Post-exercise cold-water immersion (CWI) is a popular recovery modality aimed at minimizing fatigue and hastening recovery following exercise. In this regard, CWI has been shown to be beneficial for accelerating post-exercise recovery of various parameters including muscle strength, muscle soreness, inflammation, muscle damage, and perceptions of fatigue. Improved recovery following an exercise session facilitated by CWI is thought to enhance the quality and training load of subsequent training sessions, thereby providing a greater training stimulus for long-term physiological adaptations. However, studies investigating the long-term effects of repeated post-exercise CWI instead suggest CWI may attenuate physiological adaptations to exercise training in a mode-specific manner. Specifically, there is evidence post-exercise CWI can attenuate improvements in physiological adaptations to resistance training, including aspects of maximal strength, power, and skeletal muscle hypertrophy, without negatively influencing endurance training adaptations. Several studies have investigated the effects of CWI on the molecular responses to resistance exercise in an attempt to identify the mechanisms by which CWI attenuates physiological adaptations to resistance training. Although evidence is limited, it appears that CWI attenuates the activation of anabolic signaling pathways and the increase in muscle protein synthesis following acute and chronic resistance exercise, which may mediate the negative effects of CWI on long-term resistance training adaptations. There are, however, a number of methodological factors that must be considered when interpreting evidence for the effects of post-exercise CWI on physiological adaptations to resistance training and the potential underlying mechanisms. This review outlines and critiques the available evidence on the effects of CWI on long-term resistance training adaptations and the underlying molecular mechanisms in skeletal muscle, and suggests potential directions for future research to further elucidate the effects of CWI on resistance training adaptations. Cold water immersion (CWI) is a popular recovery strategy aimed at enhancing recovery from strenuous exercise. Typical CWI protocols involve the submersion of the limbs and/or torso for ~5–20 min in water cooled to temperatures of between ~8–15°C . While outside the scope of this narrative review, readers are instead referred elsewhere for discussion of the effects of post-exercise CWI on physiological adaptations to endurance training  or anthropometric  measurements. Microscopic assessments of muscle hypertrophy assess changes in muscle fiber size and/or muscle fiber type by applying immunohistochemical techniques to skeletal muscle samples obtained via muscle biopsy. Less commonly applied in contemporary human exercise studies, molecular-level assessments of muscle hypertrophy involve the quantification of protein sub-fractions  within skeletal muscle samples obtained via muscle biopsy.Skeletal muscle hypertrophy is a complex biological construct that may be assessed at different physiological levels , and by using various measurement techniques each differing in aspects of validity, reliability, and specificity   , highlighting the potential disconnect between changes in measures of strength and muscle hypertrophy with resistance training  strength gain following resistance training with CWI application in resistance-trained individuals  describes the ability to withstand fatigue during sustained force production, which is underpinned by various physiological factors, including mitochondrial and capillary density, muscle fiber-type proportions, and muscle buffer capacity . The physiological mechanisms for the negative effects of CWI on changes in strength endurance with resistance training remain unclear.The ability to produce force rapidly  is recognized as an important component of athletic performance  movements with resistance training may be compromised by post-exercise CWI application. Whether these effects are attributed to the influence of CWI on morphological and/or neural adaptations is, however, unclear.Several studies have investigated the effects of CWI on the molecular responses to resistance training to try to identify the mechanisms by which CWI attenuates phenotypic adaptations to resistance training. A summary of studies investigating the potential molecular mechanisms that may contribute to the effects of CWI on adaptations to resistance training in human skeletal muscle is provided in As discussed previously , CWI can attenuate measures of muscle hypertrophy in response to resistance training , rpS6Ser240/244, or rpS6Ser235/236. In contrast, we observed that CWI attenuated phosphorylation of rpS6Ser235/236 and 4E-BP1Thr36/47, but had no effect on p70S6KThr389 phosphorylation  signaling pathway, which controls protein translation by the ribosome  is expressed systemically and locally within skeletal muscle. It is involved in promoting muscle hypertrophy, regeneration, and satellite cell proliferation and differentiation as well as inhibiting muscle protein degradation  is upregulated in response to anabolic stimuli, such as synergist ablation-induced overload  seen with the control condition (active recovery). These findings were confirmed by Western blot analysis of MyHCI and MyHCIIa protein content, which did not differ between CWI and control. Interestingly, additional analyses of MYH7 (type I gene), MYH1 (type IIx gene), and MYH2 (type IIa gene) mRNA expression, as well as expression of two microRNAs thought to be involved in regulation of muscle fiber type (miR-208b and miR499a) were consistent with a CWI-induced type II muscle fiber shift , these factors must be considered when interpreting evidence for the influence of CWI on physiological adaptations to exercise training.The majority of studies investigating whether CWI influences physiological adaptations to resistance training have been conducted in participants with limited or no resistance training experience. Indeed, only three studies  with gold-standard assessments of whole-muscle size  when measured at a single time point  for detecting changes in indices of skeletal muscle hypertrophy following a period of resistance training  and DXA (lean body mass) may have occurred if another gold-standard measurement of macroscopic-level muscle hypertrophy  was undertaken. Nevertheless, such discrepancies in muscle hypertrophy outcomes assessed at different physiological levels  is consistent with other findings in response to resistance training alone  concurrently, and particularly using gold-standard measures (such as MRI or CT) are required to improve current understanding of the influence of CWI on muscle hypertrophy with resistance training.As when assessing the influence of CWI on skeletal muscle hypertrophic responses to resistance training, there are various considerations when interpreting changes in maximal strength with resistance training, and therefore the potential influence of CWI on these responses. Because strength is a highly task-specific phenomenon  changes in strength with resistance training, and in turn, compromise the ability to detect potential effects of CWI on resistance training-induced strength gain. In some studies investigating the effects of CWI on resistance training adaptations, the measure of strength used was somewhat inconsistent with the modality of resistance training employed. For example, the studies by Yamane et al. , 2015 anFuture studies should therefore include multiple measures of strength  (Buckner et al., There are a number of limitations regarding the resistance training interventions used in existing studies, which likely influence their applicability to real-world scenarios. For example, some studies have used resistance training interventions that incorporate single exercises that target only smaller muscle groups during single-joint movements (Ohnishi et al., A further limitation regarding the relevance for elite athletes of studies performed to date is the relatively low training volumes and frequencies employed in those studies. Athletes typically train at least five times per week and often at considerably higher frequencies Smith, . At highVery few studies performed to date have involved female participants. The exceptions to this include Poppendieck et al. , in whicSer15, FOXO1Ser256, and rpS6Ser235/236 in the CWI group following the last session of a 7-week resistance training program compared to the first session (Fyfe et al., Repeated or prolonged cold exposure results in acclimation, which alters the thermoregulatory and metabolic responses to cold (Castellani and Young, Post-exercise CWI is a widely-used recovery modality among athletes. Nonetheless, there are relatively few studies investigating the effects of repeated CWI on adaptations to exercise, especially resistance exercise. Although post-exercise CWI may enhance short-term recovery following resistance exercise, current evidence suggests CWI has either nil or detrimental effects on physiological adaptations to resistance training, including muscle hypertrophy and measures of maximal strength, strength endurance, and power/RFD, as well as the molecular responses that underpin adaptation to resistance training in skeletal muscle. Importantly, no studies have shown benefits of CWI on resistance training adaptations. As such, there is currently no evidence to support the use of post-exercise CWI during periods of resistance training. It is important to note, however, that given the lack of available evidence and its associated limitations, there may be many potential circumstances whereby CWI application following resistance training could be beneficial, such as in females, in chronically-trained and elite athletes, during periods of high-frequency training, or in cold-acclimated individuals. Further research is required to determine the effects of post-exercise CWI on physiological adaptations resistance training in these circumstances, and to address the additional methodological limitations of previous studies.AP and JF contributed to the writing and editing of the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Prescription of post-match or post-training recovery strategies in young soccer players is a key point to optimize soccer performance. Considering that the effectiveness of recovery strategies may present interindividual variability, scientific evidence-based recovery methods and protocols used in adults are possibly not applicable to young soccer players. Therefore, the current systematic review primarily aimed to present a critical appraisal and summary of the original research articles that have evaluated the effectiveness of recovery strategies in young male soccer players and to provide sufficient knowledge regarding the effectiveness