Thromboinflammation or immunothrombosis is a concept that explains the existing link between coagulation and inflammatory response present in many situations, such as sepsis, venous thromboembolism, or COVID-19 associated coagulopathy. The purpose of this review is to provide an overview of the current data regarding the mechanisms involved in immunothrombosis in order to understand the new therapeutic strategies focused in reducing thrombotic risk by controlling the inflammation. The activation of the coagulation cascade represents a natural mechanism of defense, critical to keep physiological hemostasis in response to an infection or tissue damage in order to avoid blood loss. Nowadays, coagulation is considered a key player in the immune response, as it could prevent both viral and bacterial infections working in a bidirectional way with innate immune system . HoweverClassically, the coagulation cascade was described to be composed of two pathways, intrinsic and extrinsic, leading to a common final pathway, that originates the fibrin blood clot which is able to stop the bleeding that occurs after a vascular lesion. The intrinsic pathway begins with factor XII activation due to the interaction of blood with artificial or pathological surfaces that are negatively charged, such as DNA, RNA, polyphosphates, or atherosclerotic plaque components. The extrinsic pathway begins with tissue factor (TF) that makes a complex with factor VII at subendothelial level or over circulating immune cell membranes, as monocytes. However, in pathological situations, the pathogen recognition by immune cells amplifies procoagulant TF activity around 100 times . Both acTF is a 47 kd membrane receptor glycoprotein that plays an important role in coagulation activation in response to infectious agents or tissue injury. It is expressed in blood vessel adventitia and in circulating cells, such as monocytes and neutrophils . In the Then, immune cells release decrypted TF in a process called pyroptosis that provokes leaks in the cellular membrane and activates the inflammasome through the caspase pathways ,10. FollAdditionally, platelet adhesion to injury site turns platelets into an active state that may act as a beginner for the TF alternative pathway .In summary, published data show that TF, together with monocytes or neutrophils, is a crucial player during immunothrombosis as it can activate platelets .Inflammasomes are molecular platforms conformed by several proteins that regulate the inflammatory response as antimicrobial mechanism defense. The presence of PAMPs and other dangerous molecular signals (DAMPs) activate caspases and induces pyroptosis and cellular death through gasdermins, which are the executors of inflammation and cell death. The so called non-canonical inflammasome activation is produced as a consequence of caspase-11 induction by LPS-associated gram-negative bacteria in different immune and nonimmune cells, including neutrophils, macrophages, and endothelial cells . The casCaspase-1 leads to the canonical activation of the inflammasome and provokes NLRP3 activation and IL-1β and IL-18 cytokine release. Caspase-1 is activated in the presence of several pathogens and at the same time activates gasdermin D, this activation promotes pyroptosis that originates in gaps in the cellular membrane, increasing TF-related procoagulant activity [Recent experimental and clinical studies have demonstrated that the canonical and non-canonical activation of the inflammasome are crucial for TF release by immune cells . In thisIn conclusion, clinical and experimental evidence establish cellular death mediated by inflammasomes as a key trigger for immunothrombosis and microvascular thrombosis . Two keyRecently, new mechanisms involved in the immunothrombosis process have been proposed. One of them is related to the STING protein (stimulator of the interferon response cGAMP interactor 1), expressed in fibroblasts and endothelial cells which responds to PAMPs and DAMPs. The STING protein has been previously implicated in the inflammatory response in sepsis-associated coagulopathy in experimental models. STING favors the procoagulant response through the regulation of the calcium release and gasdermin D proteolysis, facilitating TF release . AnotherNETs are extracellular structures composed of granule, nuclear, and mitochondrial constituents assembled on a scaffold of decondensed chromatin with antimicrobial proteins and peptides ,27. NETsNucleic acids activate coagulation, with RNA binding both factors XII and XI in the intrinsic pathway. RNA is present in fibrin-rich arterial thrombi. Furthermore, histones increase thrombin generation in a platelet-dependent manner. Histones activate platelets, and platelet activation, in turn, promotes coagulation, leading to platelet-rich microthrombi formation. Within thrombi formed in vivo, NETs colocalize with VWF . FinallyIt is interesting to note that although platelet and neutrophil interplay is crucial, depending on the original stimuli platelets, they are not always needed . In factThe von Willebrand Factor (VWF) is a glycoprotein release by endothelial cells or platelets with an important role in hemostasis . FurtherIt is described that VWF is colocalized with NETs in venous and arterial thrombosis ,40, induSeveral studies have addressed the close interaction between sepsis and coagulopathy. Sepsis is characterized by a dysregulated immune system with an excessive production of cytokines, in response to infectious stimuli . This dyThere is growing interest in the immunothrombosis role in SAR-COV-2 (COVID-19) infection complications. Previously, in vitro studies demonstrated TF induction and decryption in response to different viruses, such as herpes simplex, Ebola, and HIV associated with different coagulopathy degrees and thrombosis ,49. HoweIt is known that COVID-19 induces an important coagulopathy in which multiple components are involved in immunothrombosis and play an essential role ,51. FirsThe activating interplay of thrombosis and inflammation (thromboinflammation) has also been established as a major underlying pathway driving cardiovascular diseases, such as myocardial infarction and stroke. Innate immunity and platelet crosstalk promote plaque formation and rupture, also depending on the interaction of UL-VWF with NETs . DecoratFinally, clonal hematopoiesis (CHIP) is related to inflammation and cardiovascular diseases. CHIP mutations provoke a pro-inflammatory ambient that produce an increase in the thrombotic risk and favor plaque formation. These mutations produce functional alterations in neutrophils showing a prothrombotic profile. Among them, JAK2 mutations increase thrombotic risk through PAD4-dependent NETosis .Autoimmune disorders, such as inflammatory bowel disease (IBD) and systemic lupus erythematous (SLE), are associated with the increased risk of venous thromboembolism .IBD presents an increase in proinflammatory immune cells  and cytokines. During flares, IBD patients increase procoagulant factors and reduce antifibrinolytic proteins ,57; morePatients with SLE characteristically present antiphospholipid antibodies that are related with the increased thrombotic risk in these patients . HoweverStandard antithrombotic therapy with anticoagulants is highly effective, but it is associated with increased hemorrhagic complications because fibrin is an essential component of the physiological hemostasis . UsuallyNew approaches are needed to improve unbalanced hemostasis without increasing the bleeding risk, we summarize in (a)Targeting coagulationSome treatments usually used as an anticoagulant and antiplatelet may exhibit different effects modulating immunothrombosis. In fact, heparin, one of the most common anticoagulants, at high concentrations, is able to degrade NETs and also neutralize histones in blood. Furthermore, antiplatelet drugs, such as aspirin or ticagrelor, inhibit NET release .(b)Targeting NETsSeveral targeted therapies, focused on different steps of NETosis, have been explored in recent years. DNase is a nuclease that breaks down the NETs DNA backbone; however, to exert its effects, it needs the addition of fibrinolytic agents. To date, DNase 1 has been approved as a nebulized treatment in cystic fibrosis and there are several trials assessing the efficacy and safety of intravenous DNases administration after thrombectomy .Another target to disrupt NET formation and prevent its release is the enzyme PAD4 which is essential in the early stage of NET formation . Recentl(c)Targeting inflammationThe question that should be raised is: may the inflammasome and pyroptosis inhibition be a new strategy for immunothrombosis treatment? In this regard, several JAK pathway inhibitors, such as baricitinib, ruxolitinib, or tofacitinib, may reduce immunothrombosis . LikewisFinally, some anti-inflammatory drugs used in daily clinical practice can also reduce immunothrombosis. Colchicine, frequently used in gout treatment, reduced cardiovascular events in the COLCOT study, when administered to patients who had suffered a myocardial infarction ; this dr(d)Targeting ComplementThe complement system, part of the innate immune response against bacterial and viral infections, can be activated through classical pathways (antibody-antigen complex), alternative pathways (specific surface antigen), and lectin pathways (mannose residues on pathogen surface). All of these converge in a common pathway, including C3a and C5a production and C3b-initiated pathogen opsonization, ending in C5b-9 membrane attack complex formation, which results in target cell lysis . In vitrIn the last decade, there has been a huge advance in the molecular knowledge related to immunothrombosis development. Immunothrombosis is defined as a bidirectional interaction process between the innate immune pathway and coagulation. New strategies focused on reducing the thrombotic risk without increasing the hemorrhagic risk through inflammation control have been investigated. Among them, TF expression, inflammasome and NETs blockage are new attractive strategies to block the immunothrombotic process without the bleeding effects related to the traditional anticoagulants.


