Shortly after the worst of the COVID-19 pandemic, an outbreak of mpox introduced another critical public health emergency. Like the COVID-19 pandemic, the mpox outbreak was characterized by a rising prevalence of public health misinformation on social media, through which many US adults receive and engage with news. Digital misinformation continues to challenge the efforts of public health officials in providing accurate and timely information to the public. We examine the evolving topic distributions of social media narratives during the mpox outbreak to map the tension between rapidly diffusing misinformation and public health communication.This study aims to observe topical themes occurring in a large-scale collection of tweets about mpox using deep learning.We leveraged a data set comprised of all mpox-related tweets that were posted between May 7, 2022, and July 23, 2022. We then applied Sentence Bidirectional Encoder Representations From Transformers (S-BERT) to the content of each tweet to generate a representation of its content in high-dimensional vector space, where semantically similar tweets will be located closely together. We projected the set of tweet embeddings to a 2D map by applying principal component analysis and Uniform Manifold Approximation Projection (UMAP). Finally, we group these data points into 7 topical clusters using k-means clustering and analyze each cluster to determine its dominant topics. We analyze the prevalence of each cluster over time to evaluate longitudinal thematic changes.Our deep-learning pipeline revealed 7 distinct clusters of content: (1) cynicism, (2) exasperation, (3) COVID-19, (4) men who have sex with men, (5) case reports, (6) vaccination, and (7) World Health Organization (WHO). Clusters that largely communicated erroneous or irrelevant information began earlier and grew faster, reaching a wider audience than later communications by official instances and health officials.Within a few weeks of the first reported mpox cases, an avalanche of mostly false, misleading, irrelevant, or damaging information started to circulate on social media. Official institutions, including the WHO, acted promptly, providing case reports and accurate information within weeks, but were overshadowed by rapidly spreading social media chatter. Our results point to the need for real-time monitoring of social media content to optimize responses to public health emergencies. Shortly after adopting a “learn to live with” approach to COVID-19, the World Health Organization (WHO) declared mpox, a viral zoonotic disease caused by the mpox virus, an international health concern . After cSimilar to the COVID-19 pandemic, news and updates regarding the mpox outbreak spread through mainstream media and social media platforms. However, social media is vulnerable to misinformation that can influence public attitudes toward mpox ,6. GivenIn 2022, public reports and social commentaries regarding global mpox cases became a prevalent component of ongoing news cycles. These reports and news broadcasts echo those presented during the initial stages of the COVID-19 pandemic, which emphasized disease spread, preparation, infection risk, and mitigation strategies . HoweverIt is not surprising that social media has become a primary outlet for news distribution and internetwork commentating , as it hThe rise of curated feeds tailored for each individual social media user has made it all the more challenging to discern or counter misinformation on social media . Social Although social reactions to the mpox outbreak and the COVID-19 pandemic share many similarities, mpox has unique characteristics that distinguish it from COVID-19. COVID-19 infection yields flu-like symptoms, such as headache, cough, fatigue, body aches, and general congestion in mild cases, while in severe cases, it can lead to acute respiratory distress syndrome and other potentially fatal co-occurring outcomes . On the The unique characteristics of mpox as compared to COVID-19 could potentially foster different public reactions to each disease. For instance, the differences could potentially frame mpox as less threatening or severe than the COVID-19 pandemic . The difResearch on social media’s role in shaping perceptions and behaviors during the mpox outbreak highlights the presence of prejudices and stereotypes. One study found that stigmatizing beliefs about mpox can hinder individuals from following recommended guidelines, such as vaccination uptake, handwashing, and social distancing . While sExtensive research has been conducted on mpox-related social stigma, knowledge, and attitudes, as well as qualitative assessments of mpox content on social media. However, these studies may have limitations, such as cross-sectional designs or small sample sizes. Studies suggest that interventions, whether conducted in person or on the internet, can reduce biases associated with mpox among study participants. Nonetheless, the prevalence of misinformation and fake news on social media necessitates further analyses that can offer a more nuanced understanding of mpox dialogues on these platforms. Valdez and Patterson  propose The mpox outbreak marks the first public health emergency and response following a once-in-a-generation global pandemic. While the dissemination of medically accurate facts and information about mpox may have helped quell public anxieties about infection rates and spread, the outbreak is not immune to misinformation in the digital space. Therefore, this study aimed to generate themes from a collection of tweets specifically pertaining to mpox and examine how the narrative of the outbreak evolved over time. Our study was guided by 3 research questions (RQs):RQ1: What themes emerge from a deep-learning analysis of mpox-related tweets?RQ2: How do themes identified from a deep-learning model evolve over the course of the mpox outbreak?RQ3: What do these themes collectively imply about public health responses during global public health emergencies?The findings from our study have the potential to inform the extent to which lessons learned during the COVID-19 pandemic can be applied to future public health emergencies. Examining the relative difference between medically accurate information and misinformation’s noise may also highlight the ongoing risk that social media poses in shaping norms, attitudes, and behaviors toward disease outbreaks and associated responses.Our analysis relied on a publicly available repository of 254,363 tweet IDs (“Mpox2022Tweets”) related to the 2022 mpox outbreak . We retrTo analyze our data, we applied the following analytic pipeline: (1) calculate vectors using the Sentence Bidirectional Encoder Representations From Transformer (S-BERT) algorithm and (2) data visualization using a principal component analysis (PCA) with Uniform Manifold Approximation (UMAP).S-BERT is an extension of the state-of-the-art Bidirectional Encoder Representations From Transformers (BERT) algorithm, which applies neural networks to detect patterns in large-scale text data ,34. The Text vectors calculated using the S-BERT algorithm are highly dimensional and complex. For visualization purposes, we used a combination of PCA and UMAP to reduce their dimensionality to 2 dimensions -39. PCA K-means clustering is an algorithm designed to partition data into a predefined number (K) of optimally dense subsets of data points . K-meansWe leveraged S-BERT, PCA, and UMAP to place each tweet in a visual map highlighting the structure of topic distributions within the total volume of mpox-related messages in our data. To allow visualization, we first reduced the data set to a randomly selected sample of 10% of all tweets retrieved, producing a final set of 17,646 tweets for analysis. This random sampling reduces the number of tweets to visualize while maintaining the original topic, content, and origin distributions. We then mapped each tweet in our sample into a 384-dimensional vector produced by S-BERT. These vectors provide numerical representations of each tweet’s content, so we can calculate the similarity of any