuracy at which it identifies patients correctly. This was particularly true when available treatment was capable of modifying disease progression. Finally, non-health costs and outcomes were observed for studies that developed their analyses under a societal perspective. These were not consistently reported, mostly likely due to different guidelines from decision makers.This review thoroughly examined the latest methodological challenges associated with modeling CEAs of screening tools. However, some limitations are to be noted. Studies focusing on genomic and blood transfusion screening tests were excluded. Genomic screening was excluded because a recent paper evaluated CEAs of genomic screening tests . Blood tMany new screening tools are being developed and require cost-effectiveness analyses to support their value proposition. Screening tools should follow diagnostic guidelines, but have additional challenges given that sojourn times and pre-symptomatic progression data is rarely known. Current cost-effectiveness analyses extrapolate pre-symptomatic progression from symptomatic patients and thoroughly test assumptions in sensitivity analyses, including sojourn times. By following these methodological suggestions, screening tool evaluations are expected to become a better reflection of medical practice and to provide better quality evidence for decision makers making difficult trade-offs between funding screening interventions or other health technologies.


A subadult white rhinoceros bull presented for oesophageal endoscopic evaluation and foreign body removal under general anaesthesia. The animal had a history of nasal and oral regurgitation of water and ingesta with weight-loss for 6 days prior to the procedure and had been diagnosed with oesophageal obstruction caused by a bailing wire. Anaesthesia was induced with intramuscular etorphine and azaperone delivered remotely by dart, followed by an intravenous bolus of ketamine. The trachea was intubated, and anaesthesia was maintained with an etorphine-ketamine constant rate infusion (CRI). The rhinoceros did not respond predictably to induction of anaesthesia and developed life-threatening systemic hypotension throughout the 90-minute procedure. A mega-vertebrate demand ventilator was successfully used to provide intermittent positive pressure ventilation when the rhinoceros developed apnoea. This case report describes the maintenance of anaesthesia of a white rhinoceros using an etorphine-ketamine CRI and the causes and management of hypotension and respiratory impairment observed in this patient. Ceratotherium simum) is considered as “near-threatened” by the International Union for the Conservation of Nature (IUCN) Red List of Threatened Species . We opted to use the standard etorphine-azaperone combination, as it was familiar to the wildlife veterinarian—a practice that improves overall safety , 21. EtoRhinoceros unicornis), the history of repeated etorphine-based immobilisations might have led to an opioid drug tolerance in our rhinoceros [Our animal responded with a prolonged induction time compared to its previous immobilisations, where it had attained recumbency within ten minutes. Dehydration and electrolyte and acid-base imbalances associated with regurgitation may have prolonged the induction time by altering drug uptake and distribution , 23. As inoceros . Additioinoceros .An intravenous bolus of ketamine was ultimately administered to complete induction of anaesthesia, followed by an intravenous bolus of butorphanol after recumbency was achieved. Intravenous ketamine has been used as a co-induction agent in combination with guaifenesin or diazepam in premedicated white rhinoceroses that were also compromised , 15. ButAepyceros melampus); BP, RR, and HR remained within physiological reference ranges, but animals experienced hypoxaemia [We maintained anaesthesia using an etorphine-ketamine CRI. In clinical settings, inhalation drugs such as halothane , isoflurpoxaemia .The administration of the etorphine-ketamine CRI in our compromised rhinoceros resulted in surgical plane of anaesthesia with hypotension as the main complication encountered.Rhinoceroses receiving etorphine are known to experience systemic hypertension, hypoxaemia, and acidosis –5—hypoteµg/kg), an alpha-2 adrenergic agonist. Medetomidine causes peripheral vasoconstriction and, at low doses, it leads to a transient increase in arterial BP without necessarily affecting heart rate [Arterial BP is the product of cardiac output and systemic vascular resistance and, thus, any increase in either increases BP . The choart rate , 37. Furart rate .Despite our efforts, at one hour of anaesthesia, the rhinoceros developed apnoea—an initial sign of cardiopulmonary arrest . CoronarIPPV was initiated immediately after the onset of apnoea. We used the portable mega-vertebrate demand ventilator for IPPV, which has been shown to significantly improve oxygenation in etorphine-immobilised white rhinoceroses in zoo . To the This report provides useful information on a novel anaesthetic protocol used in a compromised white rhinoceros receiving special cardiovascular and respiratory support. We believe that the use of an etorphine-ketamine CRI is an option for intravenous maintenance of anaesthesia in rhinoceroses. Further investigation of its use in healthy rhinoceroses is warranted to draw any conclusions on expected physiological side effects. Attention should be given to maintain oxygenation and tissue perfusion by administering a partial opioid agonist-antagonist and by providing oxygen insufflation and fluid resuscitation. The importance of having vascular access, tracheal intubation, and IPPV devices at hand when working with compromised white rhinoceroses cannot be overstated.