Strong partnerships between academic health professions programs and clinical practice settings, termed academic-clinical partnerships, are essential in providing quality clinical training experiences. However, the literature does not operationalize a model by which an academic program may identify priority attributes and evaluate its partnerships. This study aimed to develop a values-based academic-clinical partnership evaluation approach, rooted in methodologies from the field of evaluation and implemented in the context of an academic Doctor of Physical Therapy clinical education program. The authors developed a semi-quantitative evaluation approach incorporating concepts from multi-attribute utility analysis (MAUA) that enabled consistent, values-based partnership evaluation. Data-informed actions led to improved overall partnership effectiveness. Pilot outcomes support the feasibility and desirability of moving toward MAUA as a potential methodological framework. Further research may lead to the development of a standardized process for any academic health profession program to perform a values-based evaluation of their academic-clinical partnerships to guide decision-making. Strong partnerships between academic health professions programs and clinical healthcare practice settings, termed academic-clinical partnerships, are essential in providing quality full-time clinical training experiences ,2. UnforDecreased availability of student placement slots may require academic programs to increase their volume of clinical partners. A growing quantity of clinical partners reduces the ability of an academic program to maintain, enhance, and evaluate quality partnerships. Interactions between partners are often suboptimal, triggered by issues needing resolution rather than a drive for mutual engagement ,7. To adWhat is unclear, however, are the precise conditions and factors that promote strong academic-clinical partnerships. Such constructs have not been operationalized to date and there is no model by which an individual program may assess its priorities. The concept of partnerships remains undefined as well, referencing both legal affiliation agreements and operational relationships guiding placement processes. The inherent variability in academic program missions, resources, operations, student clinical education needs, and academic faculty skills and experiences suggests that partnership priorities are likely not the same for every program.This case report aims to present one academic DPT clinical education program’s pilot implementation of a values-based academic-clinical partnership evaluation approach, rooted in methodologies from the field of evaluation.Study subjects were not human but programs; therefore, neither approval by the institutional review board nor obtainment of the informed consent is necessary.To establish a baseline, the authors as clinical education faculty members in the DPT program at the University of Minnesota began with an informal assessment of their existing partnerships. A subjective ‘grade’ of A, B, C, or D was assigned to each partner based on interactions with that partner from 2015 to 2020 . PartnerThe authors then sought a way to quantitatively evaluate partnership factors to determine the extent to which existing clinical partners supported the program’s priority values. These values were aligned with the academic program’s mission, vision, and operational resources. Because health professions literature did not offer a systematic process to perform this evaluation, the team explored methodological processes in the field of evaluation. The faculty identified an evidence-based decision-making framework with potential called multi-attribute utility analysis (MAUA) ,9 Suppl. This frAs a pilot study, the academic clinical education faculty opted to incorporate evaluation principles associated with MAUA to assess the feasibility and desirability of conducting a full MAUA for partnership prioritization in a future study. None of these steps had been implemented in partnership literature to date.First, the authors considered partnership literature, program faculty perspectives, institutional context, and professional experience to generate their priority partnership list. Ten attributes were selected as follows: setting , level variety (early versus advanced learners), frequency (over a year), location , state (in- versus out-state), relationship with clinical education team , relationship with program/university , relationship with students , administrative burden (on program), and student burden . Each attribute was operationalized as noted with parenthetical examples.Next, the direct method was used as described in MAUA to assign importance weights to each attribute by allocating a total of 20 points among the 10 prioritized attributes based on their perceived relative importance . An iterThird, the additive approach was used to calculate the total utility, or effectiveness, of each partnership by summing the points for all attributes. The final point system indicated 20 as the highest partnership effectiveness score and 0 as the lowest. An institution-specific final rubric was created, termed the Clinical Partner Prioritization Rubric (CPPR) .An initial CPPR score was determined for 142 distinct clinical partners A, with aThe clinical education team used CPPR data to guide initial actions. The team reviewed partners with the lowest CPPR scores and determined whether attribute utilities were changeable or unchangeable. For those with multiple unchangeable circumstances , affiliation agreements were terminated, and the sites were removed from the partner list. For those with changeable circumstances , meetings were scheduled to discuss partnership growth opportunities. The team also reviewed partners with the highest CPPR scores and developed strategies to strengthen collaborative placement planning and clinical faculty training.These actions taken following the first CPPR analysis resulted in a revised CPPR mean score of 11.46/20 and a reduction in total partners evaluated from 142 to 113 . Again, The CPPR evaluation was completed again one year later. Actions following this CPPR analysis resulted in an aggregate CPPR mean score of 11.66/20 and a reduction in total partners evaluation from 113 to 107 . In the Raw response data are available from Pilot outcomes support the feasibility and desirability of moving toward MAUA as a potential methodological framework for evaluating academic-clinical partner relationships. The semi-quantitative evaluation approach developed in this pilot incorporated evaluation concepts rooted in MAUA methodology, successfully enabling academic clinical education faculty to create and consistently apply a values-based prioritization process specific to the institutional context.Over the course of one year, data-informed actions resulted in the elimination of lower-scoring academic-clinical partnerships and increased relationship-building with highly aligned clinical partners, leading to improvement in overall partnership effectiveness. Continued research may lead to the development of a standardized process by which any academic health profession program could perform a values-based evaluation of their academic-clinical partnerships to guide decision-making in partner relations. Further research is needed to assess the utility of MAUA for academic-clinical partnership evaluation over time and across institutional contexts. Questions remain regarding comparisons of priority partnership attributes across academic programs and professions, optimal frequency of partner evaluation, cutoff scores to objectively stratify levels of partnership effectiveness, and potential for a variant of this process for clinical partners to evaluate their priority values in academic-clinical partnerships.Findings in this case study begin to address national clinical education challenges cited in the literature. Further exploration of strategies and structures supporting strong academic-clinical partnerships is needed to advance knowledge regarding the conditions that promote strong clinical training of health professionals.


Since the introduction of glucocorticoid (GC) replacement therapy, congenital adrenal hyperplasia (CAH) is no longer a fatal disease. The development of neonatal screening programs and the amelioration of GC treatment strategies have improved significantly life expectancy in CAH patients. Thanks to these achievements, CAH patients are now in their adulthood, but an increased incidence of cardiovascular risk factors has been reported compared to general population in this stage of life. The aim of CAH treatment is to both prevent adrenal insufficiency and suppress androgen excess; in this delicate balance, under- as well as overtreatment might be equally harmful to long-term cardiovascular health. This work examines the prevalence of metabolic features and cardiovascular events, their correlation with hormone levels and GC replacement regimen in CAH patients and focuses on precocious markers to early detect patients at higher risk and new potential treatment approaches. Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) is an autosomal recessive disorder characterized by impaired cortisol secretion and androgen excess  is a widely recognized sign of arterial impairment and a predictor of future coronary artery disease and stroke . An incrThis effect was also present subjects with NCCAH that exhibited higher IMT values in all main arterial districts, as observed for CCAH forms ; moreoveFurthermore, some evidence indicates that IMT could be related to androgen excess , 47 too.Despite these findings, an echocardiographic study found a preserved myocardial function in young CAH adults, although higher GC doses were associated with detrimental effects on cardiac hypertrophy, left ventricular and aortic dilation and subclinical atherosclerosis . An incrPatients with CAH have an increased risk of developing insulin resistance (IR) and subsequently diabetes mellitus (DM)due to chronic GC therapy , 38, 51.One recent study examined a relatively small group of young patients  using the hyperinsulinemic-euglycemic clamp, showed a higher rate of IR in both lean and obese patients with NCCAH compared to controls. Interestingly, the compensatory hyperinsulinemia was mainly sustained by a reduction of hepatic insulin clearance rather than a net increased insulin secretion . As prevBesides GC, other risk factors such as familiar history of diabetes and obesity can disrupt this delicate balance and boost the development of DM.Androgen levels should be encountered amongst risk factors as well. To be precise, androgens have different effect on IR depending on gender; low testosterone levels promote metabolic syndrome in men , whilst Despite a host of risk factors, only the Swedish CAH registry found an increased prevalence of DM, especially in female patients, compared to general population . As for Unlike in childhood where hydrocortisone is the GC of choice, in adults there is little consensus on the most appropriate GC replacement regimen. Once final height is achieved, patients are frequently shifted to long-acting GCs to allow once daily dosing and consequent better treatment compliance . A recenAndrogen excess is one of the hallmarks of CAH, and its control is frequently challenging. Both hypoandrogenismin males and hyperandrogenism in females can lead to adverse metabolic effects thereby increasing CV risk , 61, 62.In the study of 203 patients by Arlt et al., androgens levels were poorly controlled, with most patients having either elevated or suppressed androgens, whereas only 36% presented with normal androstenedione levels  can be either associated with adverse or beneficial metabolic and cardiovascular profiles in general population. The ER22/23EK haplotype is associated with reduced GC sensitivity, thus to a more favorable metabolic profile, whilst the N363S and BclI restriction fragment length polymorphism (RFLP) cause GC hypersensitivity  compared to reference population; however, no significant differences for cardiac arrest, heart failure and atrial fibrillation were observed. An increase incidence of stroke was reported only for female with NCCAH. Instead, acute coronary syndrome was significantly increased in males