pair of tweets from the degree to which their S-BERT vectors align.To visualize our data in a 2D map, we reduced the dimensionality of the S-BERT vectors to 2 dimensions with (1) PCA to retain only the 40 most important components of the initial analysis and (2) UMAP to project each of the tweet vectors onto a 2D plane (our map). We then grouped tweets into topical clusters using a k-means clustering algorithm based on their position in the map. Silhouette testing indicated that 7 k-means clusters were optimal for separation of distinct topics, which we confirmed through our own examination of the data. We constructed an interactive map of the tweets, allowing the contents of tweets within each topic cluster to be viewed.We independently assessed the clusters with an informal qualitative thematic assessment, providing topic labels and contextualization of their meaning within the larger mpox narrative. A review and discussion of each cluster yielded consensus cluster labels, as shown in This study represents a secondary data analysis of publicly available social media data. This study and the majority of social media studies following a similar methodological pipeline were exempt from review by the institutional review board. Regardless, all data were scrubbed of any personally identifiable information prior to data cleaning, analysis, and interpretation, and stored on secure, access-limited, encrypted systems to safeguard privacy.Our study applied deep-learning models to identify themes embedded within a collection of mpox-related tweets. Broadly, we observed a wide array of topics pertaining to both accurate health messaging and misinformed perspectives. We outline key results below without comment.Our deep-learning model revealed 7 clusters embedded within our data. We observed that clusters containing public reactions and misinformation about mpox transmissibility in the MSM community emerged first and dominated activity throughout the period of analysis. These early clusters again implicated general public exhaustion and skepticism of what were perceived to be repeated and fabricated global health emergencies post COVID-19 (tweet: “Here we go again with another scamdemic!”). We also observed higher rates of sarcasm and humor in these clusters, which illustrate the public’s limited ability to internalize the potential threat mpox posed across populations . Only after weeks of unmitigated information spread did topics specific to WHO guidelines, recommendations, and otherwise responsible health messaging emerge and become more prominent. In other words, social media noise and irrelevant content preceded official social media–driven public health responses.We outlined the distribution of tweets per cluster over time in This study characterized longitudinal Twitter dialogue pertaining to the 2022 global mpox outbreak. As the first major public health emergency following the COVID-19 pandemic, this work sought to confirm ongoing research about mpox through misinformation and information overload domains. Broadly, our results largely support the proverb, “a lie will travel halfway across the world before truth has managed to put her boots on,” specifically regarding the incongruent ratio between uninformed and misinformed mpox perspectives and accurate messaging from major health outlets. We contextualize our findings below.As suggested in our findings, people may be more inclined to instinctively react to major news cycles before doing research on a topic. For example, our longitudinal analysis documented that, well before the WHO and other public health entities addressed the mpox outbreak, comments and posts about the earliest cases and the disease had already spread widely across the Twittersphere. This phenomenon of sharing and commenting in real time is largely referred to in the economic literature as “nowcasting” . NowcastOur data reveals that much of the information shared on the internet during the initial stages of the mpox outbreak was either disconnected from facts, politically biased, or contained humor and other irrelevant content. This phenomenon could be explained through the lens of the spiral of silence theory, which suggests that people influence one another’s willingness to express opinions through social interaction . AlternaOur findings suggest that accurate health messaging can be effective in engaging the public. Specifically, our analysis showed that after the WHO declared an emergency, accurate topics related to mpox and mitigation strategies emerged and spread effectively on Twitter. The WHO cluster had the most retweets (average 73.54 retweets), followed by the MSM cluster (average 60.61 retweets). Within the MSM cluster, there were 2 types of tweets: those that incorrectly referred to mpox as a disease that exclusively affects marginalized portions of the US population  and those that referred to specific mitigation strategies for the MSM community . Similarly, the case reports cluster, which was the third most retweeted cluster, also exhibited inaccurate content . However, we observed a greater number of people discussing the importance of these reports rather than dismissing them as irrelevant .Our findings appear to contradict some research that has demonstrated the challenges public health and social media entities face in monitoring and curbing the spread of misinformation related to COVID-19, such as the “Scamdemic” conspiracy theory and ongoing fake news about COVID-19 origins and vaccine mistruths [In a systematic review of social media–driven misinformation, misinformed content was most prevalent regarding smoking and vaping, yet large proportions of misinformation were also observed in studies related to vaccines and other noncommunicable diseases . In the First, from a computational and surveillance perspective, we recommend that public health institutions adopt a “situational awareness” approach to web-based messaging in which (1) social media is monitored in real-time using advances in natural language processing, computational psychology, and artificial intelligence to detect the dissemination of information that does not align with public health objectives, and (2) such information is proactively countered or augmented with messaging specifically designed to ensure the widest and most timely possible dissemination of crucial public health information ,51. In fThis study is subject to limitations we aim to address in future research. First, our analysis represents themes embedded within a fraction of the mpox Twitter data set. While it is possible to run more exploratory analyses with the entire corpus, using latent Dirichlet allocation topic models, for example, we strongly felt this more precise approach to computational thematic generation provided a more resounding portrait of discourse surrounding mpox over time. Second, we also acknowledge that we did not perform a full, in-depth qualitative review of these tweets. Though such an analysis may add nuance to our findings and discussion, our aim with this paper was to apply a novel methodological pipeline to quickly identify pockets of discourse that may be problematic or harmful amid another public health emergency. As such, we only applied a cursory qualitative review of these tweets to ensure all members of our team interpreted topics similarly. Future researchers should strongly consider replicating our findings using traditional qualitative inquiry, which can be used as a validation metric for our analytic pipeline.The global mpox outbreak offered another case study in public health response amid a global public health emergency. Although mpox infection rates never paralleled those during COVID-19, the anxieties experienced by people still reeling from pandemic-related trauma offered insight into how people’s social reactions and public health response have evolved since then. Our findings reveal a large presence of misinformed perspectives about mpox, including those at risk for infection, disbelief at the potential severity of mpox, and simple apathy toward another public health emergency.