Cryptococcosis is one of the most devastating fungal infections in humans.Despite the disease’s clinical importance, current therapy is based onlimited antifungals that are either toxic, inefficient, unavailableworldwide, or that quickly lead to resistance. The goal of this study was to provide insight into the future ofcryptococcosis treatment by describing the patent scenario in thisfield. We identified and analysed patent documents revealing compounds withanti-cryptococcal activity supported by experimental evidence. Patenting in this field has been historically low, with an overall tendencyof increase since 2012. Most applications are single filings, suggestingthat they do not encompass strategic inventions requiring broad protection.Research and development essentially took place in China and the UnitedStates, which also represent the main countries of protection. Both academicand corporate institutions contributed to patenting in this field.Universities are the leading actors, with the highest patent familycounts. The low number of patents in this field indicates that efforts to mitigatethe unmet needs for cryptococcosis treatment remain insufficient. Withoutinvestment to drive research and innovation, patients will likely continueto face inadequate assistance. Given the current scenario characterised bypoor funding and low interest for technological development, drugrepurposing may be the best alternative for cryptococcosis treatment. Cryptococcus neoformans(C. neoformans) and Cryptococcus gattii(C. gattii), is among the most lethal infectious diseases.,,Cryptococcosis was recognised as a major health threat during the AIDS pandemic of the1980s.,Cryptococcal meningitis is the most common cause of meningitis in individuals with HIV inregions of the world with high rates of HIV infection.,,Despite the substantial impact of cryptococcosis, none of the standard antifungalscurrently used to treat this disease  were launched after the 1990s.,Although the clinical severity and unmet needs are evident, drug development forcryptococcosis treatment is hindered by a clear market failure. Given that this diseasesubstantially afflicts low income populations, there is little investment anddevelopment interest on the part of pharmaceutical companies. In fact, out ofapproximately 200 organisations that completed the Global Funding of Innovation forNeglected Diseases (G-finder) annual report between 2013 and 2016, only public andphilanthropic organisations  reported having investedin cryptococcal meningitis drug development.To investigate the impact of this funding scarcity, Rodrigues and Albuquerque comparedthe number of publications in Web of Science related to cryptococcosis and other fungaldiseases to that of malaria and tuberculosis - neglected tropical diseases (NTDs) thathave well-stablished funding programs. Whereas 8827 and 5687 articles were published in2017 for malaria and tuberculosis, respectively, cryptococcosis was much lessinvestigated, only generating 213 articles.Search scope and strategy - Searches were carried out betweenNovember 2017 and February 2018 using the commercial database Orbit Intelligence. Our search strategy targeted inventions for which the veryfirst patent application was filed between 01/01/1995 and 31/12/2015, anywhere inthe world, i.e., documents with earliest priority between these dates. We searchedfor documents containing the following words in their title, abstract, or claims:cryptococ*, neoformans, gattii, or torulosis. After this initial search, thefollowing documents were selected for further analysis: (i) documents classified asA61K  or A61P  by theInternational Patent Classification (IPC) and/or Cooperative Patent Classification(CPC) and (ii) documents including the words treat*, cure, or therap* in their titleor abstract, even if not classified in the abovementioned patent classes. This lastsearch step was an attempt to broaden our search strategy, encompassing inventionsinside our scope but not classified as A61K or A61P.Grouping of search results into patent families - Documentsretrieved by our search were automatically grouped by Orbit into FamPat patentfamilies. FamPat groups together patent documents that are believed to cover thesame invention, e.g., different stages of an application in a given country orrelated applications filed in different countries. When required, these documentswere automatically ungrouped into individual patent filings, i.e., FullPatrecords.Manual cleaning of search results - Patent families were analysedindividually to exclude inventions outside our search scope or not showing evidenceof anti-cryptococcal activity. Inventions revealing possible drug targets, e.g., anessential fungal gene, but lacking experimental evidence of compounds withanti-cryptococcal activity were considered to fit this last exclusion criterion.Normalisation and de-duplication of assignees - Assignee names werenormalised using Orbit Intelligence’s assignee grouping functionality. Alternativespellings and subsidiaries were grouped under a single name when this informationwas