of the recovery methods and strategies.Methodology: A structured search was carried out following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines until November 31, 2020, using the next data bases: WOS, PubMed, Cochrane Library, Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, EMBASE, and Scopus. There were no filters applied.Results: A total of 638 articles were obtained in the initial search. After the inclusion and exclusion criteria, the final sample was 10 articles focusing on recovery in young male players.Conclusions: Neuromuscular performance can be recovered using WVB but not with SS, and water immersion protocols may also be useful, but their positive effects are not significant, and it is unable to distinguish the best water immersion method; match running performance maintenance may be achieved using water immersion protocols but no other recovery methods have been investigated; EIMD and inflammatory responses could be positively affected when water immersion and AR are applied, although SS seems to be ineffective; perceptual responses also seem to be better with CWI and WVB, but contradictory results have been found when AR is applied, and SS had no positive impact. Finally, it is important to consider that AR strategies may modify HR response and soccer-specific performance. A soccer competitive match induces greater magnitudes of exercise-induced muscle damage (EIMD), delayed-onset muscle soreness (DOMS), biochemical changes, and neuromuscular alterations  the study population comprised young male soccer players aged younger than 18 years; (II) participants used recovery methods; (III) the effects of the methods were compared with a control condition or between methods; (IV) articles examined the effects of recovery methods on physical measurements, physiological responses, perceptual measures, or cognitive function; and (V) study designs were randomized.The following exclusion criteria were applied to the experimental protocols of the investigation: (I) studies conducted using participants with a previous cardiovascular, metabolic, or musculoskeletal disorder, (II) articles regarding other team sports populations without included or duplicated articles, and (III) abstracts, non-peer-reviewed papers, and book chapters.Titles and abstracts of publications identified by the search strategy were screened for a subsequent full-text review and were cross-referenced to identify duplicates. All trials assessed for eligibility and classified as relevant were retrieved, and the full text was peer reviewed (JC-G and JM-A). Moreover, the reference section of all relevant articles was also examined using the snowball strategy ; population of the sample, indicating the number of participants; methods; characteristics of the intervention; and significant differences between the study groups.To carefully consider the potential limitations of the included studies to obtain reliable conclusions, following the Cochrane Collaboration Guidelines  .A total of 10 studies were included , which eThese strategies were applied only in young male soccer players  and included elite level  when match running performance maintenance is the main objective of the recovery strategy with post-PHV players.The precise influence of different recovery strategies on soccer-specific performance has not received consideration while studying different recovery modes in young soccer players. Only one study has been found  is significantly higher than that of PR, despite systolic and diastolic blood pressures at rest  reduced the muscle pain induced by a soccer-specific effort in high-level junior players compared with SS (Marin et al., On the other hand, young soccer players can report lower RPE values and fatigue perception when different water immersion treatments are applied. Players exposed to CWI have generally reported lower perception of fatigue compared with PR, CWT, and TWI after training sessions or during tournaments (Rowsell et al., Considering the abovementioned results, DOMS may be reduced in young soccer players using WBV, CWI, and AR, but not with SS, whereas fatigue perception may be decreased mainly with CWI because AR or SS has no positive results.For future studies, and according to results published by Buchheit et al., the implementation of post-match recovery strategies in pre-PHV players may not be necessary (Buchheit et al., Recovery strategies should be targeted against the major causes of fatigue, but evidence providing definitive conclusions that justify the prevalence of one or other recovery methods with young soccer players is lacking. Depending on the evidences of residual fatigue of each player and the main goal of the recovery strategy prescription, coaches and sports scientists must select those methods whose benefits have been previously reported, therefore individualizing recovery prescription. Considering that reason, this manuscript can help coaches and sports scientists identify and select the pertinent methods used to enhance recovery. However, the evidence-based recommendations for adults should be followed if other recovery methods that have not been included in this systematic review are going to be applied. Moreover, individually customizing the recovery modalities based on the preferences of the young soccer players is also considered beneficial.According to the included studies in this systematic review, several recovery strategies applied in young soccer players may have beneficial effects during recovery, both after trainings and matches or during congested fixture schedules. Neuromuscular performance can be recovered using WVB but not with SS, and water immersion protocols may also be useful, but their positive effects are not significant, and it is unable to distinguish the best water immersion method; match running performance maintenance may be achieved using water immersion protocols but no other recovery methods have been investigated; EIMD and inflammatory responses could be positively affected when water immersion and AR are applied, although SS seems to be ineffective; perceptual responses also seem to be better with CWI and WVB, but contradictory results have been found when AR is applied, and SS had no positive impact. Finally, it is important to consider that AR strategies may modify HR response and soccer-specific performance.All datasets generated for this study are included in the article/supplementary material.JC-G conceived and designed the investigation, analyzed and interpreted the data, drafted the paper, and approved the final version submitted for publication. JM-A and DM-J analyzed and interpreted the data. IR and ÁM-O critically reviewed the paper and approved the final version submitted for publication. SO, MD, and JS critically reviewed the paper. NT, JS, and MD approved the final version submitted for publication. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Lycium barbarum polysaccharides (COP) and Ganoderma lucidum polysaccharides (GLP), for treatment of epilepsy include regulation of inflammatory factors, neurotransmitters, ion channels, and antioxidant reactions. Especially, polysaccharides could be digested by intestinal microbial flora, referred as “intestinal brain organ” or “adult’s second brain”, may be the target for treatment of epilepsy. Actually, polysaccharides can effectively improve the type and quantity of intestinal flora such as bifidobacteria and lactic acid bacteria and achieve the purpose of treating epilepsy. Therefore, polysaccharides are hypothesized and discussed as potential agent for treatment of epilepsy.Epilepsy is a chronic neurological disorder. Current pharmacological therapies for epilepsy have limited efficacy that result in refractory epilepsy (RE). Owing to the limitations of conventional therapies, it is needed to develop new anti-epileptic drugs. The beneficial effects of polysaccharides from Chinese medicines, such as  Epilepsy is a chronic neurological disease that affects more than 50 million people worldwide and accounts for 0.6% of the global economic disease burden . Although WHO estimates that the seizures can be controlled by appropriate medications in 70% of epilepsy patients, only less than half of them have access to antiepileptic drugs in developing countries. In addition, there is still an estimated of 15 million patients have refractory epilepsy (RE) due to the pool response to existing anti-epileptic drugs . Therefobifidobacteria and lactobacillus, the more frequent the seizures. Recently, some scholars have observed that intestinal flora can regulate the function of CNS in multiple ways and can affected epileptic seizures. In addition, intestinal microflora disorder may be caused by regulating immune and inflammatory responses, changing nutrient metabolism, activating and improving microglia and astrocyte functions, changing vagal nerve activity, and reducing neuroactive substances in limbic system such as hippocampus [such as brain-derived neurotrophin (neurotrophic factor)] increased the risk and susceptibility of epilepsy  on gut microbiota dysbiosis were investigated  polysaccharides (ZJP) on intestinal microbiota were investigated and the gut flora structure was then analyzed using high-throughput sequencing. After ZJP treatment, there was a significant decrease in Firmicutes/Bacteroidetes, which suggested that ZJP showed prebiotic-like activities by positively modulating intestinal microbiota (Lycium barbarum polysaccharides (LBPS) treatment also could modulate the composition of the gut microbiota, increasing the relative abundances of Bacteroidaceae, Lactobacillaceae, Prevotellaceae and Verrucomicrobiaceae, which were positively associated with immune traits. The present results indicated that LBPS might regulate the immune response depending on the modulation of the gut microbiota, suggesting that LBPS could be developed as special ingredients for immunoregulation in association with the modulation of the gut microbiota  may inhibit the oxidative stress and inflammation in epileptic rats ignited by pentylenetetrazol by down-regulating the expression of hippocampal P2X7 receptor and NF-κB protein, and reduce neuropathological damage  polysaccharides have the abilities to regulate inflammatory factors, neurotransmitters, ion channels, enhance immune function, promote the growth of intestinal flora and antioxidant responses. 2) polysaccharide can improve the gastrointestinal health function of the body, regulate the composition of intestinal flora, reshape the intestinal flora ecology and finally to produce anti-epileptic effects. Studies have shown that microbiota intervention could control seizures in animal models. However, in patients with epilepsy, polysaccharides as the next treatment of epilepsy drugs need to be comprehensively investigated with or without combination of anti-epilepsy drugs.