with SW-CAH, especially in those with null genotype . Also inInterestingly, in the UK cohort only a minority of adults affected by CAH are regularly follow-up by an endocrinologist; this lack of disease-monitoring might negatively impact on patients’ well-being and contribute to their mortality rate .To date, few studies have assessed disease mortality in adults. Fahlhammar et al. found a higher mortality rates in patients with CAH, the main causes of death were adrenal crisis (42%), CV disease (32%), cancer (16%) and suicide (10%) . HoweverThese data were also confirmed in a recent German study which found an increased mortality in the period between 1973 and 2004 , mainly related to inadequate GC stress-dose administration, but no further deaths thereafter, supporting the importance of patient education in preventing adrenal crisis  have deficient aldosterone and cortisol production but elevated androgens and MC precursors . Arteriae tissue . Insuline tissue  potentiae tissue , but ovee tissue .Although there are no studies that directly assessed mortality in 11-OHD, these patients seem to have an increased risk of CV events but fewer adrenal crisis compared to patients with CCAH , 92, 93;The 17α-hydroxylase deficiency (17-OHD) is the second most common CAH in Brazil; besides MC excess, patients display androgen and estrogen deficiency but they do not manifest adrenal insufficiency thanks to corticosterone excess . In a BrStudies on patients with 3β-hydroxysteroid dehydrogenase type II deficiency (3β-HSD) included neonatal or children, thus there are no data on CV risk in adolescents/adults .The lipoid form (LCAH) is the second most common type of CAH in Japan and Korea . The larDiagnostic and treatment developments over the years have normalized life-expectancy in patients with CAH. Despite this, series on aging CAH patients are still limited in literature. To date, most available studies pointed to an increase cardio-metabolic risk in CAH patients. Features of metabolic syndrome can appear early in childhood and should be rapidly addressed to reduce future CV events. GC overtreatment seems to have a pivotal role in promoting weight gain, which represents the main independent risk factor for the development of metabolic syndrome and directly contributes to hypertension, IR and hypercoagulability. Long-acting GCs may be associated with adverse metabolic profile, but current data are not sufficient to draw conclusions on the best GC schedule for adult patients. Similarly, excessive MC replacement, particularly if not properly down-titrated in adulthood, can contribute to the increased CV risk. On the other hand, androgen excess can be equally harmful and negatively impact on several metabolic aspects, as observed in NCCAH. As a general rule, patients with CAH should receive the lowest possible GC dose to prevent adrenal insufficiency and signs and symptoms of hyperandrogenism. A periodic screening for arterial hypertension and metabolic comorbidities should be performed since early infancy to avoid future CV events. Similar conclusions can be drawn also for rarest forms of CAH, although the CV risk profile of these patients is less characterized due to the low number of studies available. Ongoing and future studies will clarify whether new compounds might promote reduced GC overexposure and guarantee a more stable disease control resulting in a more favorable metabolic profile. Overall, available data pointed to an increased mortality in CAH patients, probably biased by older studies when neonatal screening was not available and GC replacement not appropriate. Conversely, CV morbidity and mortality might be significantly underestimated, since most studies analyze adolescents or young adults, while CV events usually occur later in life. Future perspective can include GR polymorphisms genotyping to identify patients at higher CV risk and allow a personalized GC treatment to avoid long-term adverse consequences.MB and CS contributed to conception of the study. PM and ML performed bibliographic research. MB, PM, and ML were involved in drafting the manuscript. PM and FC were in charge of figures. MB, FC, and CS were involved in manuscript revision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Surprisingly, Cattoni et al.  reportedet al. .et al. [In this study, Spaans et al.  performeIn particular, they examined the clinical data of 5573 patients, calculating the mean pain score on a 0–10 scale at 24, 48 and 72 h after surgery; moreover, as a secondary outcome, they analysed postoperative nausea and vomiting, additional opioids, the use of rescue analgesia and length of hospital stay. The prediction of the pain level and its treatment is crucial because the incidence of chronic chest pain after video-assisted-thoracoscopic surgery must be considered [From a cursory reading of this article, one may conclude that, with the same pain score, unilateral loco-regional techniques have a shorter length of stay and a lower incidence of postoperative nausea and vomiting than thoracic epidural analgesia; despite the outcomes have been calculated by a random-effect meta-analysis, and hence can guide us to credible conclusions, the authors point out that these conclusions cannot be drawn because the pooled results show an excessively high level of variability and heterogeneity between studies.Adding the presence of confounding factors, such as study design , different thoracoscopic approaches (single-port versus multi-port) and the existence of local practices of analgesic protocols, a meta-analysis and comparisons between different analgesics are unreliable.Even though thoracic epidural analgesia in pain management in lung surgery has been used for decades, the recent PROSPECT guidelines support the loco-regional analgesic techniques discouraging the use of thoracic epidural analgesia due to its association with epidural haematomas and hypotension . It has In conclusion, the exciting issue examined in this study needs further investigation and more rigorous clinical evidence, with a well-designed randomized trial comparing loco-regional analgesia techniques to thoracic epidural analgesia to understand the best analgesic procedure that can benefit most patients undergoing thoracoscopic lung resections.


N = 210,267). We implemented univariable two-sample MR (UVMR) to identify candidate metabolic traits affecting offspring birthweight. We then applied two-sample multivariable MR (MVMR) to jointly estimate the potential direct causal effect for each candidate maternal metabolic trait. In the main analyses, UVMR indicated that higher maternal glucose was related to higher offspring birthweight ), as were maternal glutamine ) and alanine ). In additional analyses, UVMR estimates were broadly consistent when selecting instruments from an independent data source, albeit imprecise for glutamine and alanine, and were attenuated for alanine when using other UVMR methods. MVMR results supported independent effects of these metabolites, with effect estimates consistent with those seen with the UVMR results. Among the remaining 43 metabolic traits, UVMR estimates indicated a null effect for most lipid-related traits and a high degree of uncertainty for other amino acids and ketone bodies. Our findings suggest that maternal gestational glucose and glutamine are causally related to offspring birthweight.Marked physiological changes in pregnancy are essential to support foetal growth; however, evidence on the role of specific maternal metabolic traits from human studies is limited. We integrated Mendelian randomisation (MR) and metabolomics data to probe the effect of 46 maternal metabolic traits on offspring birthweight ( Birthweight is frequently used as a proxy of foetal growth in population studies. Babies born with low or high birthweight are at increased risk of neonatal morbidity and mortality, and birthweight is inversely associated with risk of long-term adverse health outcomes, such as neurodevelopmental disorders and cardiometabolic diseases ,6,7,8,9.During pregnancy, the mother experiences marked physiological changes including substantial changes in maternal metabolism ,11,12. TPrevious observational epidemiological studies have suggested that maternal metabolic traits other than glucose  are associated with birthweight ,25,26,27Mendelian randomisation (MR) is an instrumental variable analysis that uses genetic variants, usually single-nucleotide polymorphisms (SNPs), as instruments to infer causality in the presence of confounding ,30,31. MRecent technological advances in nuclear magnetic resonance (NMR) have enabled the metabolic profiling of large-scale population-based studies, including quantification of glucose, amino acids, ketone bodies, lipids, and many other metabolic traits ,36. ThisUVMR results obtained using SNPs selected from two independent genome-wide association studies (GWAS), i.e., the UK Biobank (UKBB) and Kettunen GWAS, are displayed in p < 0.05 in UVMR); higher maternal alanine ), glutamine ), and glucose ) were associated with higher offspring birthweight. Estimates for ketone bodies were imprecise and had wide confidence intervals (CI). Most lipoprotein-related traits and fatty acids were precisely estimated around the null (Using the SNPs selected from UKBB GWAS (K = 264 SNPs), UVMR of 46 metabolic traits identified three metabolic traits that fit our criteria and were included in MVMR , four metabolic traits were missing from these data and no SNPs were selected for another, leaving 41 out of the 46 metabolic traits. UVMR estimates using SNPs selected from Kettunen GWAS were largely consistent with the UKBB GWAS , althougThe mean F-statistics were calculated for each metabolic trait included in the UVMR analyses, as displayed in When conducting leave-one-out analyses using UKBB-selected SNPs, we did not observe that any single SNP was driving UVMR estimates .We selected putative causal metabolic traits to be included in MVMR: alanine, glucose, glutamine, isoleucine, pyruvate, and 3-hydroxybutyrate. MVMR results including all six maternal traits in a singular model are shown on First, we consider the results using UKBB-selected SNPs. Of the six selected candidate maternal metabolic traits in UVMR, MVMR analyses provided evidence of a direct causal effect on offspring birthweight for glucose ), glutamine ), and possibly alanine ), although estimates for the latter were partly attenuated and less precise in MVMR compared to UVMR. The magnitude of the effects demonstrated was typically slightly larger in UVMR estimates than MVMR estimates, except for pyruvate.We then consider the results using Kettunen-selected SNPs. Of the six selected candidate maternal metabolic traits in UVMR, MVMR analyses provided evidence of a direct causal effect on offspring birthweight for glucose ). The estimated magnitude of effect was slightly attenuated relative to its corresponding UVMR estimate. The precision of estimates for higher maternal alanine ) and higher maternal glutamine ) was reduced in this dataset.The conditional F-statistics were calculated for each of the MVMR selected models to test for the presence of weak instrument bias, The conditional F-statistics were calculated for the MVMR-selected models for both instrument selection approaches . For theThere was strong evidence of between-SNP heterogeneity in both MVMR models, For the six selected metabolites , we compared our main UVMR estimates using IVW to from other UVMR methods  that rely on different assumptions about the genetic instruments . We perfOur findings support a causal effect of some maternal metabolites on offspring birthweight. Taken together, our results confirm a causal effect of higher maternal glucose on offspring birthweight and suggest potential causal effects of higher glutamine. UVMR and MVMR results were supportive of an effect of higher maternal glutamine on higher offspring birthweight when using SNPs selected from UKBB GWAS, although results were less certain when using SNPs selected from Kettunen GWAS due to high imprecision resulting from the small number of SNPs being selected from the latter GWAS. This is in line with findings from a recent MR study probing the effect of 19 amino acids using large-scale data from a cross-platform metabolomics GWAS and from the same birthweight GWAS included in