known. The data was then manually cleaned to include the research institution’sname when the university’s funding agency, board of regents, or technology transferoffice appeared as the assignee instead of the university’s name.Identification of R&D country - As recommended by theOrganization for Economic Cooperation and Development (OECD), we used inventoraddress information to infer where R&D took place.Countries of protection - To determine where protection is sought, FullPatrecords were filtered by patent legal status and analysed by country code.Assignee classification - Our revised assignees were manuallyclassified as “Academy” , “Corporate” (companies), or “Individuals” . To compile assigneecounts by type, assignees were only counted and classified once, even if theyappeared as assignee in more than one patent family. To assess collaborations(assignee counts by type and number), assignees were classified and counted eachtime they were indicated as a patent family assignee, even if they had alreadyappeared in a previous patent family.Our search strategy resulted in the retrieval of 1501 patent families. Each patentfamily contains one or more individual patent applications related to a singleinvention, corresponding, for instance, to applications filed in differentcountries. Patent families and individual patent filings are herein referred to asFamPat and Fullpat, respectively. The patent families retrieved by our searchstrategy then went through two selection filters: the first excluded inventionsoutside our search scope , while thesecond excluded inventions inside our search scope but not showing evidence ofanti-cryptococcal activity. After the second filter, only 35% of inventions insideour search scope remained . These are the patent familiesthat disclosed a compound, molecule, or extract for cryptococcosis treatment withexperimental support that were first filed between January 1995 and December 2015.All of our analyses are based on this specific set of patent families.Patenting in the field of cryptococcosis treatment has increased since2012 - To obtain an overall picture of inventive activity related tocryptococcosis treatment, patent family counts were plotted by earliest priorityyear. Earliest priority year was chosen as the closest date to the invention andbest indicator of inventive performance, following the OECD’s recommendations.Applications from Chinese residents were the main driver of patentinggrowth - To infer where R&D activity took place and furtherinvestigate the above-mentioned increasing trend in patent filings, our data wasanalysed by inventor country of residence as recommended by the OECDMost patent families are alive and were filed in China and the US -Patent counts include applications that are alive, either pending examination orgranted, but also applications that are already dead, i.e., abandoned by theassignee, expired, or revoked. Hence, patent legal status was analysed to ascertainhow many of these patent families currently protect inventions or have the potentialto protect them. Our results showed that most of the 295 patent families (64%) arealive . Fromthese live families, 74% contain at least one patent in force ,whereas 26% consist of pending applications , “Corporate” (companies), or“Individuals” . As shown in Top-cited inventors and best-ranked assignees are from the academicsector - Patent landscapes can offer insights into the main players(inventors or institutions) in specific technological fields. This information canbe useful in the identification of both competitors and potential collaborators forfuture R&D. in vivo evidence againstCandida sp. and Aspergillus sp. and onlyin vitro tests against Cryptococcus sp. (datanot shown).Most new entrants in this field are institutions and companies based inChina - Given that our patent analysis covered 20 years, some assigneesmay have been active in the early years of our analysis but have since lost interestin this field. Indeed, an analysis of the timeline of patent filings by our topassignees showed that 17% of them did not file any patents in the last ten years ofour analysis (2006-2015), whereas 26% were new entrants that only filed patentsduring this later period. The majority of new entrants (83%) were universities andcompanies based in China. Out of the top assignees that have been inactive in thelast 10 years, most (75%) are US-based entities  actually contained evidence of anti-cryptococcal activity. Hence, for thecurrent landscape to more closely reflect patenting in this specific field, the useof experimental evidence as a selection criterion is crucial. A drawback of thisapproach is that evidence may become available after the patent is filed. In thesecases, patents disclosing such compounds would be missed. Nevertheless, patentlandscapes are snapshots of the patenting situation at the time of data analysis andnot a follow up of further developments that may have occurred after filing. In anycase, we conclude that the overestimation resulting from the inclusion of alldocuments regardless of experimental evidence