Spontaneous recognition memory tasks are widely used to assess cognitive function in rodents and have become commonplace in the characterization of rodent models of neurodegenerative, neuropsychiatric and neurodevelopmental disorders. Leveraging an animal’s innate preference for novelty, these tasks use object exploration to capture the what, where and when components of recognition memory. Choosing and optimizing objects is a key feature when designing recognition memory tasks. Although the range of objects used in these tasks varies extensively across studies, object features can bias exploration, influence task difficulty and alter brain circuit recruitment. Here, we discuss the advantages of using 3D-printed objects in rodent spontaneous recognition memory tasks. We provide strategies for optimizing their design and usage, and offer a repository of tested, open-source designs for use with commonly used rodent species. The easy accessibility, low-cost, renewability and flexibility of 3D-printed open-source designs make this approach an important step toward improving rigor and reproducibility in rodent spontaneous recognition memory tasks. Spontaneous recognition memory tasks are becoming standard in neuroscience labs studying cognitive function and using preclinical models of neurodegenerative, neuropsychiatric and neurodevelopmental disorders. However, variability in object selection across labs may hinder cross-lab comparisons and consensus across the field. Here, we discuss the advantages of, and optimization strategies for, the use of 3D-printed objects in rodent spontaneous recognition memory tasks, with the goal of increasing accessibility, reproducibility and rigor when running these tasks. We also share tested, open-source object designs for rats and mice with the broader scientific community.Spontaneous recognition memory tasks have become a commonly used tool to assess cognitive function in rodents. These tasks rely on innate novelty preference in rodents to assess recognition memory for object features  or polyethylene terephthalate glycol (PETG) filaments cost approximately USD$1–3 per printed object depending on object height and fill density used. This has opened the door to many open source tools and apparatuses in the field, such as automated feeding assessment devices , automatOne of the major challenges for rodent object recognition tasks is that specific object features inherently affect exploration . This isWhile studies advocate for uniformity in the size and complexity of objects , this beAnother issue that presents itself is the additional variability that is introduced when these tasks are used with animal models of neurologic or psychiatric disease, where an animal might display dysfunctions in perception, locomotion, or display anxiety-like behaviors that may cause the animal to stay close to the edges of the arena. These phenotypes may, therefore, impact the animal’s ability to perceive or interact with the object features, especially if the objects are not uniform in their appearance. As an example, an animal sticking close to the edge of an open field arena may only interact with the back of an object that has varying features on all its sides, thereby affecting the ability of the animal to assess object novelty, or inducing changes in baseline preference for the object.In recent years, 3D printers have become cheaper and more easily accessible, turning them into a staple at research institutions across the world. Their ubiquity provides an opportunity to increase cross-lab consistency in object selection in spontaneous recognition memory tasks. The flexibility afforded by 3D-printed designs is multi-fold. 3D-printed designs minimize the number of variables driving exploration by matching texture, color, scent, dimensions and surface area across all objects. Changing the filament type can also allow for integration of multi-sensory factors . Furthermore, objects can achieve any degree of symmetry or subtle manipulations of feature ambiguity, offering ample opportunity for discreet and iterative investigations of object processing. This flexibility is further critical when troubleshooting innate object bias, since any feature driving bias can easily be removed or modified into a new design, and new objects promptly printed for use  have worked well within the specified species/strains in tests of novel object recognition, object-location, temporal order recognition , which increase object exploration in this strain. In contrast, rats climb on pegs instead of exploring the objects. We have found no increase in cleanup time when using pegged objects, provided objects are properly sprayed in between trials.In our experience, C57/129J mice tend to lay considerably more on 3D-printed objects with a large flat top, when compared with objects with an angled or curved top. Anecdotally, the object with the most preference two of our labs have found for this strain was a cube with pegs, which substantially exceeded all other tested objects in preference, and was therefore never used. From this and other observations, we try and minimize using objects with large flat surfaces and square angles when working with this strain.When 3D printing objects for rodent object recognition tasks, we recommend using the same filament (we have tested PLA and PETG filaments) and color for all printed objects, to minimize variables. We have not directly tested whether changes in texture from filament type affect object exploration, but saw similar exploration levels between PLA and PETG filament printed objects. If using automated tracking software, choosing a filament color with the most contrast with the animal coat color will improve tracking. Our labs have used different strategies for immobilizing objects in the arena. Importantly, properly immobilizing objects will minimize any variability in exploration because of object weight, since all objects will be equally immovable by the animal. One option is to use an arena with a metallic floor and attach magnets to the 3D-printed object . This alWith the increasing popularity of spontaneous object recognition task variants to assess memory in rodents, approaches that help to standardize these tasks will help improve rigor and reproducibility. Here, we present a case for the use of 3D-printed object designs, and provide a framework for assessing the suitability of these objects across species and task variations. Moreover, through providing validated designs for 3D-printed objects, we hope to promote the harmonization of approaches and methods toward more generalizability of spontaneous object recognition findings.


Among patients with oligometastatic CRC, those with liver-limited disease represent a more refined subset and should always be discussed in multidisciplinary teams since they appear to more likely benefit from multimodal approaches with curative intent.6 A perioperative systemic treatment integrated with surgical liver metastasectomy should be regarded as the best multimodal approach.7 However, the best drug regimen to be adopted for this subset of patients with CRC is still debatable and should be tailored case-by-case.The definition of oligometastatic colorectal cancer (CRC) identifies a peculiar subpopulation of patients characterized by a limited metastatic spread of disease.RAS and BRAF wild-type CRC, doublet cytotoxic regimens (FOLFIRI or FOLFOX) plus an anti-epidermal growth factor receptor (EGFR) drug can represent the best option on the basis of significant response rate (RR).10 However, triplet cytotoxic regimens FOLFOXIRI plus bevacizumab or anti-EGFR drug demonstrate an impressive RR up to 87%, which are increasingly regarded as potential novel neoadjuvant standard strategies.11 However, severe treatment-related toxicities have been reported in up to 80% of patients.12 Hence, both doublet or triplet combinations and anti-EGFR or antivascular endothelial growth factor are feasible options in this subset of patients.Considering left-sided microsatellite stable, 14 Although genomics has already improved treatment choice in patients with CRC, especially for those carrying RAS/BRAF wild type, coclinical trials are becoming more and more important to directly test different treatment options in patient-derived tumors.15The generation of preclinical models such as patient-derived organoids (PDOs), recapitulating patient tumor histology and genetics, is emerging as a tool to predict treatment efficacy in oncology.Here, we present a proof-of-concept case report about the potential role of drug sensitivity testing in PDOs in the clinical decision making of oligometastatic CRC.RAS and BRAF, and no ERBB2 amplification, the patient received four cycles of neoadjuvant FOLFOX plus panitumumab  adenocarcinoma. Afterward, a computed tomography (CT) scan revealed two metastatic lesions in liver segments VIII and V , a fresh tumor sample from the metastatic liver lesion in segment VIII was used for PDOs generation. Once established (Data Supplement), these tumoroids underwent histologic analysis, confirming the correspondence and similarity between the PDOs and the metastatic tissue of origin , revealed no mutations discriminating for sensitivity to cytotoxic agents.16 We also performed whole-exome sequencing analysis on PDOs, confirming the presence of patient-specific trunk alterations, whereas no alterations conferring resistance to anti-EGFR drugs were observed  Figs B and 1E,Following surgical resection, as per clinical practice, the patient received further eight cycles of systemic treatment with FOLFOX regimen supported with peg-filgrastim prophylaxis, ending in April 2019. The patient tolerated the postoperative treatment well without relevant side effects.Despite this multimodal approach, CT and positron emission tomography scan in October 2019 showed disease relapse in liver segments VIII, VII, and V (Fig 24 By taking advantage of patient-derived xenografts,19 we previously identified optimal therapeutic regimens for CRC druggable targets such as ERBB2 amplification.27 Recently, the establishment of organoids directly obtained from surgical procedure or tumor biopsy has accelerated the possibility to test drugs on patients' avatars,28 thus offering a valid approach to test drug sensitivity on the bench, in parallel to patient care.Our groups have jointly focused their efforts on the development of preclinical models with the aim of tailoring treatment for patients with metastatic CRC on the basis of the results obtained from the pharmacologic screening on patients' avatars.7 Indeed, given performance status, tumor sidedness, and molecular status, both a triple cytotoxic regimen composed of FOLFOXIRI plus bevacizumab and a doublet cytotoxic combination plus anti-EGFR drug were feasible, reasonably expecting similar RR.12 However, PDO's pharmacogenomics profile showing resistance to OXA and sensitivity to 5-FU, SN-38, and panitumumab supported the clinical choice of FOLFIRI and panitumumab as perioperative regimen. This led to remarkable disease shrinkage, allowing for a second liver metastasectomy to improve the chance of cure, sparing side effects of other intensive cytotoxic regimens.31 Here, we limited our screening to approved drugs, but elsewhere, we already proposed rationale combinations including unapproved therapeutics on the basis of the results from drug screening on PDOs.33Here, we report the case of an patient with oligometastatic CRC whose drug screening on PDOs resembles both resistance and sensitivity to main cytotoxic agents. Most notably, PDOs drug testing was performed in parallel with clinical care. This translational paralleling is usually hampered by the time required to establish PDOs and test drug activity in the continuum of care of CRC Fig . However17 In addition, we envision the subset of patients with oligometastatic CRC as the optimal to bypass the limitation given by time required to PDOs establishment. Prospective translational trials are needed to verify the feasibility of this translational approach in peculiar clinical settings (Table This case report reinforces other recent publications in which PDOs were suggested as a potential platform to identify the best treatment for each patient.35 Indeed, diffused metastatic disease is more likely to be widely heterogeneous and patients do not achieve the same results observed on PDOs.37 Second, PDOs drug sensitivity testing constitutes a relatively expensive method to choose a systemic cytotoxic regimen. However, we reasoned that this might be justifiable to maximize the chance of cure and improve the quality of life. Finally, in hospitals where a close connection with a preclinical laboratory is not a reality, PDO-driven approach might be difficult to be set up.Treatment implementation driven by PDOs drug sensitivity testing has intrinsic limitations potentially hampering its applicability in the daily clinical practice. First, limiting factors such as tumor heterogeneity leading to potential sampling biases might represent relevant barriers toward translational applicability. Thus, we hypothesize that PDOs testing might be more helpful in patients with a low tumor burden, because of intrapatient heterogeneity that is expected to be lower in these patients.In conclusion, we provide a translational report demonstrating that PDOs drug sensitivity testing is feasible and might represent a valid tool to predict and improve the choice for the best perioperative personalized approach in patients with oligometastatic CRC. We suggest indeed that this setting, because of the time intervals between surgery and resumption of medical treatment, would offer the best choice to parallel patients' care, allowing timely modulation of the treatment strategy. These advantages should be supported by optimization of protocol standardization and balance against costs related to organoid maintenance.