our study . GlutamiIn addition to prioritising putative metabolites influencing foetal growth, our study indicates that maternal lipid traits did not seem to contribute substantially to variations in offspring birthweight in this well-nourished population. This is supported by UVMR results, which estimated a null effect for most of lipid- and lipoprotein-related traits on birthweight. These findings are in line with previous MR studies of conventional clinical chemistry lipid traits  cholesterol, and triglycerides ,33), butTo our knowledge, this is the first study to integrate MR and high-throughput metabolomics data to (de)prioritise putative maternal metabolic factors influencing foetal growth. These findings could contribute to better understanding of key maternal molecular mechanisms influencing foetal growth.One key challenge is determining which risk factors to include in the model. Including all available causal risk factors without careful consideration can be problematic due to the potential for bias due to the inclusion of highly similarly genetically predicted exposures or low power to identify the relevant risk factors when many risk factors which do not have a causal effect are included in the model . We addrOne key limitation of our study is the possibility that horizontal pleiotropy from traits not included in MVMR might have biased our results. The MVMR-IVW method will only provide a consistent estimate if all variants are valid instruments and not affected by unbalanced pleiotropy ,42. GiveAnother limitation of our study is the sample overlap between individuals in the risk factor and outcome datasets in the main analysis. Here, in the main analyses, UKBB participants were included in the SNP–risk factor and SNP–outcome estimates, with approximately ~30% of participants in the birthweight GWAS present in the UKBB metabolic traits GWAS. Selecting instruments in the same sample as the MR analysis may introduce a winner’s curse and overprediction; thus, we performed external validation and selected instruments from an independent dataset to assess the extent of the bias as a sensitivity analysis ,44. SNPsFurthermore, findings from this study should be interpreted bearing in mind that our sample mostly included individuals from European ancestry from high-income settings, which might limit the generalisability of the findings, and that the NMR platform used in this study is highly enriched for lipoprotein-related traits, whereas many other metabolic pathways are underrepresented. Thus, future research should focus on including more diverse populations and use higher-resolution metabolomics data, allowing for a broader interrogation of maternal metabolic traits. These will become feasible as the availability of large-scale GWASs in individuals of non-European settings and the use of mass spectrometry metabolomics increase. In addition, our findings are exploratory, and further MR studies investigating the mechanisms linking genetic variants to specific candidate metabolic traits  are warranted to assess in depth the credibility of these findings and the plausibility of bias due to horizontal pleiotropy.Importantly, genetic association data for offspring birthweight reflected direct maternal genetic effects  ,46.p < 0.05), which were then taken forward into multivariable MR (MVMR) analyses. MVMR is an extension of UVMR that is suitable to jointly estimate the direct causal effect when considering risk factors that may be correlated, such as metabolic traits. In MVMR, multiple genetic variants that are potentially associated with several measured risk factors of interest are used to simultaneously estimate the direct causal effect of each risk factor on the outcome [Many genetic variants regulate processes that affect multiple metabolites; thus, results from UVMR are likely biased by horizontal pleiotropy. Therefore, we used UVMR to identify candidate metabolic traits : mean = 56, SD: 8) for which metabolic traits were available using linear mixed model (LMM) association method as implemented in BOLT-LMM (v2.3) adjusting for genotype array, fasting time, and sex (hereafter ‘UKBB GWAS’), as previously described ,52,53,54Genetic association data for offspring birthweight were extracted from a recent GWAS meta-analysis including 210,267 European participants, combining results of 41 studies from the EGG consortium and UKBB, with mean age at delivery ranging from 24.5 to 31.5 years (see The NMR platform used in this study includes many lipids and lipoproteins that are known to be closely (i) numerically and/or (ii) biologically related. As an example of (i), concentrations of cholesterol in different lipoprotein particles sum to the concentration of total cholesterol; therefore, total cholesterol is correlated with cholesterol in specific lipoproteins. As an example of (ii), the three glycolysis metabolites  are metabolised via the same biological pathway , and, as a result, are correlated. This can result in variance inflation and biased estimates of effects in both observational and MVMR analyses if an attempt were made to mutually adjust for all or even a subset of them at the same time, unless one has extremely large sample sizes .Therefore, we applied three exclusion criteria to the full list of 249 NMR metabolic traits to reduce redundancy in our UVMR analyses and avoid multicollinearity in our MVMR models .First, we excluded those with multiple measures that reflected the same metabolic entity  or where multiple measures reflected a composite measure of highly related traits . As a result, we excluded 84 derived ratios and three composite fatty-acid measures .Second, among lipoprotein-related traits, we selected measures related to circulating lipid composition , apolipoproteins A1 and B, and total lipids in 14 lipoprotein subclasses , IDL, large, medium, and small LDL, very large, large, medium, and small HDL). It has been demonstrated previously that we cannot conditionally predict different lipid measures within these subclasses in the same MVMR model due to the very high correlation between these traits . This maThird, we checked the genetic correlation across the remaining measures . If two After all exclusions, detailed in We estimated the effects of maternal metabolic traits on offspring birthweight using UVMR and MVMR. Genetic association data for metabolic traits and offspring birthweight were harmonised to reflect the same effect allele using allele frequency information to infer the strand for palindromic SNPs . PalindrWe selected SNPs strongly and independently associated with each of our selected metabolic traits using a threshold of We present UVMR results according to subclasses of metabolic traits .To test instrument strength, we calculated the mean F-statistics across SNPs for each metabolic trait included in the UVMR analyses ,47.We also performed leave-one-out analyses, sequentially omitting the indicated SNP and rerunning the analysis. This may indicate whether the estimated association is being substantially driven by a singular SNP.All metabolic traits that demonstrated statistical evidence of an effect in the UVMR prioritise candidate maternal molecular traits influencing foetal growth. Our findings confirm previous studies on the strong relation between maternal glucose and offspring birthweight, highlight glutamine as a potential causal metabolite, and do not support a relationship between several maternal lipids and offspring birthweight. Identification of specific metabolic traits represents a unique opportunity to understand the relation between the intrauterine environment and offspring growth.


The diaphragm is both the main respiratory muscle and the septum separating the thoracic from the abdominal cavity. As most tissues, it is supplied by a vascular lymphatic system whose function is to absorb fluid, solutes and cells from the interstitial tissue surrounding the cells and to propel the so formed lymph back into the venous blood stream. However, the diaphragmatic lymphatic network plays an additional role, being directly involved in draining fluid from the pleural and peritoneal cavities. The aim of this review is to present a comprehensive description of the structure and function of the diaphragmatic lymphatic network, including its unique morphology, the mechanisms supporting diaphragmatic lymph formation and progression and the importance of the mechanical events developing in the diaphragm during tidal breathing on lymph formation and propulsion. This information may prove to be useful in understanding some abnormal fluid accumulation in the pleural or peritoneal cavities observed in clinical settings.+ structures on both sides of the diaphragm—both in its the muscular and tendinous portion, but with different vessel density and configurations. On the pleural side, most LYVE1+ configurations are vessel-like with scanty stomata, while the peritoneal side is characterized by abundant LYVE1+ flattened lacy-ladder shaped structures with several stomata-like pores, particularly in the muscular portion. Such a complex, three-dimensional organization is enriched, at the peripheral rim of the muscular diaphragm, with spontaneously contracting lymphatic vessel segments able to prompt contractile waves to adjacent collecting lymphatics. This review aims at describing how the external tissue forces developing in the diaphragm, along with cyclic cardiogenic and respiratory swings, interplay with the spontaneous contraction of lymphatic vessel segments at the peripheral diaphragmatic rim to simultaneously set and modulate lymph flow from the pleural and peritoneal cavities. These details may provide useful in understanding the role of diaphragmatic lymphatics not only in physiological but, more so, in pathophysiological circumstances such as in dialysis, metastasis or infection. The diaphragmatic lymphatic vascular network has unique anatomical characteristics. Studying the morphology and distribution of the lymphatic network in the mouse diaphragm by fluorescence-immunohistochemistry using LYVE-1  revealed LYVE1 The diaphragm is a unique tissue whose structure is specifically adapted to drive lung expansion and collapse during the respiratory cycle, while also compartmentalizing the thoracic from the abdominal cavity. In addition to its main respiratory function, the diaphragmatic tissue plays an important role in setting and maintaining the fluid volume and hydraulic pressures in the pleural and peritoneal cavities. Indeed, the diaphragm is equipped with a well-developed network of lymphatic vessels whose function is to produce and propel diaphragmatic lymph produced by the drainage of fluid, solutes and cells from the surrounding interstitial space: the pleural and the peritoneal cavities. While the tendinous and muscular diaphragm contribute little to total diaphragmatic lymph production, the latter mostly depends upon the drainage of pleural and peritoneal fluid. Therefore, the diaphragmatic lymphatics network plays a crucial role in several functions, including lung-chest-wall mechanical coupling and control of pleural and peritoneal fluid and solute turnover. The aim of this review is to present a comprehensive analysis of what is actually known on: (a) the very peculiar morphology of the diaphragmatic lymphatics, (b) the mechanism supporting diaphragmatic lymph formation and progression, (c) the physiological role of the diaphragm in the pleuro-peritoneal fluid dynamics and (d) the relevance of the lymphatic diaphragmatic network in clinical settings.The existence of mesenteric, inguinal and axillary lymph nodes was described by Hippocrates of Cos (ca. 460 BC–ca. 370 BC) and later by Rufus of Ephesus, who practiced medicine in Imperial Rome in the 2nd century B.C.; however, it was only in the 18th century that Paolo Mascagni (1752–1815), professor of Anatomy in Siena and Florence, realized the first systematic description of the lymphatic system in humans. continuations from arteries, but a particular system of vessels by themselves” and that lymph was formed by the absorption of fluid from the tissues into peripheral lymphatics. By the end of the 18th century, the gross anatomy of the lymphatic system was mostly known, yet the absorptive nature of lymphatic vessels from the body tissues was identified only in 1762 by William Hunter (1718–1783) who correctly proposed that the lymphatics were not “The German pathologist, Friedrich Daniel von Recklinghausen 1833–1910), introduced the concept of connective tissue drained by lymphatics, revealed the existence of the Kampfmeier foci and was the first to propose the presence of lymphatic “stomata” on the peritoneal surface of the diaphragm 833–1910,,3 that l2 [Although documented over the costal and the mediastinal parietal pleura (average density: ~100/cm2 ), the grBecause of their diameter  than of the pleural (≈5.3%) diaphragmatic surface. After its beginning with stomata, the diaphragmatic lymphatic network is hierarchically organized into (1) submesothelial lacunae running beneath both the pleural and peritoneal surfaces; (2) small lymphatic vessels running through the skeletal muscles and tendinous fibres; (3) large collecting lymphatics in the deep central stratum of diaphragmatic tissues . AlthougBecause of the thinness of the tendinous region in the mouse diaphragm (≈260 µm), its lymphatic network could usually be visualized from both the pleural (PL-T) and the peritoneal (PE-T) sides of the tendinous diaphragmatic region . Linear As in other tissues, lymphatics of the diaphragm are equipped with two types of unidirectional valves: (a) primary valves in the vessel wall, formed by cytoplasmic extensions of adjacent endothelial cells protruding into the capillary lumen ,10, whicA well-defined, abundant lymphatic mesh was also observed in the muscular diaphragm, but with strikingly different morphological characteristics between PL and PE sides.