would be much more prejudicial thanthe possible underestimation resulting from the use of an experimental evidencefilter.An important limitation of patent landscapes is that patent applications are draftedto maximise protection, making broad claims that are not necessarily experimentallyconfirmed. To circumvent this limitation, only documents containing evidence ofanti-cryptococcal activity were added to our analysis. In the absence of such afilter, we would obtain a picture of all patents that claim to disclose a compoundwith anti-cryptococcal activity, even if Cryptococcus sp. is quite low,despite the increasing trend since 2012; and (ii) none of the top inventors from ourpatent search list cryptococcosis as their main line of research, although somefocus on the development of antibacterial and antifungal compounds and on other NTDs(data not shown). These findings are also supported by previously published analysesof this same patent collection,Cryptococcus sp. was usually very preliminary, consistingmostly of MIC  tests; and (iii) less than 5% ofthe companies appearing as assignees in our selected patent documents actuallyincluded cryptococcosis treatment in their publicly available pipeline. Such lowinterest is not surprising, given that R&D funding for drug developmenttargeting cryptococcosis is very scarce despite the clinical importance of thisfungal infection.Our results indicate little interest in drug development for cryptococcosis. This issuggested by the following findings: (i) the number of patents that actually presentsome evidence of activity against The increase in filings since 2012 could indicate hope for improvement in thetreatment of cryptococcosis. However, these patent families are essentially formedby individual applications. This suggests they do not encompass very strategicinventions that would require broad protection. In the case of blockbuster drugs,for instance, patents are filed in several countries and a single patent family maycontain hundreds of patents. Hopefully in the years to come, this increasing trendin filings will be followed by a similar growth in patent family size.Our results seem to suggest decreasing interest in the field from US residents, giventhe slight decline in the respective patent filings since 2005 and the fact thatmost inactive players in this same period are US-based institutions. The rise inpatent filings since 2012 was mainly driven by Chinese applications and most newentrants in this field are also Chinese, revealing important contributions ofChinese institutions to patent filings in this area. Indeed, this may be the resultof an intensification in Chinese R&D efforts aimed at cryptococcosis treatment.However, patenting incentives introduced by China’s National Patent DevelopmentStrategy (2011-2020) may also have fueled patent numbers. The strategy introducedmeasures to enhance China’s intellectual property system by encouraging localindividuals, institutions, and companies to pursue intellectual property protectiondomestically and abroad. It included quantitative patent-per-capita targets to bereached by the end of specific years  and government incentives for filing them, including subsidies to coverpatent costs. This resulted in an upsurge in patent applications in China by Chineseresidents, not exclusively resulting from increased R&D. Chinese patentsubsidies also encouraged the following strategies: (i) repeated patent applicationsfiled for the same invention; (ii) splitting technological development into smallerinventions to boost the number of applications; (iii) filings for inventions alreadydisclosed; and (iv) filing applications only to meet patent targets.Our assessment of countries wherein patent protection is most often sought showedChina and the US in the top positions. As these are also the main R&D countries,this result appears to reflect the usual bias for filing domestic applications(applicants tend to file patents in their home country). South Africa was the onlyAfrican country with 20 or more live patents.in vivo evidence against Cryptococcussp.An analysis of all patent assignees indicated that both the academic sector andcompanies contributed to patent filings in this field. The academic sector seems tohave a slightly more prominent role, given that the top assignees and most-citedinventors are from this classification, as are 64% of the patents that actuallydisclose ,,In view of the inadequate funding directed at cryptococcosisGiven the lack of collaboration in the area, investing in collaborative work may alsodrive innovation in this field, engaging experts to work together toward a commongoal sharing R&D risks and costs. More specifically, academia-pharmapartnerships have the added benefit of maximising the strengths of the respectivepartners, integrating expertise in the technical field with knowhow to translateresearch findings into drugs.,,Despite the many advances brought about by collaborative R&D efforts, the numberof approved drugs in recent decades is far from ideal, and many challenges stillexist for NTD drug development.