Patient-reported outcome measures (PROMs) are a valuable metric for assessing the quality of life and overall well-being in patients with ventricular arrhythmias (VAs) and/or implantable cardioverter-defibrillators (ICDs). The incorporation of PROMs into the workflow of a VA clinic not only allows for more patient-centered care but also may improve detection and treatment of clinically relevant anxiety or depression symptoms. Awareness of the factors known to correlate with adverse PROM scores may guide PROM administration and subsequent referral to mental health services. Further, change or stability in PROM scores can be used as a gauge to guide the effectiveness of cardiac and psychological treatment in certain populations that are the focus of this manuscript: patients with ICDs (with and without shocks), cardiac arrest survivors, and those with inherited arrhythmia syndromes.  Additional randomized data are required to confirm clear improvement in PROMs with psychological interventions.from the perspective of patients, not providers. Patient-reported outcomes (PROs) are defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.”Pharmacologic, ablation, and implantable device–based treatments for ventricular arrhythmias (VAs) have grown considerably, with a priority on reducing morbidity and mortality. However, there is a growing need for providers to address the quality of life (QOL) and psychosocial well-being of patients with VAs, particularly those who have experienced or are at risk for cardiac arrest or implantable cardioverter-defibrillator (ICD) shocks. This requires assessment ,PROMs were originally primarily used within a research context and are gradually being incorporated within health systems in order to assess symptom severity, inform treatment decisions, facilitate patient-provider discussions, monitor health and well-being, and connect providers to patient-generated health data.The overarching objective of this manuscript is to provide guidance to electrophysiology (EP) programs wishing to integrate PRO assessments, particularly for 4 categories of VA patients: cardiac arrest survivors, ICD recipients (with a focus on patients who receive shocks), those who undergo ventricular tachycardia (VT) ablation, and patients with inherited arrhythmia syndromes.,Survival to hospital discharge for out-of-hospital cardiac arrest (OHCA), a significant portion of which are due to VAs, increased from 10.2% in 2006 to 12.4% in 2015.P = .03).There is emerging evidence that psychoeducational interventions can improve outcomes following OHCA. A randomized controlled trial (RCT) demonstrated that a psychosocial intervention achieved a reduction in risk of cardiovascular death of 86%  either routine or selective (based on the risk factors above) use of PROMs to identify individuals experiencing clinically significant depression, anxiety, and/or PTSD, and (2) providing mental health treatment by a practitioner who understands the unique and enduring challenges associated with surviving a significant acute medical event that approximately 90% of the population does not survive.,,,Prevalence of anxiety and depression in ICD recipients has been reported by a meta-analysis to be 11%–28% with diagnostic interviews and 5%–63% based on PROMs, representing the large variability among studies.,,29However, despite ICD recipients as a group not clearly having a reduction in QOL, anxiety and depression can develop in a subset of patients, even in the absence of shocks. Risk factors that have been associated with anxiety and/or depression postimplant include younger age,“Device acceptance” has been defined as “the psychological accommodation and understanding of the device and the derivation of benefit in terms of biopsychosocial functioning.”Randomized trials of psychosocial interventions for ICD-associated anxiety and depression have included in-person cognitive behavioral stress management therapy,Prior to ICD implant, cardiologists should be mindful of risk factors for psychological distress leading to poor device acceptance, including those listed above. Patients who report or exhibit significant ICD-related anxiety should be offered for preimplantation psychological therapy (in advance of elective procedures). Also, the physician should make apparent to the patient, especially in the setting of primary prevention ICDs, that an ICD will reduce the risk of sudden cardiac death from VAs but will not treat the underlying etiology of sudden cardiac death, and an implant may lead to new potential sources of anxiety.More than half of patients receiving ICDs for secondary prevention experience ICD shocks in long-term follow-up.The Florida Shock Anxiety Scale (FSAS) is a 10-item PROM that evaluates device-specific fears in regard to a device shock and assesses ability of the patient to cope with possible device therapy.Once a patient's QOL is affected by anxiety regarding ICD shocks, psychosocial therapies are needed. Sears and colleaguesPatients who suffer repeated ICD shocks from VT storm can often meet formal criteria for PTSD. One group administered multimodal psychotherapy (8–15 sessions over 1 year) to 18 ICD patients with diagnosed PTSD after VT storm (mean 19 shocks), and none of them met PTSD criteria at 1 year, with significant reductions in anxiety and avoidance behavior.increase the risk for arrhythmias. In a study of 645 patients assessed for depression by the Center of Epidemiological Studies Depression Scale PROM, moderate-to-severe depression was associated with a 3-fold increased risk of ICD shocks, despite controlling for multiple confounders.Conversely, depression and anxiety have also been hypothesized to ,Based on the above data, clinicians should consider screening for anxiety and depression with PROMs either routinely, or selectively among patients who have had VT storm or 5 or more ICD shocks. Patients with clinically elevated symptoms should have concerns addressed by their Device Clinic team, including a written “ICD Shock Plan” that explicitly states the criteria for which a patient should notify the clinic and/or seek medical attention after ICD shock(s). In our and others’ experience, explicit patient education surrounding ICD shocks may decrease anxiety by discussing the meaning of shocks and plans for prevention/avoidance of inappropriate shocks.P = .0003) and clinically significant depression from 26% to 18% (P = .22).Randomized trials of VT catheter ablation have demonstrated reductions of ICD shocks by 33%-73% and VT storm by 44%-70% over a 22-to-28-month follow-up.There are no known published psychosocial interventions developed as an adjunct to VT ablation. However, given the high baseline Hospital Anxiety and Depression Scale – Anxiety (HADS-A) and Hospital Anxiety and Depression Scale – Depression (HADS-D) scores among VT ablation patients and the psychosocial impact of ICD shocks, adjunctive psychosocial therapy may improve PROs. Therapy may also indirectly address adherence to antiarrhythmics, anticoagulants, heart failure medications, weight loss, and exercise, all of which may improve PROs and hard clinical outcomes of VT ablation.Often affecting pediatric or young adult patients as well as their family members, inherited arrhythmia syndromes pose unique psychosocial challenges. Parents of patients may also be affected: among families affected by congenital long QT syndrome, 61% of parents of long QT syndrome patients report a fear of their children dying.Arrhythmogenic right ventricular cardiomyopathy (ARVC) often presents in young patients and is often accompanied by prescribed exercise restrictions to prevent disease progression, both of which also pose unique psychosocial issues. The correlation between prescribed exercise withdrawal with worsening anxiety and depression is well described, with increased fatigue, lower self-esteem, and irritability noted, especially in patients with longer withdrawal of exercise.Catecholaminergic polymorphic ventricular tachycardia is often triggered by physical or emotional stress and, like ARVC, is often treated with exercise restriction. A small cross-sectional survey study reported the significant psychosocial effects of this disorderGenetic arrhythmia syndromes’ unique aspects of phenotypic uncertainty, young age of affected patients, family dynamics, and prescribed exercise restriction pose psychological risks at every clinical step: prediagnosis, disease progression, treatment, and screening/surveillance of family members. The routine use of PROMs may be useful for screening and monitoring of psychological symptoms, which may otherwise go undiagnosed amidst ICD interrogation, genetic testing, and medication management. Incorporating dedicated psychological counseling into genetic arrhythmia clinics and centers will provide tailored treatment for anxiety and depression, likely improving PROs, device acceptance, medication and exercise compliance, and clinical outcomes.Patients with or at risk of VAs may have reduced QOL and/or elevated anxiety and depression symptoms, which can be quantified using PROMs. In our practice, we administer a battery of PROMs  most likely to benefit from psychological counseling. Finally, limited data suggest that VA patients have interest in support groups,