+ configurations were constituted by linear lymphatic and loops  were about three times longer than those with no valves/lymphangions. Perpendicularly oriented vessels were significantly larger and shorter than parallel vessels with lymphangions, but comparable in length with the parallel vessels without valves. Intraluminal valves and lymphangions were found in only ≈7% of the perpendicular analysed vessels [Smaller LYVE1 vessels . + flattened lacy-ladder shaped membranous structure (LLS), consistent with previous descriptions of large submesothelial lacunae [+ lymphatic endothelial cells were not found, of variable shape and dimensions. The LLS covered a very significant fraction (≈15%) of the PE-M surface area and occupied ≈34% of the PE-M tissue volume, respectively. No lymphangions were observed in LLS. On the PE-M side, an extensive and unique LYVE1 lacunae ,15, was Stomata observed in PL-T, PL-M, PE-T and PE-M regions of the diaphragm were invariably located over the surface of underlying lymphatic vessels or LLS . The stoTiny tubular lymphatics (Φ ≤ 15 μm), presumably the initial lymphatic capillaries, were sparsely arranged in the diaphragmatic interstitial space with their major axis parallel to that of either the tendinous or muscular fibres . The denIn cross section, submesothelial lacunae were observed on both diaphragmatic sides, although PE side lacunae were significantly deeper compared to the PL side. Lymphatic conduits about 200 µm long depart from the PL and PE submesothelial structures  and peneThe diaphragmatic lymphatic network is rather unique from several standpoints: (a) it must simultaneously absorb fluid from compartments characterized by quite different hydraulic pressures regimes, making fluid pressures much more subatmospheric in the pleural than in the peritoneal cavity or in diaphragmatic interstitium ,20,21,22lymph-net) which develops when intraluminal lymphatic pressure (Plymph) falls below the pressure in the pleural, peritoneal or surrounding interstitial fluid. Direct measurements show that Plymph values as low as ≈−20 cmH2O can be attained in the pleural apposition zone of the rodent diaphragm, both in open thorax [lymph values able to sustain drainage of pleural fluid. Data recorded from intercostal lymphatics in spontaneously breathing rats [lymph may range between ≈−0.5 cmH2O at end-expiration and ≈−24 cmH2O at end-inspiration, indicating that pleural lymph may be produced throughout the whole respiratory cycle. The formation of diaphragmatic lymph occurs when fluid passively enters the lymphatic structures driven by a net hydraulic pressure gradient  than pleural fluid pressure, ΔPlymph-promoting diaphragmatic peritoneal lymph flow is expected to be even higher than ΔPlymph-sustaining pleural lymph flow. Plymph clearly present cyclic oscillations which reflect: (a) the transmission to the vessel lumen of stresses developed in the diaphragmatic tissue upon local cardiogenic [Direct measurements of diaphragmatic Pdiogenic  and/or rdiogenic  tissue ddiogenic ,12,26,27lymph shows cyclic pressure swings [lymph through: (a) rhythmic displacement of mediastinum and phrenic centre; (b) transmission of sphygmic waves along the aorta and the arteries feeding the diaphragm; (c) transmission of arterial pulsation though the hepatic surface facing the peritoneal diaphragmatic dome. Consequently, Plymph is negative both during the diastolic and systolic cardiogenic phase (45%) or only during the diastolic phase (50%). The cardiac cycle also affects interstitial tissue pressure [lymph, determining cyclic expansions and compression of diaphragmatic lymphatics, thus contributing to development of ΔPlymph and the formation of lymph from diaphragmatic interstitium. Even in open chest paralyzed rabbits, pleural diaphragmatic Pe swings ,16 able pressure  that chalymph is not directly known, as it is not possible to measure Plymph in a closed chest during spontaneous breathing. However, in analogy with what has been observed in pleural intercostal lymphatics, where ΔPlymph could instead be measured in intact rats during spontaneous or assisted ventilation [The role of the respiratory cycle in sustaining diaphragmatic ΔPtilation , we hypoThe impact of diaphragmatic tissue displacement on the lymphatic circuit critically depends upon the mechanical properties of the lymphatic vessel wall and of the surrounding muscular tissue. (A)The vessels laying over the muscular/tendinous plane immediately beneath the mesothelial surface and delimited mostly by mesothelium are the most compliant ones; they are exposed to the highest circumferential tensile stresses, particularly along the contact edges of the mesothelial wall with the stiff diaphragmatic tissue basement. From the mechanical standpoint, such disposition favours high chances of dilatation of discontinuities of the mesothelial surface, represented, for example, by stomata and/or primary valves ,10, thus(B)The vessels laying deeper within the diaphragmatic thickness  are char(C)The vessels partly covered by mesothelium, and partly immersed in the muscular/tendinous tissue, show a transitory intermediate behaviour, being involved in both lymph production and propulsion.The mechanical features of the various portions of the diaphragmatic tissue play a relevant role in enhancing and modulating lymph flow. Indeed, through a Finite Element Model  taking ilymph between the interstitium and the lymphatic lumen [lymph swings, attributable to spontaneous contraction of the vessel wall, have also been documented at the outer peripheral rim of the muscular pleural diaphragm [In almost still, non-thoracic issues, lymph formation and propulsion are driven by cyclic contractions of lymphatic muscular cells in the vessel wall ,27,29. Cic lumen , promotiic lumen ,34,35. Aiaphragm . Indeed,iaphragm , lymphatiaphragm ,16,17,242+ channels, whose threshold potential is reached through a slow depolarizing inward currents (Ih), similar to what is observed in the cardiac sinoatrial pacemaker cells [+ channels initiating the action potential and subsequent phasic contraction of the vessels [+ channel inhibitors only partially abolish the spontaneous contraction, particularly in smaller mesenteric vessels. In addition, the ionic mechanism of the spontaneous depolarization moving the cell potential to reach the activation threshold is not explained by these mechanisms. Hence, spontaneous firing of lymphatic muscle cells might actually depend upon alternative mechanisms, such as the occurrence of an inward hyperpolarization activated current, which has been proposed to explain spontaneous contractility in mesenteric lymphatics [Several studies have been carried out to explain the genesis of the spontaneous contractility observed in the lymphatic vessel wall. Electrophysiological data demonstrated that lymphatic muscle cell contraction may be triggered by: (a) small transient cell depolarizations, likely due to spontaneous transient inward currents ,37,38,39er cells ,37,40; , which induces the spontaneous depolarization of cardiomyocytes of the sinoatrial node [Studies on diaphragmatic lymphatics revealed that the spontaneously depolarizing current occurs through hyperpolarization-activated cyclic nucleotide-gated (HCN) channels whose inhibition leads to either a complete or significant blockade of spontaneous contractions, indicating their direct involvement in spontaneous lymphatic pacemaking . HCN are K+ ions ,44 and t K+ ions . All foumphatics , even thing ones . Channelial node ,46,47 an− ions through NKCC exchanger, potentially leads to hyperpolarization and decreased contraction frequency. Alternatively, hyperosmolarity is known to induce membrane hyperpolarization of vascular endothelial and smooth muscle cells [+ pump inhibition [Lymphatic intrinsic contraction frequency and strength can be modulated by several factors, such as shear stress ,48, tranle cells , and redle cells  by meansle cells , KATP mele cells , Na+ pumhibition  and inhihibition ,63. The hibition  and in dhibition . Finally, although likely of minor importance in modulating lymph flow in the diaphragmatic tissue, whose temperature is steady and similar to that of the thermic core, it is worth noting that spontaneous diaphragmatic lymphatic contraction frequency is sensitive to temperature changes—the maximal thermal sensitivity being achieved at a temperature of ≈36.7 °C ,67. TherOnce formed in initial lymphatics, diaphragmatic lymph is propelled along the lymphatic network to reach, mainly, the right lymphatic duct to eventually be emptied into the venous blood stream. The path followed by the newly formed lymph along the diaphragmatic lymphatic circuit is highly variable and depends upon factors such as the specific location of the vessel within the diaphragm  as well as upon whether the diaphragm is relaxed or contracted within the respiratory cycle. During tidal expiration, with an almost relaxed or low-tone diaphragm, lymph flow is supported by active spontaneous contraction of specific segments of lymphatic loops ,42,68 orAn important role in lymph formation and kinetics is played by inspiration, which implies contraction and change in the shape of the diaphragm with a shortening of the outer muscular fibres and an increased tensile stress of medial tendinous fibres. In an open chest rodent, the impact of diaphragmatic muscle contraction on lymph flow depended upon the alignment of a specific lymph vessel, with respect to muscle fibres orientation , as welllymph in all superficial submesothelial vessels upon their orientation, with respect to muscle fibres; such Plymph drop likely reflects an enlargement of the vessel diameter when the contracting underlying muscle shortens anisotropically, pulling on the vessel wall [lymph decreased in vessels running parallel to the major muscle fibres axis and increased in vessels oriented perpendicular to the muscle fibres direction. As far as vessel orientation is concerned, diaphragmatic muscle contraction simultaneously induces (a) compression of lymphatic vessels very close to and placed in roughly perpendicular direction with respect to muscle major axis, a phenomenon likely mirroring an increased transmural pressure across the vessel wall; (b) enlargement, shortening and an increased tortuosity of lymphatic vessels running parallel to the diaphragmatic muscle fibres . The depsel wall ,33. On tlymph in submesothelial diaphragmatic lymphatics decreases more than in the pleural fluid, thus increasing the pleural to submesothelial diaphragmatic lymphatics pressure gradients. In addition, on inspiration, the contracted diaphragmatic muscle fibres shorten, stretching the medial tendinous fibres, a condition that might squeeze deeper lymphatics, enhancing