Neurons generate numerous cell-specific isoforms of genes that are expressed more broadly. Here, we review mechanisms that generate neural-specific alternative splicing and 3′UTRs and their biological impacts on the nervous system. Cell-type–specific gene expression is a fundamental feature of multicellular organisms and is achieved by combinations of regulatory strategies. Although cell-restricted transcription is perhaps the most widely studied mechanism, co-transcriptional and post-transcriptional processes are also central to the spatiotemporal control of gene functions. One general category of expression control involves the generation of multiple transcript isoforms from an individual gene, whose balance and cell specificity are frequently tightly regulated via diverse strategies. The nervous system makes particularly extensive use of cell-specific isoforms, specializing the neural function of genes that are expressed more broadly. Here, we review regulatory strategies and RNA-binding proteins that direct neural-specific isoform processing. These include various classes of alternative splicing and alternative polyadenylation events, both of which broadly diversify the neural transcriptome. Importantly, global alterations of splicing and alternative polyadenylation are characteristic of many neural pathologies, and recent genetic studies demonstrate how misregulation of individual neural isoforms can directly cause mutant phenotypes. Most protein-coding genes in higher eukaryotes are subject to alternative processing yielding multiple mRNA isoforms, thereby diversifying the functional transcriptome . The abiMany classes of alternative mRNA processing include usage of different promoters, inclusion of distinct internal exons, and deployment of alternative last exons (ALEs) and/or 3′ UTRs . ConceptIn this review, we will focus on alternative splicing (AS) of internal and 3′ terminal exons and on alternative polyadenylation (APA) to generate distinct 3′ UTRs. We note that others have extensively reviewed general mechanisms and regulation of alternative splicing  and APA It was originally conceived that each gene generates an individual protein product . HoweverSplicing involves the stepwise actions of the spliceosome, a large and dynamic machine that at its core comprises a series of small nuclear ribonucleoprotein particles , each composed of small nuclear RNAs and their associated partners . The smaAccurate splicing is critical because misprocessing causes inclusion or exclusion of sequences from the intended transcripts, and/or throws the downstream sequence out of frame. However, the selection of appropriate splice sites, even in a constitutive fashion, poses a conundrum. This is because of the limited primary sequence information for where to cleave and join 5′ and 3′ ends of introns, namely, at 5′ GU and AG-3′ dinucleotides . AlthougWhen introns are short (<200 nt), the likelihood of illegitimate splice site matches is smaller, although certainly still well-documented in different kingdoms . In thesSpecific and accurate execution of constitutive exon ligation involves, in part, the active suppression of illegitimate, but biochemically valid, splice sites . HoweverAnother fundamental aspect of eukaryotic mRNAs is that they bear terminal features that are not specified by the genome, that is, a 5′ cap and 3′ polyadenylate (pA) tail. These untemplated sequences protect mRNAs from degradation by a variety of professional exoribonucleases that destroy uncapped and/or untailed mRNAs. On the 3′ end, the cleavage and polyadenylation (CPA) machinery first identifies appropriate cleavage locations within primary transcripts, thereby separating the nascent RNA from RNA polymerase II, and subsequently adds the pA tail . These cAs with splicing, a similar puzzle exists as to how specificity of 3′ mRNA cleavage is achieved. The known PAS signals are themselves insufficient to explain accurate cleavage only at the 3′ ends of transcripts because 3′ UTRs and especially introns are enriched in AU sequences. Thus, numerous PAS-like sequences must seemingly be ignored by the CPA machinery to generate full-length mRNA. This specificity is explained in part by additional motif information located in the vicinity of bona fide 3′ cleavage sites, including upstream UGUA (recognized by the CFIm complex) and downstream U/GU (recognized by CstF complex) . HoweverBecause introns can be extremely long, they contain not only fortuitous splice site matches but also cryptic polyadenylation signals. Inappropriate action of the CPA machinery within an intron will create an alternative gene product with a distinct 3′ UTR from the downstream model, and high likelihood of encoding a truncated protein that may also bear a foreign C-terminus. One strategy to prevent this is “telescripting,” whereby U1 snRNP protects elongating Pol II from premature CPA . In partA single classification of IPA belies the complexity of functional outcomes on these alternative transcripts, and these can generate either 3′ terminal extensions of an existing exon or enable splicing into a distinct 3′ terminal exon . In any In some cases, fortuitous IPA events will generate a truncated transcript containing arbitrary sequence . A typicNumerous laboratories and researchers are dedicated to unraveling the molecular strategies and mechanics of splicing and 3′ formation, simply in a constitutive fashion. However, the complexity of alternative mRNA splicing and 3′ formation events raises even more challenges. There is already seemingly not enough primary sequence information to distinguish “intended” processing events from the forest of “illegitimate” matches to splicing and polyadenylation signals. Given this, how can alternative splicing AS,  and APA It is instructive to frame the breadth of these questions. If there were only a few AS and APA events, it might suffice to invoke specific regulatory phenomena at those loci. However, the advent of widespread genomic profiling has led to