Climate change is unleashing novel biotic antagonistic interactions for forest trees that may jeopardize populations’ persistence. Therefore, this review article envisions highlighting major opportunities from ecological evolutionary genomics to assist the identification, conservation, and breeding of biotic resistance in forest tree species. Specifically, we first discuss how assessing the genomic architecture of biotic stress resistance enables us to recognize a more polygenic nature for a trait typically regarded Mendelian, an expectation from the Fisherian runaway pathogen–host concerted arms-race evolutionary model. Secondly, we outline innovative pipelines to capture and harness natural tree pre-adaptations to biotic stresses by merging tools from the ecology, phylo-geography, and omnigenetics fields within a predictive breeding platform. Promoting integrative ecological genomic studies promises a better understanding of antagonistic co-evolutionary interactions, as well as more efficient breeding utilization of resistant phenotypes. Forecasting tree responses to climate change has typically considered shifts in their phenology and geographic distribution in the face of changing abiotic pressures. However, biotic interactions may equally be altered by niche decoupling , in turnFluctuating biotic interactions due to antagonistic biota such as pathogens, insect pests, and weeds are responsible for yield losses ranging from 17.2% up to 30.0% in major food crops . AlthougThe pace at which climatic threats may be altering biotic interactions urges intensifying novel experimental and analytical approaches to better comprehend the effect on the plant disease triangle (PDT). PDT postulates that any plant disease is the result of the interaction between a host’s genotype, the biotic stress, and their environment . GenomicTherefore, this review article aims to highlight major ecological evolutionary genomics’ tools to assist identification, conservation, and pre-breeding of biotic resistance in forest trees. Specifically, our first goal is to summarize the main trends when exploring the genomic basis  of biotic stress resistance in forest tree species, by wondering whether resistance types segregate as major Mendelian loci, a prediction from the Fisherian runaway  pathogenThe molecular mechanisms of antagonistic biotic interactions can be synthesized in three steps: attack, recognition phase, and resistance responses . A serieAfter the recognition phase, plants will usually activate their defense responses, which can be induced in multiple signaling pathways through invader-specific effectors. Ultimately, plants deploy a variety of morphological and physiological mechanisms to reduce damage from pests and pathogens such as the production of toxic or antimicrobial chemicals or proteins, programmed cell death, and compensation .When summarizing the gemomic architecture of resistance to biotic stress in forest tree species, it is outstanding to find a similar proportion of articles classifying the resistance trait as Mendelian, as well as polygenic . This inper se  [Genes and markers involved in resistance to biotic stress can be divided into two categories. The first is involved in pathogen recognition , while the other is more involved in defense response alogues) . The besalogues) . The LRRalogues) .TNL and CNL proteins appear within this category, which recognize pathogen effectors that are secreted into the cell, allowing plants to trigger the effector-activated immune response (ETI). This response generally results in the production of ITP/ITN, calcium, phytohormones, burst of oxidative reactive oxygen species, activation of the MAPK cascade, and transcription of defense genes of hypersensitive response to limit pathogen spread .Pinus lambertiana Dougl. [Meanwhile, TM-LRRs can be subdivided into two classes: receptor-like kinases (RLKs), and other receptor-like proteins (RLPs). RLKs and RLPs are pattern recognition receptors (PRRs) for a wide range of pathogens. They are used as the first line of recognition by plants and for the immune response triggered by microbial inducers PAMP or MAMP, which are highly conserved microorganisms’ structural molecules such as flagellin, chitin, and lipopolysaccharides . RLKs ana Dougl. .Arabidopsis [Another group of genes involved in plant resistance mechanisms are the pathogen response or defense genes (DGA genes), which are not as conserved as the RGA (and thus are more likely to exhibit a polygenic tendency ). Howevebidopsis . Of courQualitative and quantitative resistances are two other classifications that are recurrent when discussing responses to antagonistic biotic interactions given various degrees of complexity in the genomic architecture of the resistant phenotype . The forArabidopsis and N gene (mosaic virus resistance gene) in tobacco [Qualitative resistance has been detected mainly in the defense of plants against biotrophic pathogens, while quantitative resistance is more often involved in the defense response to broader plant pathogens, from biotrophs, hemibiotrophs, and necrotrophs. For instance, the Pto gene in tomato confers qualitative resistance, similar to RPS2 in  tobacco . Quantit tobacco .Overall, reconciling alternative classifications of the molecular responses to biotic stresses is challenging owing to reiterative knowledge gaps on the functionality or the nature of the associated genomic regions. Besides, rampant polymorphism at downstream levels , as wellThe stability of forest biomass in the world is threatened by the incidence of pests and diseases that cause a continuous deterioration of health . It is cTherefore, it is necessary to improve data compilation and access on plant genetic resources  with a fUnfortunately, studies of genetic biotic resistance in forest stands still lack cohesion. Although the infectious agent is known in all surveyed studies , the regSustainable forestry development must also better integrate disciplines that adjust to the particularities of each locality. In this way, it may be achievable to select elite genotypes, and identify genetically improved clones with narrow pre-adaptations  that canTree pre-breeding requires an interdisciplinary approach  to speedIn recent years, there has been increasing interest in merging several disciplines to gather more cohesive inferences in the field of forest genetics . For insThe impact of pests and diseases on the distribution of forest trees, and their regeneration mechanisms , has beeLocal adaptation conceptualizes the trend that local populations tend to have a higher average fitness in their native environment than in other environments, or when compared with foreign introduced populations . DespiteAttempts to identify candidate genes of adaptive importance, and to relate genetic variation in these genes to phenotypic expressions in multi-locality field trials, have typically been hampered by a complex polygenic architecture , and a la priori weighted resistance mapping through more conventional methods such as quantitative-trait loci (QTL) mapping or genome-wide association studies (GWAS) [A useful type of polygenic model, yet to be calibrated within an omnigenic framework , is genos (GWAS) . These ms (GWAS)  via SNP-GP may also go beyond pre-breeding efforts, and feedback on restoration optimization  and provGenetic drift refers to random allelic fluctuations within genepools . It is tOn the other hand, modern CRISPR/Cas9 gene editing technology is capable of modifying the immune response function in eukaryotic cells via a highly specific RNA-guided complex . This tehttp://www.evoltree.eu/, accessed on 16 September 2021), and North Carolina State University’s Central America and Mexico Coniferous Resources Cooperative  a not-for-profit international tree breeding organization partnered with private companies in the forestry sector around the world. Both alliances may serve as inspiration to build a stronger networking around breeding for biotic resistance in forest trees. Ultimately, promoting more of these partnership efforts will enhance multi-locality trials and data sharing among countries [Joint research efforts to study more systematically the genomics of forest pathology across the enviromics continuum must be envisioned . At the ountries , while iMeanwhile, these trans-disciplinary initiatives undeniably require support from both the public  and the private  sectors. Public–private alliances must be conceived as opportunities to put in place more realistic agreements of data embargo, and for the quarantine of genotypes across institutional and political borders. Unfortunately, overwhelming regulatory issues still tend to put cross-country field trials on hold by preventing an effective mobilization of seeds, seedlings, and data . Hence, Forest pathology must start integrating more thoroughly disciplines that allow understanding the biology and natural evolution of trees under biotic stress, seeking the conservation of the mechanisms by which species have defended themselves from biotic antagonistic agents.Polygenetic biotic resistance must be acknowledged as an equally plausible pre-adaptation as Mendelian inheritance. The latter configures a long-standing expectation from the Fisherian runaway pathogen–host concerted arms-race evolutionary model. According to this theoretical paradigm, loci conferring resistance are predicted to evolve in concert due to strong selection towards more durable and unbreakable resistance. In turn, concerted molecular evolution would likely promote long-term linkage disequilibrium and reduced recombination, making several resistance loci behave as a single Mendelian locus.Another prerogative must focus on deepening our ecological understating at the pathogen–species–environment interface, while better integrating this classical PDT paradigm with the modern disciplines of forest genomics, molecular biology, phylo-geography, and predictive breeding .Promoting open access and information agreements among national and international parties  is equally relevant to build more cohesive input datasets to ultimately leverage these ‘big data’ integrative approaches for forest pathology breeding.