lymph propulsion. The propelling phase might be particularly efficient in deeper lymphatics whose low compliance [In terms of diaphragmatic pleural fluid drainage, this quite complex behaviour likely guarantees absorption of pleural fluid into submesothelial lacunae, both during expiration, when the muscle fibres are almost relaxed, and during inspiration, when Pmpliance  likely dmpliance . Indeed,mpliance ,23,33 thIndirect estimates on various mammalian species suggest that physiologically normal pleural lymph flow amounts to 75% of the total pleural fluid turnover (about 0.2 mL/(kg·h) ,71,72 orThe confocal images presented in An important issue to be addressed is whether, in spite of the observed morphology, fluid and solutes may actually cross the diaphragm under normal or pathophysiological conditions using such a pleuro-peritoneal route . In physHowever, a series of experiments aimed at detecting the transdiaphragmatic distribution of fluorescent dextrans, injected in either the pleural or peritoneal cavity , showed lymph is very low in diaphragmatic lymphatics facing the pleural (about −10 mmHg [Such results suggest that (a) diaphragmatic lymph flows down the pressure gradients arising between the pleural or peritoneal cavities and the lumen of diaphragmatic lymphatics draining from the respective serosal cavity . Such gr−10 mmHg ,24) and −10 mmHg ) cavitieBased on these premises, potential pleuro-peritoneal leaks might indeed occur in conditions which imply pathophysiological alterations of the closing/opening capacity of intraluminal valves. Such conditions might be associated with very large pleural effusion and/or ascites when lymphatic structures might become overdistended, impeding the valve leaflets to efficiently close and thus, compromising the whole diaphragmatic lymphatic function. These considerations might explain the clinically relevant pleural effusions observed in patients undergoing peritoneal dialysis ,85,86,87Hence, although the complexity of a diaphragmatic lymphatic network has been increasingly revealed in the last decades by the continuous development of immunohistochemical and imaging techniques, many aspects of the mechanisms sustaining lymphatic drainage are still unclear and further research is needed on topics such as: (a) the actual correspondence between imaging/morphological evidences and functional dynamic behavior or, as an example, between observed increased lymphangiogenesis and measured increased lymph flow; (b) the interplay between tissue forces and active contraction in sustaining lymph flow; (c) the mechanisms through which lymph vessels “sense” the need for an increased lymph flow and trigger an increased draining function, either through lymphangiogenesis and/or through increased contraction frequency and stroke volume.Clarifying these points will not only deepen our knowledge on the lymphatic vascular system in general, but will allow clinicians to better understand, and likely exploit, the role of the diaphragmatic lymphatic system in processes such as dialysis, tumor metastasis, infection, immunity and nutrition.The lymphatic network of the mammalian diaphragm is morphologically designed to maximally exploit the anatomic and mechanical properties of the surrounding tissue to maintain the physiological fluid homeostasis in the pleural and peritoneal serosal cavity. Despite the thinness of the diaphragmatic tissue, particularly in its tendinous central area, the three-dimensional structure of the diaphragmatic lymphatic network modifies on the pleural with respect to the peritoneal side, and within the same diaphragmatic side, and on the muscular with respect to the tendinous regions of the diaphragm. Diaphragmatic lymphatic function is propelled and driven by a complex combination of spontaneously contracting lymphatic segments at the peripheral diaphragmatic rim and passive conduits exposed to swinging mechanical tissue stresses associated to cardiac and, more so, respiratory activity. Unlike what is observed in most other tissues, the impact of external tissue forces, in particular related to respiratory diaphragmatic contraction/relaxation cycles, prevails over the active, spontaneous contraction of lymphatic muscle in sustaining lymph flow. However, the latter seems to play a pivotal role in organizing the entire diaphragmatic lymph flow and in modulating its entity in the face of changes in osmotic or thermic tissue environment, thereby witnessing an unexpected complexity of the lymphatic vascular system.


Neurodegenerative dementias such as the behavioral variant of frontotemporal dementia, Alzheimer’s disease, and Parkinson’s disease dementia are linked to various behavioral and psychological abnormalities. Whether these abnormalities precede, coincide or follow the onset of cognitive symptoms is still controversial in existing literature, with trajectories available so far dependent on types of dementia. The authors aim to review the different kinds of premorbid behavioral symptoms/personality traits associated with an increased risk of developing specific types of neurodegenerative dementia. Neuroticism has been associated with an increased risk of Alzheimer’s disease and late-onset behavioral abnormalities with the behavioral variant of frontotemporal dementia. The presence of obsessive–compulsive spectrum disorders in Parkinson’s disease dementia is also not rare. Analyzing this evidence, we propose “behavioral biomarkers” as neuroticism in Alzheimer’s disease, late-onset behavioral abnormalities in behavioral variant of frontotemporal dementia, and obsessive–compulsive traits in Parkinson’s disease dementia. These noninvasive behavioral biomarkers will be of immense help, particularly in developing countries, and will prevent the need for costlier investigations and aid in therapeutic strategies. Neurodegenerative dementias such as the behavioral variant of frontotemporal dementia (bvFTD), Alzheimer’s disease (AD), and Parkinson’s disease dementia (PDD) have been associated with various behavioral and psychological abnormalities. Whether these abnormalities precede, coincide or follow the onset of cognitive symptoms still remains controversial and elusive in existing literature, with trajectories available so far dependent on types of dementia.The authors, herein, aim to review the different kinds of premorbid behavioral symptoms/personality traits associated with an increased risk of developing specific types of neurodegenerative dementia.Behavioral symptoms and dementia have intriguing associations, with undefined temporal relationships concerning the appearance of cognitive symptoms . BehavioMost importantly, whether premorbid personality/behavioral patterns switch to different behavioral phenotypes or are merged with cognitive symptoms of dementia is still unresolved. However, several factors  underpin the intricate relationship of premorbid behavior symptoms with dementia , 3. AssoAD can be better categorized as a progressive heterogeneous neurodegenerative disorder (with memory deficit being the most prominent symptom) co-clustering with several behavioral symptoms with undefined temporal relationships . BehavioTerracciano et al.  reviewedThe answers to some important questions remain elusive to date: (1) how do personality traits modulate the AD neuropathology?; (2) is there any impact of genetic modulation?; (3) how do premorbid behavior/personality traits determine the onset of cognitive impairment?; (4) do behavioral and psychological symptoms of dementia share its phenotypic similarity with premorbid behavior or whether there is any change?; (5) if there is any change, how and when does it occur? Some studies have unfurled the intricate crucial relationship between premorbid conscientiousness, extraversion, openness, and agreeableness, which proved to be protective factors against behavioral and psychological symptoms of dementia in future . ReverseTaken together, all previous data suggest that behavioral symptoms may be a prelude to AD and also to disease progression.Frontotemporal dementia is subclassified into a few groups: bvFTD, non-fluent variant primary progressive aphasia, and semantic variant primary progressive aphasia and a related group that includes frontotemporal dementia motor neuron disease, progressive supranuclear palsy syndrome, and cortico-basal syndrome .BvFTD is characterized by a diverse spectrum of behavioral problems and personality changes, including psychosis, disinhibition, compulsions, overeating, hyperorality, loss of empathy, and apathy which may appear long before disruption of conventional cognitive domains and thus, may mimic a diagnosis of primary psychiatric disorder , 16. In The neuroanatomical basis of bvFTD has been thought to originate from the dysfunction of cortical brain circuits involving the orbitofrontal cortex (OFC), dorsolateral prefrontal cortex, and medial prefrontal cortex and its subcortical connections , primarily responsible for disturbances in emotional states and abnormal social behaviors , 16. MagPatients with bvFTD often show a marked lack of empathy and warmth in interpersonal relationships due to disruption in the right anterior temporal lobe, right medial OFC, and anterior insula , 16. DysThe plethora of psychiatric abnormalities in bvFTD has been associated with the C9ORF72 mutation . MeislerPatients with bvFTD are characterized by grey matter loss and corresponding white matter fractional anisotropy reduction in the frontal and temporal lobe , 27. DifThe clinical characteristic of Parkinson’s disease is not merely confined to motor symptoms as numerous behavioral symptoms such as depression, anxiety, obsessive–compulsive disorders, delusions, hallucinations, psychosis, and cognitive changes are common and manifest at some point in the disease course. The clinical features of PDD encompass cognitive impairment , behavioral symptoms, autonomic dysfunction, sleep disorders, and parkinsonism . The temDespite being considered a common neuropsychiatric condition in the general population, the prevalence of the obsessive–compulsive disorder is over 30% in patients with Parkinson’s disease . AdvanceMild cognitive impairment is common in non-demented patients with Parkinson’s disease and is considered a risk factor for dementia . DepressFrom pieces of evidence extrapolated from contemporary research, it can be assumed that behavioral issues and cognitive impairment in various neurodegenerative dementias  are threaded together, sharing some common neuropathological processes . The vulnerability and temporal sequence of appearance of behavioral and cognitive symptoms are quite unpredictable and variable, depending on specific types of dementia. The neuropathological basis of developing behavioral issues/personality traits long before overt cognitive symptoms, remains elusive. Still, it is assumed to play in the continuum with the neurobiological basis of the development of cognitive symptoms later on. The complexities of an interrelated and integrated continuum of the neurobiological basis of behavior and cognitive symptoms may not always be evident; however, the basic scientific understanding behind this assumption cannot be ignored. Based on current research depicting the association of high neuroticism and low conscientiousness with AD; the intriguing relationship of late-onset behavioral abnormalities (which is misdiagnosed frequently as late-onset bipolar affective disorder) with bvFTD; and intertwined association between obsessive–compulsive disorder with PDD. Researchers are in a relentless search for developing novel biomarker(s) in neurodegenerative dementias. Although several biomarkers are currently available , none proved to be cost-effective and widely available. Consequently, scopes for application of these conventional biomarkers in developing, low and middle income countries are limited.The authors, herein, propose to consider specific “premorbid behavioral conundrum/personality traits” as a noninvasive, cost-effective, and bedside biomarker(s) of neurodegenerative dementias , which will be immensely beneficial, especially in developing low and middle income countries in terms of feasibility of the wider application, cost-effectiveness  as well as potential prevention  and earlier diagnosis and treatment of neurodegenerative dementias.