the realization that higher eukaryotes make extraordinarily broad use of both AS and APA. Indeed, available data from 15 yr ago revealed that the vast majority (>90%) of mammalian multi-exon genes undergo alternative splicing . This prThe long history of developmental biology studies has revealed a constellation of cell types that emerge from divisions of the fertilized egg, which must differentiate properly and assemble into distinct tissues and organs that underlie a functionally mature organism. The diversity of recognized cell types continues to increase with the application of technologies such as single-cell RNA sequencing (scRNA-seq). This technique promises to reveal “all” cell types and cell states, perhaps in the end revealing that every living cell is quantifiably a little different from every other. Although all researchers can debate what the most interesting cell types are, it is without question that neurons comprise one of the most diverse subclasses of cell types . This caDiversity alone may suffice to explain the need for highly regulated gene expression in neurons. Many neural-specific genes, and accordingly neural-specific transcript isoforms, are required for distinct fates and/or maturation. Beyond this, neurons exhibit many unique properties that impose specialized regulatory requirements, beyond what exists in non-neural cell types. For example, neurons are famously the most polarized cell type of all and can be meters long in some animals. Accordingly, there must be strategies to transport transcripts to appropriate locations in neurons and for them to be subject to differential regulatory outcomes . Moreover, the unique physiology of neurons, coupled with their long lifespan encompassing the lifetime of the individual, likely underlie exceptional regulatory needs of neurons. Consistent with these notions, alternative splicing is especially prevalent in the nervous system , and neuHow are neural-specific programs of alternative isoforms implemented? Most evidence suggests that core spliceosome and CPA mechanics are similar across cell types, and certainly, numerous splice sites and pA sites are constitutive. Nevertheless, there are many reasons why these mRNA-processing machines may have differential activity on identical sequences in different cell types, such as cellular concentration of these complexes, the dynamics of RNA polymerase II, and especially, the influence of transacting factors. With respect to the latter, neurons might uniquely express factors that enable them to recognize mRNA-processing sites unavailable to other tissues, or alternatively, to suppress universally used sites. Both strategies can yield similar outcomes, and may work together.Although broadly expressed factors can clearly regulate cell-specific processes, RBPs that are specifically expressed or excluded from neurons comprise logical candidates for neural isoform regulators. Indeed, cell-specific RBPs that regulate neural splicing include members of the ELAV/Hu, Nova, Mbnl, Rbfox, Ptbp, CELF, and SRRM3/4 families, along with other factors such as TDP-43 . These fAlthough genetic data by itself does not rule out indirect effects, many of these RBPs bind specifically in the vicinity of alternative exons, often within flanking intronic regions, suggesting they directly guide isoform selection. However, manipulation of many of these factors can alter both exon inclusion and exclusion events. Can the same factor achieve opposite mRNA-processing outcomes? Although rules are not absolute, the positional binding of RBP-splicing regulators can be correlated to functional outcome. These principles were revealed by computational prediction of conserved RBP motifs and with cross-linking and immunoprecipitation (CLIP) maps of RBP occupancy. For example, with both Nova  and RbfoDrosophila GCAUG. Strikingly, CLIP assays of Rbfox in the soluble nuclear fraction showed preferred association with 3′ UTRs, but CLIP data from the high molecular weight nuclear fraction showed its predominant association within introns in the vicinity of regulated exons, and overlapping consensus sites . This suRecently, the LASR complex was extended to include the Rett syndrome factor methyl-CpG–binding protein 2 (MeCP2), with evidence that MeCP2 disease mutants impair recruitment of Rbfox to LASR accompanied by defective splicing of Rbfox targets . In addiThese seem to embody general principles. First, alternative splicing of other splicing factors  serves to include exons that encode disordered, tyrosine-rich regions that mediate multivalent assemblies . InteresA specialized type of neural-preferred splicing concerns microexons . OperatiMicroexons present special mechanistic challenges for splicing, as they verge on the limits of concurrent occupation of 3′ and 5′ splicing complexes for exon definition. Their small size also presents limited sequence space to encode desired amino acids and exonic splicing enhancers to promote their inclusion. However, a potential clue as to the regulation of microexons comes from their preferred inclusion in neurons, either as constitutive exons of neural-specific genes or as alternatively spliced neuron isoforms . This suIndeed, several neural-splicing regulators mentioned above, including Rbfox, PTBP1-2, and nSR100/SRRM4, are also involved in neural microexon splicing  Irimia . For exaHow does SRRM3/4 achieve specificity? It turns out that their target exons generally have weaker 3′ splice sites with weaker polypyrimidine (U/C) tracts, and also bear PTBP-binding sites, which along with their unconventional length makes them prone to skipping . InteresCaenorhabditis elegans and mammals , whereas fne mutants are relatively normal; however, the elav/fne double-mutant deregulates nearly 1,000 neural alternative splicing events .To what extent do RBP paralogs harbor intrinsically distinct functions? Or, could their separable genetic requirements be explained simply by differential expression? In the case of Ptbp1/2, some exons