Most neonatal deaths occur in low- and middle-income countries (LMICs). Limited recommendations are available on the optimal personnel and training required to improve identification of sick newborns and care-seeking from a health facility. We conducted a scoping review to map the key components required to design an effective newborn care training program for community-based health workers (CBHWs) to improve identification of sick newborns and care-seeking from a health facility in LMICs.We searched multiple databases from 1990 to March 2020. Employing iterative scoping review methodology, we narrowed our inclusion criteria as we became more familiar with the evidence base. We initially included any manuscripts that captured the concepts of “postnatal care providers,” “neonates” and “LMICs.” We subsequently included articles that investigated the effectiveness of newborn care provision by CBHWs, defined as non-professional paid or volunteer health workers based in communities, and their training programs in improving identification of newborns with serious illness and care-seeking from a health facility in LMICs.Of 11,647 articles identified, 635 met initial inclusion criteria. Among these initial results, 35 studies met the revised inclusion criteria. Studies represented 11 different types of newborn care providers in 11 countries. The most commonly studied providers were community health workers. Key outcomes to be measured when designing a training program and intervention to increase appropriate assessment of sick newborns at a health facility include high newborn care provider and caregiver knowledge of newborn danger signs, accurate provider and caregiver identification of sick newborns and appropriate care-seeking from a health facility either through caregiver referral compliance or caregivers seeking care themselves. Key components to consider to achieve these outcomes include facilitators: sufficient duration of training, refresher training, supervision and community engagement; barriers: context-specific perceptions of newborn illness and gender roles that may deter care-seeking; and components with unclear benefit: qualifications prior to training and incentives and remuneration.Evidence regarding key components and outcomes of newborn care training programs to improve CBHW identification of sick newborns and care-seeking can inform future newborn care training design in LMICs. These training components must be adapted to country-specific contexts.The online version contains supplementary material available at 10.1186/s12884-021-04240-3. While neonatal and child mortality decreased substantially worldwide from 1990 to 2019, the burden of under-five mortality remains significant in low- and middle-income countries (LMICs) .Moreover, survival rates differ among age groups of children younger than five years with a particularly high burden in the neonatal period (first 28 days of life). In 2019, 47% (2.4 million) of under-5 deaths occurred among neonates [Over the past two decades, considerable progress has been made in improving the proportion of births attended by skilled health personnel  and occurring in a health facility in LMICs. From the period 2000–2006 to 2014–2020, the proportion of births occurring at a health facility in West and Central Africa, Eastern and Southern Africa, and South Asia increased from 38 to 55%, 37 to 66%, and 31 to 74%, respectively [Of all neonatal deaths globally, about two thirds occur after the first 24 h of life and almost three-quarters of neonatal deaths occur during the first week of life . MoreoveThe World Health Organization (WHO) 2013 recommendations on postnatal care of the mother and newborn  and the In 2015, the United Nations created the Sustainable Development Goals (SDGs) as the successor to the MDGs. Centred on reducing child mortality, SDG3.2 aims to decrease neonatal mortality to fewer than 12 deaths per 1000 livebirths and end preventable deaths of newborns and children under five years of age . More thThis study followed the PRISMA-ScR checklist  with search terms reflecting the concepts of “low/middle-income countries”, “postnatal care” and “provider type” was performed. We conducted an analysis of the results from the preliminary search to inform the development of the full search strategy, which was conducted across Medline (Ovid), CINAHL (EBSCO), Global Health (Ovid), the Cochrane Library collection of databases (Wiley), and DARE (Database of Abstracts of Reviews of Effects) from 1990 to March 31, 2020. We also searched the grey literature including all registered clinical trials on Among the articles included in the initial search, major areas of study within newborn care included newborn resuscitation, breastfeeding promotion, kangaroo mother care, umbilical cord care, prevention of mother-to-child transmission of HIV (PMTCT), identification of sick newborns and care-seeking from a health facility. After reviewing these various areas, we decided by consensus to narrow our inclusion criteria to focus specifically on studies of CBHW newborn care provision and training programs to improve identification of sick newborns and care-seeking in community-based settings outside of the hospital and primary health care facilities. Thus, the revised inclusion criteria were studies that: 1) investigated the effectiveness of CBHW newborn care providers and their training programs to improve identification of newborns with serious illness and/or care-seeking from a health facility, and 2) occurred in community-based settings in urban or rural areas of LMICs.We defined CBHWs as health workers who meet the following criteria: 1) have some training in carrying out functions related to biomedical health care delivery, 2) have no formal professional or paraprofessional certificate, 3) provide care in community settings, that is, at patients’ homes or based at peripheral health posts not staffed by physicians or nurses, and not at primary health care facilities, and 4) are either paid or volunteer , 17. ‘NeWe excluded studies conducted in neonatal intensive care units or tertiary care centres, studies conducted in high-income countries, review articles, conference abstracts, study protocols, case reports, commentaries and editorials.The total number of studies was divided among three reviewers  and two of the three reviewers independently performed the eligibility assessment for each study in a standardized manner using predefined inclusion and exclusion criteria, first in abstract form followed by full-text format. Disparities between reviewers were resolved by discussion and where there was still lack of agreement, a fourth reviewer (MC) was consulted.Two reviewers (AF and EH) extracted the data from all included studies onto a data extraction form. Information collected included first author and year of publication, country and study setting, study design, characteristics of the neonatal subjects, characteristics of the newborn care providers, duration and content of training if available, the content and coverage of the intervention and the outcomes as they pertained specifically to the identification of newborns with serious illness and care-seeking from a health facility.We did not perform a formal assessment of methodological quality as this is not a typical feature of scoping reviews .The flow diagram of study selection is shown in Fig. The search strategy identified 11,647 articles. After adjusting for duplicates, 9263 studies remained. Of these, 635 studies met the initial inclusion criteria. Within these results, 35 articles –54 detaiThe included articles were published between 2005 and 2020. Studies represented 11 countries across three sub-continents , village health workers (VHWs), traditional birth attendants (TBAs), accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), female community health volunteers (FCHVs), community-based surveillance volunteers (CBSVs), community volunteers (CVs), lady health workers (LHWs), health extension workers (HEW) and peer educators. The most common provider type was the CHW.Thirty-one studies used home visits as the platform of care delivery. One study investigated women’s group meetings . AnotherThe content of training varied but generally included history-taking, clinical assessment of mothers and newborns, identification of newborn danger signs, decision making for referral and facilitation of referral compliance, skills development for behaviour change communication, and data recording. Examples of newborn danger signs included: red umbilicus or cord with pus, newborn feeling hot or cold, failure to breastfeed, convulsions, rapid breathing, lack of body movement when stimulated, yellowing of the palms and soles, chest in-drawing and grunting . TraininApproaches to training included didactic teaching, demonstrations, role-plays, simulation exercises, practicing physical examination on newborns, group discussions, effective communication and educational messages and train-the-trainer models. Case vignettes were used as teaching tools and photographs and audiovisual materials were used as references for various neonatal danger signs. One study employed a technique called “microteaching” which involved several rounds of video recording with ongoing provision of feedback to continually improve newborn care provider performance .Six studies evaluated provider knowledge of newborn danger signs –51, 53. The included studies demonstrated that training newborn care providers can improve identification of sick newborns and care-seeking from a health facility in LMICs. Increasing appropriate assessment of a sick newborn and referral to a health facility requires measurement of five key interrelated outcomes that cover both knowledge and practice of newborn care providers and caregivers: 1) provider knowledge of newborn danger signs, 2) caregiver knowledge of newborn danger signs (through education from provider), 3) correct identification of sick newborn by provider, 4) correct identification of sick newborn by caregiver and 5) appropriate care-seeking from a health facility   [The median training duration was 39 days with a wide range among studies of four days to 17 months. One study showed intermediate ASHA to post-graduate female investigator agreement on the need for further assessment of infants kappa 0.48,  <0.001) . Disagre <0.001) . Compare <0.001) –48. Of n,  <0.001Two studies assessed newborn care provider knowledge of newborn danger signs and both were conducted in Uganda , 44. NalSix studies showed that various newborn care providers including CBSVs, VHWs, CHWs and FCHVs were able to correctly classify sick newborns at home visits with high inter-rater agreement when compared to a gold standard  , 28, 30.Nine studies included supervision and on-the-job training as part of CBHW training programs , 43, 44.Eleven studies assessed caregiver knowledge of newborn danger signs and all showed significant improvements in this outcome in post-intervention groups compared to pre-intervention groups and in intervention groups compared to control groups , 52, 54.Seventeen studies showed that newborn care provider training and home visits improved appropriate care-seeking from a health facility by a caregiver at end line compared to baseline or in intervention versus control groups , 49, 50.Perceptions of gender roles are also an important consideration in community-based newborn care. One study in eastern Uganda highlighted that engaging husbands to support their wives in newborn care was challenging due to a perception that caregiver information on newborn care was designed for women . HoweverNewborn care providers’ level of education and competencies prior to initiating training varied widely among studies. Years of school education ranged from at least primary education to a minimum requirement of grade 12 education. In most studies, the minimum required education was at the primary level, with some requiring additional years at the secondary level. Most studies did not mention years of field experience for given CBHW cadres. In one study, CBSV experience ranged from eight months to 25 years with a mean of seven years . AnotherIncentives and remuneration for newborn care providers varied widely. Some studies specifically stated that no monetary incentives