The chelating thiol dimercaptosuccinate (DMSA) and the traditional agent D-penicillamine (PSH) are effective in enhancing the urinary excretion of copper (Cu) and lead (Pb) in poisoned individuals. However, DMSA, PSH, EDTA (ethylenediamine tetraacetate), and deferoxamine (DFOA) are water-soluble agents with limited access to the central nervous system (CNS). Strategies for mobilization of metals such as manganese (Mn), iron (Fe), and Cu from brain deposits may require the combined use of two agents: one water-soluble agent to remove circulating metal into urine, in addition to an adjuvant shuttler to facilitate the brain-to-blood mobilization. The present review discusses the chemical basis of metal chelation and the ligand exchange of metal ions. To obtain increased excretion of Mn, Cu, and Fe, early experiences showed promising results for CaEDTA, PSH, and DFOA, respectively. Recent experiments have indicated that p-amino salicylate (PAS) plus CaEDTA may be a useful combination to remove Mn from binding sites in CNS, while the deferasirox–DFOA and the tetrathiomolybdate–DMSA combinations may be preferable to promote mobilization of Fe and Cu, respectively, from the CNS. Further research is requested to explore benefits of chelator combinations. Acute poisonings with manganese, iron, or copper compounds can, in many cases, be satisfactorily treated by chelator monotherapy . Early cManganese (Mn) exposure with brain deposition can lead to a neuropsychiatric disturbance known as manganism [anganism  (Table 1anganism . Since tanganism . Currentanganism .Iron (Fe) dyshomeostasis occurs in PD patients, typically showing elevated levels of Fe bound to neuromelanin in the substantia nigra [ia nigra . This foia nigra . Howeveria nigra . Other nia nigra . Excesseia nigra  and neuria nigra .Copper (Cu) is a well-known neurotoxic metal when occurring in excess in CNS, although it is also essential for several enzymes including cytochrome c oxidase, superoxide dismutase (SOD1), dopamine beta-hydroxylase, and tyrosinase [rosinase . Althougrosinase . Furtherrosinase , althougrosinase ,17. Thusrosinase . It has rosinase , which mrosinase . Excesserosinase .acute poisonings [chronic poisonings with cerebral deposits of manganese, iron, or copper compounds, in addition to emphasizing the presumed benefits of combining an aqueous soluble rapidly excreted chelator with a lipophilic or low-molecular-weight metal carrier with the ability to shuttle across the brain–blood barriers and, thus, deliver the toxic metal via ligand exchange to the exporting water-soluble agent  or to tetrathiomolybdate [+ metal ion. Here, softness is related to the deformability of the outer electron shell, as well as to the size of the ionization energy, and it involves a propensity to form covalent bonds between interacting species, which are characterized by minor differences in electronegativity. Hardness favors complexation by ionic bonds, with the binding forces being dependent upon large differences in electronegativity between interacting species. The HSAB theory proposed by Pearson is useful for the evaluation of chemical affinities ,37. For tal ions . These solybdate . In partAnimal experiments are essential for the evaluation of chelation therapy, particularly in the case of chelator combination . HoweverThe BAL–EDTA combined treatment previously recommended in acute lead poisoning uses rather high and often toxic BAL doses. When combined with high doses of DMSA, BAL in lower doses is supposed to act as a shuttler, since DMSA can generate a significant metal CNS-to-blood gradient through its chelation in the extracellular environment ,40. BeyoManganese, iron, and copper are essential trace elements for humans . OccupatCombined chelation therapy with CaEDTA and a membrane penetrating chelator is an attractive option for treatment of manganism. Recent experiences have reported that chelation treatment may improve the clinical features in overexposed welders when administered in the early phases of the clinical course [Chelation therapy is the recommended treatment. The extracellularly distributed chelator CaEDTA increases the amount of Mn excreted in the urine; however, its effect on clinical symptoms has been debated . The siml course . Sodium l course ,53. It iIt is well known that frequent blood transfusions as given in some chronic diseases may lead to general siderosis but usually without brain Fe accumulation. Thus, the brain Fe homeostasis seems to be independent from the systemic regulation of Fe homeostasis. However, localized brain Fe deposits characterize some neurodegenerative diseases, including Friedreich’s ataxia and aceruloplasminemia , as wellThe main iron storage protein ferritin is found in glial cells but generally not in neurons . NeuronsIron chelation therapy with the parenterally administered chelator deferoxamine  has played a vital role in the management of patients with transfusional siderosis after the introduction of this agent . HoweverOral treatment with the agent deferiprone (Ferriprox) offers an important supplement to the subcutaneous infusions of deferoxamine in the treatment of iron overload . DeferipCombined chelation therapy with DFOA and deferiprone is an attractive option for removal of brain Fe deposits [deposits ,67. It wdeposits . The advdeposits ,5.A relatively new alternative in Fe chelation therapy is deferasirox (Exjade), which is an orally active chelator forming a 2:1 complex with Fe, with the chelate being excreted via bile. Several phase III clinical trials with this agent have reported its convincing efficacy in mobilizing Fe deposits ,70. It iIn exogenous overexposure, as well as in the metabolic error known as Wilson’s disease, copper can exert toxic effects. Copper compounds are used in wood preservatives and fungicides, as pigments in paints, and as additives to fertilizers. Numerous fungicides still have Cu in their formulations . As for With regard to disturbances in the copper metabolism, Wilson disease (WD) is known as an autosomal recessive disease affecting primarily the Cu excretion via bile and the hepatic synthesis of ceruloplasmin  caused bor deferiprone is recommended for treatment of siderosis, and DMSA is considered promising for poisonings with copper although PSH is the traditional agent in cases of WD. It should be recalled here that adverse effects of PSH are so common as to be therapy-limiting in several cases. In the treatment of metal poisonings with cerebral deposits and neurological symptoms, a strategy with combined chelation therapy using a lipophilic in addition to a hydrophilic chelator may improve the therapeutic value. A lipophilic or low-molecular-weight agent tentatively binds and transfers the toxic metal from intracellular binding sites along a concentration gradient from brain to the circulation. Subsequently, after ligand exchange, metal excretion is taken care of by a hydrophilic chelator, e.g., by EDTA, DFOA, or DMSA. A simplified model illustrating the problems with mobilization of toxic metals from CNS is shown in subacute or chronic cases in the present review. The “shuttling plus decorporation” principle has to some extent already been adopted for mobilization of Fe in thalassemia and related sideroses by using the extracellularly distributed DFOA in combination with the low-molecular-weight agent deferiprone. Manganism may require a triple combination with CaEDTA, PAS, and L-dopa. Further exploration of the combined chelator concept to target intracerebral and intracellular metal toxicity is requested, both experimentally and clinically.Today, CaEDTA is a standard treatment for manganese poisonings, DFOA Here, it should be admitted that currently available chelators are not as target-specific as endogenous chaperones for the metals in question. Upon designing new metal-binding drugs, the targeting of intracellular sites such as the mitochondria represents a challenge. For instance, currently available chelators seem inefficient in mobilizing metal deposits in mitochondria  that areToday, combination therapy represents an attractive approach for enhancing metal mobilization from the body by reducing individual doses of chelators, thereby limiting drug-specific adverse reactions. Thus, combination therapy with two or more drugs may prove more efficient and tolerable than monotherapy . RegardiCancer therapy has shown great interest in antagonizing iron and copper effects in tumors to limit angiogenesis, as well as for the delivery of extra metal in order to enhance production of cytotoxic ROS (reactive oxygen species) in malignant cells. Thus, the studies on chelator effects and metal antagonism can benefit from the cancer research field and vice versa ,100.(1)Symptoms on neurotoxicity should ideally be identified early and chelation therapy should ideally be started before substantial irreversible brain damage has occurred. However, although symptoms on neurodegenerative diseases cannot be reversed, it will be of great interest if the disease progression can be prevented.(2)Doses and circulating chelator levels must be controlled to enhance intended metal removal.(3)The levels of essential metals must remain sufficient within cells for metalloenzyme biosynthesis.(4)Regular control of blood and tissue metal pools is needed.Crucial therapeutic principles, which are valid for the treatment of Mn, Fe, and Cu toxicity, can be summarized as follows:Patients on chelation therapy need a close clinical follow-up and neurological assessment plus monitoring of renal and liver functions. In treated cases of Wilson’s disease, as well as in NBIAs and in manganism, collection of genetic information is essential to establish valid genotype–phenotype information. Conclusively, it should be emphasized that there is a lack of high-quality evidence to estimate the relative therapeutic effects of drugs and drug combinations used in the medical conditions under investigation. Multicenter randomized comparative trials are highly needed.