exhibit differential sensitivity in selected assays . Howevert others . In addic rescue . Thus, tDrosophila ortholog SRRM234 but is only expressed in neural isoforms as a consequence of ALE splicing  or perhaps other factors yet to be identified.Only recently it was determined that the family of neuronal ELAV/Hu RBPs globally instructs the generation of neural-extended 3′ UTRs in osophila . These s isoform  Drosophiltensions . Thus, tDrosophila Elav does not seem to displace CstF or CPSF  are certainly prime suspects. In fact, this family was previously shown to promote 3′ UTR extension of the HuR gene itself , and HuCet sites , and avaDrosophila involved switching from proximal to distal ALE isoforms in neurons at the erect wing and neuroglian loci . Astonishingly, this allele is homozygous lethal at early postnatal stages, accompanied by selective misexpression of Bak1 proteins in the brain and ectopic neural apoptosis  animals exhibit selective behavioral alterations in social paradigms, along with increased transmission at inhibitory synapses and increased levels of certain synaptic proteins (eIF4G1(∆MIC) mutants  example. Although alternative splicing of the former effectively silences this isoform in neurons via NMD, alternative splicing of the latter alters the functionality of neural eIF4G isoforms, outlining a paradigm by which the function of essential, ubiquitous factors can be modulated in a cell-specific manner.Together, this work provides a converse situation to the Drosophila longitudinals lacking (lola) locus is required in several tissue settings, but lola mutants were first isolated on the basis of neural differentiation defects  impairs certain aspects of neural development and function  houses one of the Hox gene clusters, and notably contains three homeobox genes that govern abdominal segment identities  exhibits normal external patterning , the most overtly misexpressed protein is the Hox cofactor homothorax (Hth)  , 2020.hth is predicted to be heavily targeted by conserved binding sites for both miR-iab-4/8, many of these are located in its neural-specific 3′ UTR extension  mutant virgin females also adopt mated behaviors. Moreover, this could be directly traced to failure of neural APA-mediated repression because deletion of the hth neural 3′ UTR  largely phenocopied the hth(∆miR) allele  allele . AltogetThe neural transcriptome is highly diversified in multiple ways that are unique to this celltype and likely underlie the unique attributes and properties of neurons. Although the community has made great insights into how this is accomplished, we are still some ways from a complete understanding of its complexity. Even though there has been great progress using deep learning to predict the “splicing code” , we are Most of the mechanisms discussed in this review regard strategies by which the selection of alternative splicing sites, and of APA sites, is executed locally and independently. If and how these isoform programs are coordinated is not fully understood, but the application of long-read sequencing permits coordinated splicing events  and coorFinally, it is worth considering whether aspects of documented isoform complexity might reflect errors . Althoug


Cell, Wang et al. demonstrated a novel method of somatic adeno-associated virus (AAV)-transposon in vivo clonal screening (termed MOSAICS), which is capable to generate multiple mutant hepatocyte clones within the same tissue and thereby to scan for non-alcoholic steatohepatitis (NASH) target genes  is the most common liver disease affecting about 20–30% of the global population and associated with metabolic dysfunction. NAFLD can progress to NASH, characterized by liver inflammation, steatosis and hepatocyte ballooning, and NAFLD/NASH can lead to fibrosis, cirrhosis, and ultimately liver cancer. For decades, researchers have been seeking to understand its pathogenesis and to discover therapeutic strategies to treat NAFLD/NASH. However, up to now, there is still no specific pharmacotherapy available.2 Therefore, MOSAICS as an experimental approach to screen for somatic mutations that protect cells from metabolic injury in NAFLD could be valuable to uncover potential therapeutic targets. The unique vector designed for MOSAICS made it possible to quantify the single guide RNA (sgRNA) expression that is integrated into the cell genome and thereby measuring clone expansion. Utilizing this method, the authors found several previously undiscovered NASH-related genes, the deletion of which prevented hepatocytes from western diet-induced cell injury and improved liver steatosis.1Somatic mutation is a non-heritable gene mutation that occurs in aged or chronically injured somatic cells, and this phenomenon is also observed in NAFLD patient livers. It has been suggested that somatic mutations are an adaptive mechanism that renders the mutated cells  resistant to insults.Mboat7), in western diet-induced mouse NASH models. They first identified that whole-liver knockout of Mboat7 exacerbated steatosis and liver injury.1 Next, to mimic somatic mutations in the liver, they generated small clones of Mboat7−/− hepatocytes marked by fluorescent proteins by low-dose injection of AAV serotype 8-TBG-Cre. They found that these mutant clones were more vulnerable to the western diet-induced injury, and the clone size decreased dramatically, indicating that cells with these somatic mutations do show different responsiveness to injury.1As a start, the authors tested the effect of somatic mutation of a well-known NASH-related gene, membrane bound o-acyltransferase 7  that promoted clone expansion when deleted.1 These genes have been found involved in lipid metabolism and pathogenesis of fatty liver diseases.To discover somatic mutations in fatty liver in a more high-throughput way, the authors screened out 63 candidate genes from the sequencing database that might play a role in the pathogenesis of NASH. Then, they designed sgRNA libraries and generated somatic mosaic livers