were offered while others included both monetary and non-monetary incentives. Examples of non-monetary incentives included T-shirts, working materials, briefcases and certificates following training. No clear descriptive association between incentives and key outcomes emerged. One study found through qualitative interviews that incentives were important motivators for CHWs and helped to minimize the dropout rate (3.6%) . At the This review identified 35 articles detailing 28 studies that evaluated CBHW newborn care providers’ ability to recognize sick newborns and improve care-seeking for sick newborns from a health facility in LMICs. Most studies reported that newborn care training and provision can be effective in improving identification of sick newborns and care-seeking from a health facility in diverse LMIC settings where resources are limited and rates of neonatal mortality are high. Key interrelated outcomes that should be measured in an effective newborn care training program include, but are not limited to, high newborn care provider and caregiver knowledge of newborn danger signs, correct identification of sick newborns by providers and caregivers and appropriate care-seeking either through caregiver referral compliance or caregivers themselves seeking care for their newborns based on their knowledge and ability to correctly identify newborn danger signs. Although these outcomes have been identified as important for effective newborn care programs, there is limited understanding regarding the associations between these outcomes and their relative impact on reducing neonatal morbidity and mortality. For example, there is a need to further investigate whether caregiver knowledge of newborn danger signs is associated with improved care seeking. Important components to consider when designing and implementing a newborn care training program to achieve key outcomes were extracted. Facilitators included sufficient duration of training, refresher training and retraining, supervision and on-the-job training and community engagement. Barriers included context-specific understanding of newborn illness and gender roles that may deter care-seeking. Components with unclear benefit included qualifications and experience prior to newborn care training and incentives and remuneration. The studies in this review evaluated key outcomes individually; however, a next step would be to investigate how the components correlate to achieve the desired outcome of improved newborn health.Duration of training varied widely but less than 11 days of training generally led to poorer outcomes compared to training in the range of weeks to months. The potential benefit of training duration longer than 11 days is important to consider given current WHO recommendations of three to six days for CHW training courses in newborn care . SufficiAlthough the ability of newborn care providers to identify danger signs in newborns was generally positive, one study showed a significant decline in provider knowledge of newborn danger signs at one year post-training  and anotSimilar to refresher training, supervision and on-the-job training were also shown to be essential components of newborn care training programs to reinforce skills and ensure and maintain quality newborn care. Supervision strategies ranged from direct observation to large CBHW group meetings to troubleshoot challenges. Further research is needed on the effects of various supervision strategies on CBHW performance.Three studies showed no difference between baseline and end line or between intervention and control groups regarding care-seeking from a health facility by a caregiver for a sick newborn. Context-specific perceptions attributing newborn illness to ‘evil eye’ or ‘witchcraft’ deterred caregivers from seeking care from a health facility and perceptions that newborn care information was designed for women deterred the involvement of men in supporting their wives in newborn care. Therefore, more emphasis on developing skills for behaviour change communication and counselling to educate regarding context-specific perceptions of newborn illness and gender roles that may deter care-seeking from a health facility is critical. Beyond simply educating newborn care providers and caregivers about newborn danger signs, community leaders and members need to be actively involved in designing training and interventions in order for the intervention to be trusted, well-received and effective in a given country’s specific socio-cultural context.Related to culturally-sensitive care, another critical CBHW training component is respectful and dignified care. None of the included studies specified details related to the incorporation of respectful care into training programs. However, given the increasing evidence of disrespect, abuse, mistreatment and stigmatization of newborns , future One included study evaluated TBA performance in identifying newborns with danger signs . It is iThe importance of prior education and experience and of the presence of incentives and remuneration in improving key outcomes is likely context-specific. Training interventions, and those designing and implementing them, should account for factors that would affect a newborn care provider’s clinical abilities such as educational background, previous training and medical experience, status in the community and remuneration. For example, an ASHA in India is the first point of contact for most communities for primary care and maternal and child health issues and needs to fulfil the educational criteria of being literate with “preference in selection to those who are qualified up to 10 standard … this may be relaxed only if no suitable person with this qualification is available” . The ASHBeyond improving provider and caregiver knowledge of newborn danger signs, identification of sick newborns and appropriate care-seeking through a newborn care training program, it is also important to ensure that transport to a health facility is quickly accessible once the decision to seek care has been made. Studies in LMICs have shown that transport-related delays are a significant contributor to neonatal deaths , 9. In sThis scoping review narratively described key components to be considered in designing an effective CBHW newborn care training program to improve identification of sick newborns and appropriate care-seeking. These components align with recommendations from the WHO 2018 guideline on health policy and system support to optimize community health worker programs which include supportive supervision, remuneration and community engagement . Future This review had several limitations. First, as is the case with scoping review methodology, we did not assess the quality of selected studies. The overall high proportion of improved outcomes could be attributed to publication bias. However, this review provides an overview of the available evidence for the effectiveness of newborn care providers in the identification and referral of sick newborns upon which further interventions and strategies can be evaluated and implemented at scale. Second, the included studies only represented 11 countries across three subcontinents and many LMICs were not represented which limits the generalizability of our findings. Future development and implementation of newborn care provider training should be adapted to local cultural, socio-economic and political factors. Third, the time of publication of included articles varied widely with the earliest article published in 2005. Since that time, notable advancements have been made in the evidence base for newborn interventions. These include increased coverage of facility-based deliveries and deliveries attended by skilled health personnel , chlorheTraining newborn care providers to successfully identify sick newborns and improve care-seeking behaviour is an important contributor to the global goals of decreasing neonatal mortality and ending preventable deaths of newborns as outlined in the SDG3.2. High newborn care provider and caregiver knowledge of newborn danger signs, correct identification of sick newborns by providers and caregivers and appropriate care-seeking from a health facility are important outcomes to be measured when designing a newborn care training program to reduce neonatal morbidity and mortality. Facilitators to achieve these key outcomes include sufficient duration of training, regular refresher training, supervision and on-the-job training and community engagement. Barriers include local perceptions of newborn illness and gender roles that may deter care-seeking from a health facility. Components with unclear benefit include qualifications prior to training and incentives and remuneration. Training curriculum development must be culturally-sensitive, respectful and grounded within specific local contexts. Our findings can inform the design of future CBHW newborn care training programs in LMICs. Further research is needed to determine the relative impact of the facilitators, barriers and components with unclear benefit on key outcomes and to investigate the associations between key outcomes and their relative impact on reducing neonatal morbidity and mortality.Additional file 1. 1 PRISMA-ScR checklist. PRISMA-ScR checklist.Additional file 2. Full electronic search strategy for Medline (Ovid). Full electronic search strategy for Medline (Ovid).Additional file 3. Characteristics of studies on postnatal care providers in low-and middle-income countries (expanded). Expanded results table.


Recently, monoclonal antibodies (mAbs) directed against calcitonin gene-related peptide (CGRP)  or its receptor (Erenumab) have been approved for clinical use as prophylactic drugs for high-frequency episodic and chronic migraine. While their therapeutic effects on headache pain is well documented, there is scarce information on the usefulness of these medications in preventing migraine aura, which is believed to be associated with cortical spreading depression (CSD). Because of their large size, mAbs cannot easily cross the blood–brain barrier in high quantities, rendering the peripheral trigeminovascular system to likely be a major site of their action. In this paper, we report two cases of patients suffering from migraine with and without aura, who reported a complete disappearance of aura or reduced aura duration and intensity while taking Galcanezumab or Erenumab, respectively. Then, we present a brief overview of the literature about the controversial relationship between CSD and CGRP and about the potential “additional central” role of these mAbs in the pathophysiology of migraine aura. Migraine aura consists of focal reversible neurological deficits with a gradual and progressive onset that typically precedes or accompanies headache, or occurs without headache in up to one-third of patients. Clinical manifestations are extremely variable and may include alterations of sensitivity and disorders of language and/or of strength, but visual symptoms remain the most common. Many patients diagnosed with migraine aura (MA) occasionally have attacks of migraine without aura (MO) and vice-versa. Although the etiopathogenesis of MA has not yet been fully clarified, cortical spreading depression (CSD) seems to have a pivotal role and is closely connected to the release of calcitonin gene-related peptide (CGRP) ,2. In faSeveral studies point towards important distinct familial, structural, and functional brain features between MA and MO ,7,8. MA Recently, new therapies have emerged for the management of episodic and chronic migraine in adults, including CGRP receptor antagonists (Gepants) and anti-CGRP monoclonal antibodies (mAbs) directed against CGRP  or its receptor (Erenumab) ,10. TriaAccording to the “neurovascular theory”, the activation of the trigeminovascular system (TGVS) and the release of numerous neuropeptides and vasoactive mediators  play a key role in migraine pathogenesis . ExperimTo date, although a known correlation exists between migraine, migraine aura, and CGRP release, the efficacy of these medications on the occurrence of auras and their possible effects on CSD remain to be elucidated. In relation to this issue, we report two cases of migraineurs who reported a complete disappearance of aura or reduced aura