As per a recent study conducted by the WHO, 15.4% of all cancers are caused by infectious agents of various categories, and more than 10% of them are attributed to viruses. The emergence of COVID-19 has once again diverted the scientific community’s attention toward viral diseases. Some researchers have postulated that SARS-CoV-2 will add its name to the growing list of oncogenic viruses in the long run. However, owing to the complexities in carcinogenesis of viral origin, researchers across the world are struggling to identify the common thread that runs across different oncogenic viruses. Classical pathways of viral oncogenesis have identified oncogenic mediators in oncogenic viruses, but these mediators have been reported to act on diverse cellular and multiple omics pathways. In addition to viral mediators of carcinogenesis, researchers have identified various host factors responsible for viral carcinogenesis. Henceforth owing to viral and host complexities in viral carcinogenesis, a singular mechanistic pathway remains yet to be established; hence there is an urgent need to integrate concepts from system biology, cancer microenvironment, evolutionary perspective, and thermodynamics to understand the role of viruses as drivers of cancer. In the present manuscript, we provide a holistic view of the pathogenic pathways involved in viral oncogenesis with special emphasis on alteration in the tumor microenvironment, genomic alteration, biological entropy, evolutionary selection, and host determinants involved in the pathogenesis of viral tumor genesis. These concepts can provide important insight into viral cancers, which can have an important implication for developing novel, effective, and personalized therapeutic options for treating viral cancers. Currently, much of the collective research efforts across the world have been directed at understanding cancer pathogenesis and pathways involved in carcinogenesis . Cancer Similarly, after extensive research to evaluate promoters of cervical cancers in Mexican women, researchers have found a high viral load of human papillomavirus (HPV) in women’s reproductive tract, indicating a significant role of chronic HPV infection in cervical cancer . These vIn preclinical studies, latent membrane protein 1 of EBV (EBV-LMP1) was found to cause upregulation of mitochondrial enzymes, which includes glutaminase-1 (GLS1), isoforms of kidney-type glutaminase (KGA) and glutaminase-C (GAC) that boosts the pathogenesis of classical Hodgkin’s lymphoma (cHL) ,11,12. IOwing to the experimental support for the role of viruses in carcinogenesis, researchers have postulated some of the essential characteristics for identifying the role of the virus in cancer pathogenesis ; these iOncogenic viruses can be divided into direct and indirect oncogenic viruses. Indirect oncogenic viruses cause chronic and sustained alterations in cellular and subcellular pathways that lead to the clinical endpoint of cancer by activating alternative pathways, for example, inflammatory pathways. In contrast, direct oncogenic viruses use intracellular viral components to drive the cancer pathway . Direct Researchers worldwide have contributed to comprehensive genome and whole-transcriptome analyses of cancerous samples that have collected information about human cells and other cancer-causing pathogens . InternaCOVID-19 infection is considered a serious health problem and has caused heavy mortality in cancer patients and patients with other comorbidities ,58,59. IIn earlier studies, it has been reported thatSARS-CoV-2 induced hypoxia causes activation of HIF-1α which is an essential biomarker of acute myeloid leukemia (AML), especially in those patients who haveFlt3-ITD  mutations. In vitro studies conducted by ,66 foundFurthermore, many in-vitro studies have found that autophagy-related drugs can serve as potential therapeutic drugs against SARS-CoV-2 . In addiIn cancer biology, there are numerous mechanisms and pathways involved in carcinogenesis. Early studies in this area have identified a limited number of cancer pathways involved in viral oncogenesis. Still, with the advancement of research, more pathways and complexity have been found in viral cancer pathogenesis . AlthougThe first animal model investigation on carcinogenic virus discovered the viral genome to encode the oncogenes v-src, v-myc, and v-ras that transform healthy developing cells into malignant cells. Subsequently, these genes were found to be involved in other cancers and were found to be dysregulated in cancer cells . It has Cancers caused by viruses may not appear immediately after infection; instead, they appear 15 to 40 years later . The rar4+ Co-receptor, henceforth causing immobilization and apoptosis of B lymphocytes [Furthermore, DNA viruses such as EBV and KSHV cause the synthesis of a diverse set of viral oncoproteins, and these proteins precisely target the cellular host machinery . A variephocytes . Additiophocytes ,86,87, wphocytes . In addiphocytes . Furtherphocytes . The devphocytes . In the Inhibition of apoptosis is considered the most critical cancer biomarker among the various hallmarks  Figure . These pSimilarly, it has been found that other viruses, such as KSHV, disrupt pathways involved in apoptosis. For instance, viral constituents cause inhibition of ORF16 required for activation of apoptosis. Similarly, MCPyV causes overexpression of BIRC5/survivin mRNA production and inhibits caspase-mediated apoptosis . AdditioCancer cells undergo a paradigm shift in metabolism from aerobic to anaerobic respiration and utilize alternative metabolites for cellular metabolism, and this process is known as the Warburg effect . For insThrough the activation of EBNA2, which triggers a myc-dependent metabolic program to increase amino acid and nucleotide synthesis, EBV infection promotes the adhesion and proliferation of B cells . Viral iIn thermodynamics, entropy is the property of complex systems with multiple microstates, and the same applies to complex biological systems. Viral infection increases the number of microstates in biological systems and hence enhances genetic entropy . This geThe co-existence of viral-infected cancerous cells that survive under harsh environmental conditions is characterized by low oxygen levels and acidified environment . Low oxyOncogenic viruses cause the synthesis of extracellular vesicles, which contain viral cargos, and these vesicles fuse with neighboring cells and result in the transmission of oncogenic viruses to neighboring cells . SubsequEvolutionarily, the survival of predatory viruses and cancerous cells is only possible in an immune-compromised environment. Viral cancers are found to increase in an immune-compromised state induced by alterations and modulations of immune response by virus and their metabolites . OncogenReprogramming of the transcriptional network is the hallmark of cancerousproliferation. It has been reported that early viral synthesized proteins cause dysregulation of the transcriptional network in favor of viral growth inside host cells. For instance, viral oncoproteins  and T-antigens are known to cause profound alteration in the transcriptional network of p53 and Rb-family complexes . Viral oOncogenic Viral infection can cause epigenetic reprogramming through a diverse set of mechanisms by acting on various hotspots. For instance, the following epigenetic reprogramming pathways have been identified in viral cancers, including (i) Hyper- methylation of various genes responsible for establishing viral infection (HPV and EBV carcinomas). (ii) Hypermethylation results in the down-regulation of TET1  and TET2Oncogenic DNA viruses such as EBV have viral-specific programs designed to ensure the persistence of viral particles inside proliferative cells, which act as clonal outgrowths for cancer cells. These viruses encode proteins that protect viral DNA from degradation caused by cellular enzymes and non-enzymatic processes. Integration of viral genome with host cell genome occurs at specific sites of the host genome. For example, HBV viral genome has been observed to integrate at oncogenic hotspots such as TERT (telomerase), ERBB2, and PTPN13 loci . Based oViral cancers are mostly descendant cells derived from progenitor cells infected with oncogenic viruses . HoweverIn addition to host factors, environmental factors also contribute to viral carcinogenesis. For instance, co-infection of a host cell with the malaria-causing organism and HIV results in alterations of an immune response directed against virally infected cancer cells  Figure . As per The late importance of the virome and microbiome on the skin and the mucous membrane has been identified as a risk factor for the progression of viral oncogenesis. Recent studies have reported that bacteriophage communities cause gut dysbiosis in colorectal cancer and make conditions favorable for establishing opportunistic organisms  Figure . SubsequA commensal virome on the skin is beneficial against skin cancers through the mediation of the host immune system/response. It has been found that increased CD8 (+) T response against commensal viruses on the skin results in the development of vacant niche areas on the skin, which can be occupied by oncogenic viruses and subsequent cutaneous damage caused by chemicals and other physical factors results in the development of skin cancer .Host cells contain an important regulator called Krüppel-associated box domain-containing zinc finger proteins (KRAB-KZFPs), a transcriptional product of this regulator that causes inhibition of retroviruses proliferation. The product inhibits retroviral multiplication by acting on the GC region of the retrovirus. However, under evolutionary pressure, these types of viruses have low GC content to evade a host protective mechanism that identifies significantly elevated levels of GC as foreign material and henceforth promotes its degradation. Furthermore, zinc-finger CCCH-type containing 11A (ZC3H11A) regulates RNA transport with the host cell. During infection with an oncogenic virus, this export mechanism is hijacked by viruses, and they use it for the transport of viral RNA cargo .miRNA is the non-coding RNA that plays a role in post-transcriptional modification of gene expression. Such miRNAs originating from a diverse set of oncogenic viruses result in a wide array of modifications in the host environment ranging from immune evasion to inhibition of apoptosis  Figure . Among aHERV are the viral genomic elements introduced in the human genome almost 4.5 million years ago. These elements have exhibited co-evolution with the human genome and have transmitted across the generation following Mendelian inheritance. Most of these HERVs have been maintained under transcriptional control and have lost their function of replication and expression. The loss in functionality has been attributed to the long-term accumulation of mutations, frameshift mutations, and recombination culminating in the formation of solitary Long Terminal Repeats (LTRs) . Due to Oncoviruses have been found to interact with HERV, which results in the expression of dormant HERV sequences  Figure . These iHERV causes the reprogramming of somatic cells and induces Pluripotency characteristics in differentiated cells, and HERV-H is supposed to play a significant role in reprogramming. The role of HERV in carcinogenesis is because of their ability to cause the reprogramming of Cancer Stem Cells (CSC) . HERVs aHERV expression determines disease progression, the outcome of therapeutic intervention, and survival in different types of cancers. Colorectal cancer caused by activation of endogenous retroviral expression and concurrent CD8 (+) infiltration is very refractory to treatment. It has been observed that HERV-W causesthe cellular transition, cellular transformation, transcriptional alterations, and enhanced cell migration which increases cancer potential of Colorectal Cancer induced by endogenous oncoviruses . AlthougViruses are minute but complex organisms which cause a wide array of diseases in the animal kingdom, ranging from pandemics such as COVID-19 to various types of untreatable cancers. There is a lack of in-depth understanding of why some viruses are carcinogenic while others closely related are non-carcinogenic. From the findings of researchers across different fields of oncology, some common findings they highlighted include host factors such as immunosuppression, deleterious mutations, and Co-infection with other microorganisms. The common viral factors responsible for carcinogenesis include the ability of oncogenic viruses to attack various cellular pathways and perturb translational, transcriptional, and epigenetic pathways. These perturbations can have temporal and spatial heterogeneity and complexities, but still, they provide new insight into viral carcinogenesis and host determinants of the disease. Although various therapeutic alternatives are available against viral cancers, they lack efficacy, and their chronic use has been found to promote immune evasion by cancer cells. Hence, to develop an effective therapeutic regimen against viral cancers, a deeper understanding of mechanistic pathways involved in cancer carcinogenesis is needed. Understanding viral carcinogenesis can solve some critical questions about viral cancer biology, such as rate limiting steps involved, genetic hotspot, reversion of cellular microenvironmental conditions to retard the proliferation of cancer viruses, and the role of dampening genetic noise as a therapeutic intervention.