with mutant clones of all the candidate genes in each mouse followed by NASH modeling. By measuring clone expansion and sgRNA expression, the authors identified five top-ranked genes  and Smyd2 (epigenetic factor) resulted in the most significant reduction of liver injury and steatosis, even though Tbx3 and Smyd2 have not been linked to NAFLD/NASH pathogenesis before. RNA-sequencing further disclosed altered hepatic gene expression profiles, which partly overlapped in the liver of these knockout mice, especially in lipid metabolism, inflammation and fibrosis pathways.1 Finally, to verify the therapeutic potential of these newly discovered NASH genes, the authors tested the effect of AZ505, a selective SMYD2 inhibitor, in the western diet mouse model. Intraperitoneal administration of AZ505 significantly reduced liver mass and improved liver steatosis compared to the control group.1Although somatic mutations impacted the susceptibility of mutant hepatocyte clones to lipotoxicity in NASH models, it is unknown whether these cellular or clonal mutations have the same effect at the tissue or organ level. To detect whether the whole-liver deletion of these non-canonical NASH genes can achieve amelioration of liver steatosis, the authors generated 20 knockout mouse strains with the deletion of each of the transcription or epigenetic regulators of interest. Among them, over half presented with decreased liver weight upon challenge with western diet. Surprisingly, knockout of 3 In fact, deleting the discovered genes significantly reduced liver steatosis, but showed rather limited effects on liver fibrosis.1 Antifibrotic therapy for NASH is challenging yet crucial, as inflammation and fibrosis are main drivers of patient-related outcomes in NAFLD/NASH.4 Thus, targeting a distinct pathway globally in the liver may not be suitable to substantially halt inflammation or fibrosis, as compared to cell-type specific approaches. Similarly, deleting a gene (or gene variant) in the liver may have systemic consequences, as demonstrated for the natural E167K variant of TM6SF2. This TM6SF2 variant favors lipid accumulation in hepatocytes by decreasing lipid secretion, while protecting the body from adverse cardiovascular effects of circulating lipids.5 The validation of any interventions predicted from the MOSAICS screen would need to pay particular attention to these outcome-relevant hepatic and extrahepatic consequences, including hepatic fibrosis, hepatocarcinogenesis, circulating lipid profiles and cardiovascular risk.Taken together, the authors described an innovative in vivo platform, MOSAICS, to generate mosaic liver harboring various somatic mutant hepatocyte clones. They applied this platform to screen genes that affect clonal fitness in NASH models and validated the effect on the NASH phenotype in whole-liver knockout mice for selected gene targets. These findings may indeed facilitate the identification of new therapeutic targets and strategies. However, by design, this approach will primarily identify genetic and epigenetic pathways related to metabolic injury in hepatocytes, while important pathogenic pathways activated in non-parenchymal cells—e.g., the matrix-producing activated hepatic stellate cells as main drivers of liver fibrosis—and/or in immune cells, which define the transition from steatosis to NASH, will remain concealed.Cell paper by Wang and colleagues represents a fresh and rational approach to drug discovery, its successful translation into novel therapeutics for NAFLD is yet to be demonstrated.Nonetheless, understanding cellular adaptations to injury by somatic mutations certainly advances our understanding of NAFLD pathogenesis. In addition, as loss of functional hepatocytes is a common consequence of most liver disorders, it might be interesting to test the MOSAICS platform on other liver diseases, such as genetic disorders, drug toxicity or alcohol-related liver disease, to identify unexpected genes related to hepatocyte fitness in different pathological milieus. While the


The diagnosis of isolated spinal cord lesions is often challenging in clinical practice, and it is not uncommon for the etiology of such isolated lesions to remain unclear despite extensive workup and investigations. Magnetic resonance imaging (MRI) is extensively utilized for assessing spinal cord disease, despite certain radiological patterns suggesting certain pathologies, diagnostic uncertainty remains. Development of adjunct tests and techniques, radiographic or otherwise, is needed. Here, we present two cases in which flexion-extension cervical spine MRIs improved diagnostic ability by demonstrating dynamic cervical cord compression as an etiology for isolated intramedullary cervical spinal cord lesions. Magnetic resonance imaging (MRI) is the preferred imaging modality for the spinal cord, but isolated spinal cord lesions presenting as hyperintense intramedullary signals on T2-weighted imaging generally do not confer enough specificity to make a diagnosis. Clinical evaluation is paramount and remains the cornerstone of the workup of spinal cord lesions, as it helps in narrowing the differential diagnosis. Spinal cord lesions can occur in the setting of neuroinflammatory diseases such as idiopathic transverse myelitis and multiple sclerosis, metabolic conditions, neoplastic disease, or intrinsic structural pathologies. However, extrinsic compression is a common cause of intramedullary T2 signal abnormality and may not always be readily apparent on routine spine imaging. Flexion-extension studies may demonstrate intermittent spinal cord compression, and this should be considered in the differential of isolated cervical cord lesions.Case oneA 40-year-old man with no significant past medical history was referred to the neurology clinic for a three-year history of constant, non-painful numbness affecting both feet, up to the ankles bilaterally. His symptoms were worsening gradually over the previous year. The neurological examination was significant