duration and intensity while taking Galcanezumab or Erenumab, respectively.2) initially presented at our Headache Center of Tor Vergata in November 2020. She had suffered from migraines with and without aura since her childhood. She provided written informed consent to this discussion of her disease situation. A 53-year-old female Caucasian patient of normal body weight —9/10), mostly unilateral (changing sides), with concomitant moderate photo- and phonophobia and a slight increase in headache during physical activity. The attacks occurred 16–18 days per month and were preceded by visual auras twice per month, with severe resultant disability (Migraine Disability Assessment Test Score (MIDAS)—110 at presentation, see Neurophthalmological examination performed during the visual phenomena was normal, not fulfilling the criteria for retinal migraine . MoreoveFor acute therapy, the patient used oral Eletriptan (40 mg), with moderate success but with constant medication-overuse (more than 10 days per month). The patient was diagnosed with chronic migraine with and without aura and medication overuse, based on the International Classification of Headache Disorders 3rd edition (ICHD-3) . DiffereTherefore, Galcanezumab was administered, starting with a subcutaneous loading dosage of 240 mg and then 120 mg each month thereafter, according to the current Italian Medicines Agency (AIFA) migraine guidelines [Simultaneously, she noted an initial increase of aura episodes without headache, which completely disappeared 3 months after having begun the Galcanezumab treatment see . A 48-year-old man had been suffering from migraines with and without aura since he was 20 years old, but he did not have serious problems until last year, when headache episodes became more frequent and he had to refer many times to our Emergency Department. He provided written informed consent for this discussion of his medical case.The attacks were characterized by unilateral beating pain, high intensity (NRS—9/10) together with nausea, vomiting, and photo-phonophobia. Visual migraine aura occurred every 15 days, with scotoma that spread gradually over ≥5 min and was followed by headache within 40 min.Neurological examination and brain MRI without contrast were unremarkable. During his last presentation at our Emergency Room of Tor Vergata Hospital in December 2020, he reported a burden of 12 monthly migraine days, fulfilling the ICHD-III criteria for high-frequency episodic migraine , and ratAfter an 8-month treatment, migraine frequency decreased to 2 days per month and the use of triptans was gradually reduced see . HoweverIn these two cases of migraineurs, we showed that the new class of peripherally acting preventive mAbs could interfere with the clinical presentation of migraine aura. This may be due to indirect secondary changes after peripheral modulation of sensory input, or may represent an “additional central” mode of action. Although the etiopathogenesis of migraine aura is not fully clarified, evidence supports the hypothesis that Cortical Spreading Depression (CSD) is an underlying physiological process that could activate the trigeminal nociceptive system both peripherally and centrally in animal models, possibly provoking headache ,14,15. IDespite the importance of both CSD and CGRP in migraine, the relationship between these two players remains unexplored and is controversial. There are several intriguing observations that indicate potential functional and anatomic connections between the two. First, in animal models, CGRP contributed to CSD-associated hypoperfusion and the secondary local changes due to CSD  caused a CGRP release at the cortical level . The cloA wide variety of experimental triggers, such as hypoxia or glyceryl trinitrate, provokes migraine attacks in susceptible subjects . MoreoveTaken together, these data suggest that CGRP release following CSD events induces a positive feedback loop, facilitating the development of the CSD itself and an increased susceptibility to migraine. This may support the potential use and effectiveness of new therapies which target CGRP  or its receptors (Erenumab) in order to prevent not only migraine pain but also migraine aura . Until today, these molecules have demonstrated high responder rates and favorable adverse event profiles in the prophylaxis of both high-frequency episodic and chronic migraines, but studies on their efficacy in preventing migraine aura and CSD are still lacking ,10. MoreA recent study using a murine model showed that CSD has effects on the spontaneous and evoked activity of high-threshold trigeminal neurons at spinal and dorsal horn levels. In the same study, the anti-CGRP-mAb Fremanezumab, administered intravenously in the rats, was able to prevent the CSD-mediated activation of central trigeminovascular neurons . FremaneNew data suggest that mAbs may have potential central properties, so they could influence CSD generation and the clinical manifestation of migraine aura, but the exact mechanisms remain unclear ,23,24. Since CGRP and its receptors are widely distributed throughout the cortex, it is possible that sufficient quantities of mAbs can reach the central nervous system (CNS) and inhibit CSD . Recently, an fMRI study demonstrated that administering Erenumab modulates the activation of specific cerebral areas after trigeminal nociceptive input, including the thalamus, the insular cortex, and the secondary somatosensory cortex. It is only in responders’ patients that it induces a significantly reduced activation of the hypothalamus, a relevant central structure of migraine attack generation and chronification . MoreoveAlthough no data for Erenumab have been published yet, another animal study showed the presence of Galcanezumab in peripheral and central tissues within 24 h of subcutaneous injections, which persisted for over 168 h . There wNonetheless, previous studies using animal models of migraine aura found that even when the BBB was damaged and Fremanezumab was allowed to reach the cortex, it was able to slow down the propagation velocity of CSD and reduce the following cortical recovery period, but could not abolish the initiation of CSD depolarization waves . TherefoOn this basis, real-world data and prospective studies with a higher level of standardization and larger sample sizes would be beneficial to clarify if these new drugs are able to modify the presentation of aura in patients suffering from such high-frequency forms of attacks or in patients suffering from both MA and MO. For patients, aura symptoms are alarming and may be transiently debilitating. A better understanding of the relationship between CSD, migraine aura, and CGRP and of the differential responses to therapy may be an important step towards more personalized medicine.


The key uremic toxins that contribute to VC, i.e., p-cresyl sulphate (PCS), indoxyl sulphate (IS) and trimethylamine-N-oxide (TMAO) originate from bacterial metabolism of gut microbiota. All mentioned toxins promote VC by several mechanisms, including: Transdifferentiation and apoptosis of VSMC, dysfunction of endothelial cells, oxidative stress, interaction with local renin–angiotensin–aldosterone system or miRNA profile modification. Several attractive methods of gut microbiota manipulations have been proposed in order to modify their metabolism and to limit vascular damage (and VC) triggered by uremic toxins. Unfortunately, to date no such method was demonstrated to be effective at the level of “hard” patient-oriented or even clinically relevant surrogate endpoints.Chronic kidney disease (CKD) affects more than 10% of the world population and leads to excess morbidity and mortality (with cardiovascular disease as a leading cause of death). Vascular calcification (VC) is a phenomenon of disseminated deposition of mineral content within the media layer of arteries preceded by phenotypic changes in vascular smooth muscle cells (VSMC) and/or accumulation of mineral content within the atherosclerotic lesions. Medial VC results in vascular stiffness and significantly contributes to increased cardio-vascular (CV) morbidity, whereas VC of plaques may rather increase their stability. Mineral and bone disorders of CKD (CKD-MBD) contribute to VC, which is further aggravated by accumulation of uremic toxins. Both CKD-MBD and uremic toxin accumulation affect not only patients with advanced CKD (glomerular filtration rate (GFR) less than 15 mL/min/1.72 m In addition, PCS led to imbalance between matrix metalloproteinases and tissue metalloproteinase inhibitors, thus contributing to plaque instability .2 or treated with maintenance dialysis) [Gross et al. in their research focused on the possible contribution of PCS to oxidative stress. Indeed, the authors demonstrated that PCS activates oxidative stress both in endothelial cells and VSMC. In addition, PCS promoted phenylephrine-induced contraction of smooth muscles within aortic wall and in consequence—promoted aortic wall remodeling, largely resembling remodeling found in patients with chronic uremia. It should be emphasized that all the above results obtained in an animal model were triggered by PCS in concentrations corresponding to those found in patients with advanced CKD  .TMAO is another uremic toxin originating from gut microbiota metabolism . The rolYazdekhasti et al. have demonstrated the possible role of TMAO in atherogenesis in apo-E-null mice. In their experiments, authors exposed mice to three diets with an equivalent content of protein, but originating from different sources, namely fish, casein and soy . Interestingly, diet based on fish-derived protein led to the development of more advanced atherosclerosis in aorta, and the atherosclerotic lesions were also more calcified. Animals fed with fish protein-based diet were characterized with significantly higher mRNA expression of several inflammatory markers  in aortic wall as compared to those fed with casein-based or—especially—soy-based diet. Since TMAO concentration was approximately six times higher in animals receiving fish-based protein, as compared to remaining two diets, it is fair to speculate that TMAO originating from fish protein metabolism may be the key factor responsible for observed differences . One couHuman studies provide equivocal results. On one hand, observational study in 4007 patients subjected to elective coronary angiography has demonstrated the relationship between fasting plasma levels of TMAO and incident major adverse cardiovascular events  during 3 years of follow-up  . HoweverIn summary, although experimental data clearly point on the pivotal role of discussed toxins on the development of VC, the clinical studies analyzing an outcome of the patients with different stages of CKD depending on serum levels of uremic toxins provide equivocal results, and—as for now—no firm conclusion on their impact on patient-oriented endpoints can be drawn ,89,90,91The pathways involved in the development and progression of the VC are displayed on Modification of microbiota composition and metabolism has been postulated for a long time as an attractive way to control uremic toxemia (and possibly—to inhibit such systemic consequences of CKD as VC). Prebiotics, probiotics, modification of diet composition, the use of non-absorbable antibiotics or supplementation of amino acid ketoanalogues may represent strategies to influence the local synthesis and absorption of uremic toxins by means on their impact on microbiota ,92,93. SIn summary, almost all known pathways contributing to VC in CKD can be linked at some way with the molecular effects of gut microbiota-derived uremic toxins. The promotion of VC starts early in the course of CKD. Theoretically, exposure to these toxins is largely preventable by apparently simple manipulations on gut microbiota. Unfortunately, to date no intervention performed in humans demonstrated efficacy in terms of protection from progression of CKD, nor protection from systemic consequences of CKD (including cardiovascular morbidity). To date none of the interventions applied to treat CKD  was demonstrated to stop or reverse VC. Even successful kidney transplantation with at least partial restoration of kidney function does not stop or reverse this process, although is usually able to slow it down ,101,102.