Apoptosis is widely known as programmed cell death eliciting no inflammatory responses. The intricacy of apoptosis has been a focus of an array of researches, accumulating a wealth of knowledge which led to not only a better understanding of the fundamental process, but also potent therapies of diseases. The classic intrinsic and extrinsic signaling pathways of apoptosis, along with regulatory factors have been well delineated. Drugs and therapeutic measures designed based on current understanding of apoptosis have long been employed. Small-molecule apoptosis inducers have been clinically used for eliminating morbid cells and therefore treating diseases, such as cancer. Biologics with improved apoptotic efficacy and selectivity, such as recombinant proteins and antibodies, are being extensively researched and some have been approved by the FDA. Apoptosis also produces membrane-bound vesicles derived from disassembly of apoptotic cells, now known as apoptotic bodies (ApoBDs). These little sealed sacs containing information as well as substances from dying cells were previously regarded as garbage bags until they were discovered to be capable of delivering useful materials to healthy recipient cells . In this review, current understandings and knowledge of apoptosis were summarized and discussed with a focus on apoptosis-related therapeutic applications and ApoBDs. Apoptosis is a highly regulated process of cell death. Unlike necrosis which is a traumatic version of cell death, apoptosis is a rational and active decision made to sacrifice specific cells for the greater benefits of the organism. It is a normal physiologic process routinely carried out in multicellular organisms . While mOne notable feature of apoptosis is it exerts its effects mainly through action of a type of serine proteases known as caspases. A death signals are relayed through signaling pathways which ultimately lead to activation of caspases responsible for the execution of cell destruction . Both exMany forms of cell death exist, most of which can be triggered by various stimuli and physiological conditions. Among them, apoptosis and necrosis have been a well-known duo frequently being compared. In 1965, John Foxton Ross Kerr at University of Queensland made the first distinction between apoptosis and necrosis. Further refinements aiming to better interpret apoptosis followed. But it was not until 1972 when the term ‘apoptosis’ was first proposed by Kerr et al. [p53, initiates apoptosis in certain cell types. p53 is an extensively studied tumor suppressor. Overwhelming evidence points to its exceeding importance in prevention of cancer development. The p53 tumor suppressor gene is most frequently mutated  in cancer cells [p53-based preventive system malfunctions or loses its function completely.In cell cycle, apoptosis acts as a fail-safe measure that ensures fidelity and quality of proliferation. While certain degrees of genetic variation are allowed and favored for evolution, reproduced cells with extensive genetic errors and cellular damages are subjected to apoptosis. A key player in the cell cycle machinery, er cells , renderip53-dependent apoptotic pathway [p53 paves way for apoptosis by activating pro-apoptotic factors  while suppressing antiapoptotic factors  [p53 has been recognized for its critical function to initiate apoptosis in cell cycle, along with the ability to induce cell arrest and DNA repair in recoverable cells. There are many other cell cycle regulators besides p53 that can influence apoptosis . Nevertheless the mechanistic details of apoptosis in cell cycle are beyond the scope of this review.Stimuli such as DNA damage, hypoxia, and expression of certain oncoproteins  activates the  pathway . Once co, Bcl-2) . As a weMany researches highlighted the importance of apoptosis in the self-defense mechanism, or in other words, the immune system. The immune system is in charge of defensing the host against an array of external pathogens. Apoptosis is an integral part of the immune system where it facilitates to maintain a homeostasis of the immune system. For example, apoptosis is burdened with the responsibility to regulate immune responses, i.e., to induce death of T and B cells at certain time point to limit an immune response because a prolonged response would otherwise be deleterious to self. Second, the immune system depends upon apoptosis to eliminate unneeded T and B cells to be functionally mature . For exaApoptosis plays an indispensable and irreplaceable role both under physiological and pathological conditions. Anomalies in apoptosis have become a major field of interest to researchers and are associated with a broad spectrum of pathological conditions, e.g., developmental defects, autoimmune diseases, cancer, etc. Some diseases pertain to deficiency of apoptosis while others pertain to its redundancy. For example, one of the hallmarks of cancer is evasion of apoptosis, meaning insufficient apoptosis overwhelmed by the limitless replicative potential of cells . On the Certain morphological changes exhibited by apoptotic cells have been well identified and documented. These changes include cell blebbing and shrinkage, nuclear