for mildly reduced sensation for light touch and temperature, with moderately reduced vibration and proprioception in a stocking-like distribution up to the lower shins, and with mild lower extremity hyperreflexia. Cranial nerves, motor power, and gait were all normal. MRI of the brain and thoracic spine were unremarkable. MRI of the cervical spine showed an isolated T2-hyperintense lesion involving the right spinal cord at the level of the C4-C5 disc associated with mild enhancement that was deemed potentially suggestive of neuroinflammatory etiology Figure . There wExtensive workup including infectious, nutritional, and autoimmune panel was negative . The Mayo serum autoimmune myelopathy panel (Mayo Labs Test ID: MAS1) was negative. Cerebrospinal fluid (CSF) analysis demonstrated a mildly elevated protein of 54 mg/dL (reference range = 15-45 mg/dL), with no pleocytosis and absent oligoclonal bands. Nerve conduction studies and electromyography showed reduced right radial sensory amplitude, absent sural, and superficial fibular responses suggestive of peripheral neuropathy. Further workup of neuropathy demonstrated positive antibodies to trisulfated heparin disaccharide suggestive of peripheral neuropathy.While peripheral neuropathy was deemed likely to be the cause of the patient’s symptoms, the etiology of the patient’s isolated spinal cord lesion remained unclear. Given the presence of mild spinal stenosis without cord compression on MRI with a neutral neck position, a dynamic MRI of the cervical spine with neck flexion and extension was performed Figure . The extCase twoA 46-year-old woman with a history of rheumatoid arthritis presented to the neurology clinic complaining of neck pain radiating to the right upper extremity associated with an unsteady gait. The patient reported that the pain originally began 10 years prior, following a motor vehicle accident, and initially subsided with physical therapy. The pain then became worse and more persistent over the previous two years radiating to the right upper extremity and associated with weakness in the right arm and hand. The neurologic examination was significant for symmetric hyperreflexia in the lower extremities and extensor plantar response on the right, in addition to mild weakness with right wrist extension and finger abduction.Brain MRI demonstrated scattered nonspecific small T2 hyperintensities Figure . MRI of Workup including aquaporin-4 antibody, double-stranded DNA, Sjogren’s syndrome antibodies (SSA and SSB), antinuclear antibody (ANA), and Mayo serum autoimmune myelopathy panel (Mayo Labs Test ID: MAS1) was unrevealing. Vitamin B12, vitamin D, ceruloplasmin, and complement levels were within normal limits. Serum copper levels were minimally elevated which normalized on repeat testing. CSF analysis was unremarkable, demonstrating the absence of oligoclonal bands. Given the unrevealing workup, the patient was observed without intervention.Several months later, she developed left hand, torso, and left leg numbness. Given the progression of her symptoms and concern for congenital stenosis, a repeat MRI of the cervical spine was performed, this time with neck flexion and extension protocol, which demonstrated stability of the T2 hyperintensities, but with substantial spinal cord compression at C3-C4 and C4-C5 upon neck extension Figure . As the Degenerative cervical myelopathy, an age-related condition of the cervical spine, can cause significant neurologic dysfunction. MRI plays an essential role in the evaluation of suspected myelopathy and helps with identifying underlying etiology. Hyperintense intramedullary signals on T2-weighted imaging are nonspecific and may be due to ischemic, infectious, inflammatory, demyelinating causes , as wellIn the first case, the patient’s clinical presentation was typical for neuropathy, and was highly atypical for a demyelinating process such as multiple sclerosis (MS), with absent lesions on brain MRI. The cord lesion noted did not fully explain the patient’s symptoms. However, given the preserved and relatively increased reflexes noted on the examination, a superimposed myelopathy was suspected. The patient’s initial MRI did not clearly demonstrate compression; however, dynamic MRI with flexion and extension demonstrated compression upon extension which explained the hyperintense signal within the cord. Eventually, further evaluation led to an underlying etiology for the neuropathy which was the most likely cause of his symptoms. Investigation for inflammatory etiologies of his spinal cord lesion, which was ultimately deemed a “red herring,” led to delayed testing and diagnosis of his neuropathy.In the second case, although the hyperintense lesions in the spinal cord led to concern of demyelinating disease, brain MRI and CSF analysis were not suggestive of MS or any other central nervous system neuroimmune condition. Dynamic cervical MRI with flexion and extension demonstrated cervical cord compression that was not apparent on the initial MRI, and the patient had significant improvement in symptoms after surgical decompression.Compressive myelopathy typically exhibits focal T2 hyperintensity in the cord at the level of spinal stenosis with or without associated enhancement . DespiteThis case series highlights the need for considering compressive etiology for isolated intramedullary cervical spinal cord hyperintense lesions before more invasive diagnostic testing. Flexion and extension MRI of the cervical spine can be used to evaluate isolated cervical spinal cord lesions seen on static MRI before further workup for other causes such as demyelinating disease. While extension exacerbates spinal compression due to the reduction in spinal canal dimensions, flexion can also intensify certain compression scenarios mainly in severe degenerative disc disease. Integrating flexion and extension MRI can accelerate the detection of compressive causes, minimizing invasive procedures and enhancing patient outcomes via timely intervention.