fragmentation, condensation and fragmentation of genetic materials , and formation of small vesicles known as ApoBDs. Cells undergo a characteristic shrinkage during the early stage of apoptosis. Cell size becomes smaller while the contents within the cells experience a denser packing. Another phenomenon known as pyknosis (irreversible condensation of chromatin) also occurs concomitantly at the early stage of apoptosis. These changes can be observed by light microscopy while electron microscopy can better visualize subcellular changes like pyknosis. Following the early stage of apoptosis, another phenomenon known as karyorrhexis, which refers to fragmentation of the nucleus, ensued. Karyorrhexis is accompanied by further blebbing of the plasma membrane that tears apoptotic cells into small ApoBDs. Current knowledge states that ApoBDs contain remnants of apoptotic cells  where the contents of apoptotic cells are randomly distributed to each apoptotic body. Therefore, a specific organelle or a nuclear content may be or may not be present in a particular apoptotic body. These ApoBDs are then engulfed by phagocytes, e.g., neutrophils, macrophages, and dendritic cells (DCs), for final degradation. Phagocytosis marks the terminal step of an apoptotic cycle and it is believed that the essence of this step is to prevent spillage of hazardous materials packed within the apoptotic cells into the surroundings. The reason for forming ApoBDs has remained elusive. Details regarding ApoBDs will be discussed in the next section.The biological mechanism of apoptosis is exceedingly sophisticated. A complete implementation of apoptosis involves interplay of a wide array of proteins and signal transducers as well as cascades of signaling pathways. Two major apoptosis pathways exist: extrinsic and intrinsic. The extrinsic pathway refers to receptor-mediated initiation of apoptosis. The death receptors in the extrinsic pathway are all anchored to the cell membrane by their transmembrane regions. Upon interaction with an extracellular ligand, membrane receptors relay death signals into intracellular space via their cytoplasmic death domains. Membrane receptors involved in apoptosis belong to the tumor necrosis factor (TNF) receptor superfamily, whose activation depends upon two major ligands: TNF and Fas. TNF and its receptors, namely TNFR-1 and TNFR-2, are responsible for initiating a major apoptosis pathway: the TNF pathway. The interaction between TNF and its receptors has been shown to relay death signal through recruitment of two adaptor proteins: TNF receptor-associated death domain (TRADD) and Fas-associated death domain protein (FADD), and effect programmed cell death through the action of caspases. TNF ligands form homotrimers which bind to TNF receptors on the membrane. Upon binding, adaptor proteins are recruited  to TNF receptors on the cytoplasmic side where death domains on the adaptor proteins interact with its counterparts on the receptors. FADD recruits its downstream interactor, procaspase-8 in this case, via homotypic interaction of the death effector domains (DED). Procaspase-8 then undergoes auto-cleavage to yield active caspase-8 which initiates the execution phase of cell death. Caspase-8 cleaves procaspase-3 via proteolytic cleavage to produce active caspase-3 responsible for the final execution of proteolytic degradation of a variety of intracellular proteins. Fas-mediated pathway undergoes a much similar signaling process. FasL (Fas ligand) triggers the pathway by binding to Fas receptors . FADD associates with the Fas receptors and recruits caspase-8. Fas receptors, along with FADD and procaspase-8, form the death-inducing signaling complex (DISC).p53 which is frequently mutated in cancer cells, yet endowing TRAIL with another crucial therapeutic advantage [A third extrinsic apoptotic pathway has been shown to be therapeutically exploitable, the TNF-related apoptosis inducing ligand (TRAIL) pathway. TRAIL, alternatively known as Apo2L, was first identified by its sequence homology to FasL . It is advantage . Howeverdvantage . Researcdvantage . Receptodvantage . Anotherdvantage . This vaThe intrinsic pathway of apoptosis is characterized by non-receptor-mediated initiation and mitochondrial regulation. In the intrinsic pathway, stimuli directly generate intracellular signals which lead to biochemical changes within the cell. When a stimulus is present, it elicits disruption of the mitochondrial transmembrane that dissipates the membrane potential, rendering it more permeable. The stimulus also results in formation of mitochondrial permeability transition pore (MPT) on the outermembrane that channels pro-apoptotic factors into the cytosol . ApoptosFurthermore, research has shown that endoplasmic reticulum (ER) is also involved in apoptosis. Redundant accumulation of proteins and disturbance of calcium homeostasis within ER can trigger ER stress and therefore apoptosis. Mouse bearing caspase-12 knock-out are resistant to apoptosis, indicative of caspase-12’s involvement in ER-mediated apoptosis pathways . CaspaseCaspases are pivotal components of apoptosis p53 has been shown to regulate members of the Bcl-2 protein family [p53 can directly induce transcription of Bax which is a pro-apoptotic protein [Members of the Bcl-2 protein family are responsible for regulation of apoptosis . Two subn family . For exa protein .As previously described, apoptosis is a highly controlled physiological process in multicellular organisms. Research on molecular mechanism of apoptosis reveals that anomalies in apoptosis lead to many diseases. Therefore, factors involved in apoptosis regulation are of tremendous diagnostic and intervention value in curing diseases .Defective apoptosis is associated with many types of illness including autoimmune diseases, neurodegenerative diseases bacterial and viral diseases, heart diseases, and cancer ,43.Several reports have linked autoimmune diseases directly to dysregulated apoptosis and impaired clearance of apoptotic cells . Rapid cWhile dwindled apoptosis of immune cells facilitates autoimmunity and fosters autoimmune diseases, too much apoptosis is as well a pathological condition . NeurodeTo summarize, impaired clearance of apoptotic cells, and too little or too much apoptosis are both disease-prone. Thus tuning apoptosis to a balanced state can serve to treat diseases . If autoClearance of apoptotic cells has been a major field of study in apoptosis-related researches. Efficient and timely clearance of apoptotic cells is crucial to avoid immune response to autoantigens and prevent perturbation to ambient cells and tissues . MajoritBreakage of apoptotic cells into ApoBDs was previously believed to be a random process until a recent discovery revealed that a well-coordinated process is responsible for the formation of ApoBDs. As shown in It is now assumed that membrane blebbing is a prerequisite for apoptotic body formation . HoweverClearance of ApoBDs has been a focus in apoptosis-related researches. Phagocytes recognize ‘find-me’ signals released by apoptotic cells and ‘eat-me’ signals on the ApoBDs to engulf them . Ingestiin vitro studies showed that suppression of apoptotic blebbing, therefore formation of ApoBDs, impaired clearance of apoptotic cells by monocytes and macrophages [Although ApoBDs can readily be engulfed by phagocytes, intact apoptotic cells can be engulfed just as effectively . In factrophages ,107.Extracellular vesicles  play a critical role in intercellular communications by transporting intracellular signaling molecules  LikewiseRecent studies have unraveled involvement of ApoBD in progression, metastasis, and formation of microenvironment of tumor. The discovery of ApoBD has offered new insights and explanations for physiological and pathological conditions. During the period of apoptosis, membrane blebbing promotes distribution of nuclear material into ApoBDs . HorizonApart from nucleotides, proteins can be transferred by ApoBDs to phagocytes, such as macrophages and DC cells, for immunoregulation. ApoBDs of thymocytes from BALB/c mouse are enriched with autoantigens and pro-inflammatory factors, along with 142 different protein including histones, hsp90, and many immunoproteins . SimilarContents of within the ApoBDs may be used for a number of purposes such as activation of immune system, recruitment of dying cells and regeneration of damaged tissues. Rubartelli et al. first reported that DC can selectively engulf ApoBDs . DC is ain vitro cells by apoptosis-resistant DC cells. Therefore, these DC cells expressed lowered level of CD40 and CD86, and pro-inflammatory cytokines. As a result, autoimmunity against cells is reduced. These results suggest that ApoBDs can act as regulators at the cellular level and therefore possess conspicuous biological significance.Schiller and co-workers observed that immunogenic molecules enter ApoBDs in the early stage of apoptosis before DNA fragmentation . JAK1/STFurthermore, ApoBDs are carriers of contagious materials of pathogens. For example, ApoBDs of HIV-infected T cells can transfer proteins and genomic contents of HIV to adjacent epithelial cells where transcription and expression of viral proteins are furthered and assembly of HIV takes place . BesidesTo conclude, ApoBDs are messengers containing legacy of its progenitors, whose destiny lies far beyond being ‘garbage bags’ as we previously assumed. They can be recycled to initiate an array of biological responses. Further understanding of ApoBDs is essential to complete delineation of apoptosis.The more efforts invested, the more we realize how complex the process of apoptosis is. It is a highly coordinated process of both morphological and biochemical change. Depending on the cell type and disassembly pattern, ApoBDs of different size and amount can be generated. Therefore, an obvious question can be asked: why the universal process of apoptosis can present itself in various ways? Why different cell types employ different ways of breakage? What controls the release, size and contents of ABs? By solving these mysteries, we become one step closer to complete understanding of programmed cell death under both physiological and pathological conditions. Lastly, it is encouraging that drugs that block or promote ApoBD formation have been advanced to the stage of clinical trials . Therefo