Modern medical imaging systems provide ever-more information about the patient’s health condition. Precision, resolution, and sensitivity are increasing, and new possibilities of differentiating the condition of tissue appear. Such advances are also taking place in musculoskeletal imaging. Ever-more accurate imaging in various modalities allows us to discover new relationships between the image and the diagnosis. It is, therefore, important to use all this information to best serve the patient, hence research related to the analysis of medical images is so important, because it allows us to indicate what is invisible to the naked eye or quantify what has so far been measured by humans or subject to discretionary assessment.This collection includes 25 works related to the analysis of images created during diagnostics of the musculoskeletal system using various modalities, starting with X-ray and fluoroscopy, before moving onto conventional or spectral computed tomography, magnetic resonance imaging, ultrasound, and elastography and PET/CT and ending with systems for analyzing patient mechanics. Research was carried out related to the detection of various conditions, parameterization of clinical and population phenomena, and detection of image–clinical condition relationships. Despite the current popularity of machine learning techniques , the colRecently, radiomics has played an increasing role in analysis of biomedical images, being a tool for the quantitative description of digital image content. Radiomic features can be divided into histogram-based, texture-based, and shape-based features . Of mostIn ,9, the rResearch described in  aimed toThe author of  investigp-value of 4.95 × 10−14. The primary revelation from this investigation is that age-related structural variations in the femoral neck region are more profound compared to other femoral components. By understanding the correlations between textural features in X-ray images and age, physicians can make more informed diagnoses linked to bone health- and age-related changes. The methodology proposed can be pivotal in enabling the early identification of osteoporosis. Early detection enables timely interventions, which can improve outcomes and reduce the risk of fractures.The objective of the research presented in  was to dAnother paper  considerFor patients with medial open-wedge high tibial osteotomy (MOWHTO), unintended distal tibial rotation is observed . While cOne potential benefit for physicians is that the EOS system, being a low-dose imaging modality, exposes patients to significantly less radiation compared to standard CT scans. This allows physicians to more frequently order imaging if required without subjecting patients to high radiation doses. Three-dimensional limb modeling gives physicians a comprehensive view of the limb, which could be essential for surgical planning and assessment. Automation feature in EOS can potentially save physicians time, as manual measurement can be time-consuming and prone to human error. As the study suggested that there was negligible variation between CT and EOS in terms of capturing pre- and post-operative changes, physicians can feel confident using the EOS system as a reliable diagnostic tool. Lower radiation exposure and potentially shorter imaging time can enhance the patient’s comfort and experience, which indirectly benefits the physician by facilitating easier patient management and improved patient compliance. Depending on the physical setup and equipment requirements, the EOS system might offer benefits in terms of space utilization or ease of operation compared to traditional CT systems. Incorporating advanced imaging technologies like the EOS system can enhance the systems’ diagnostic capabilities, patient care, and operational efficiency for physicians.p < 0.001). Individual bone compartments demonstrated sensitivities ranging from 86.7 to 93.8% and specificities ranging from 84.2 to 94.1%. Positive predictive values varied from 82.4 to 94.7%, while negative predictive values were between 87.5 and 93.3%. The proposed TMD method offers robust diagnostic accuracy in detecting BME in extremities, suggesting its potential as a routine diagnostic tool in emergency scenarios.Bone marrow edema (BME), indicative of acute fractures, is difficult to discern using traditional computed tomography (CT) scans . The effThe TMD method on SCT provides high sensitivity and specificity, enabling physicians to make confident and accurate diagnoses of BME and acute fractures. With a reliable method to detect BME, physicians can quickly determine the best course of treatment for patients, potentially leading to faster recovery times. Given the highlighted potential of this approach in emergency situations, it could be invaluable for physicians in these settings, where time-sensitive decisions are crucial.T2 mapping has been studied for its capability to detect and quantify anomalies in the long biceps tendon (LBT) . The resPhysicians can benefit from the study because the clear distinction between healthy and pathological tendons, as demonstrated by the T2 values, allows early and accurate diagnosis of tendon anomalies. With specific T2 values associated with healthy and pathological tendons, physicians can quantitatively track the progress of treatments, whether conservative or surgical.Hydroxyapatite deposition disease (HADD) is a complex condition marked by the deposition of hydroxyapatite crystals in soft tissues, resulting in inflammation and pain . This reThe review provides a holistic understanding of HADD, ranging from its etiology to treatment, allowing physicians to deepen their knowledge of the disease. By understanding the radiological findings and the potential of HADD to mimic other diseases, physicians can make more accurate diagnoses, reducing the chance of misdiagnosis.p ≤ 0.014). Remarkably, the reduced-dose Br76 exhibited a CNR comparable to the full-dose Br84 (p > 0.999) and surpassed Br98 (p < 0.001) across all tissues. Utilizing a photon-counting detector CT for ankle arthrography with ultra-high-resolution collimation offers remarkable image clarity and detailed tissue analysis, augmenting the inspection of intricate anatomical structures. While osseous structures were best depicted using an ultra-sharp convolution kernel, soft tissues notably benefited from a convolution kernel with a reduced spatial frequency.The objective of study  was to eThe ultra-high-resolution capability ensures that the clinician obtains unparalleled clarity in images, essential for discerning minute anatomical variations or potential pathology. The flexibility to choose between different convolution kernels based on spatial frequencies means that clinicians can optimize image quality based on the specific tissue or structure that they are investigating. The capability of the reduced-dose (3 mGy) Br76 to offer comparable CNR to the full-dose Br84 and even surpass Br98 indicates that clinicians can achieve high-quality images while reducing radiation exposure to the specimen or patient.Study  probed tThe ability of T2 mapping to distinguish between healthy labral substances and SLAP lesions with high sensitivity and specificity provides physicians with a reliable diagnostic tool. This helps in performing accurate assessment, reducing the risk of misdiagnosis. Before the potential confirmation via arthroscopy, T2 mapping offers a non-invasive method to detect SLAP lesions. This can save patients from unnecessary invasive procedures and related complications.Shear wave elastography (SWE) is an emergent diagnostic modality employed to discern tissue abnormalities . Within Thanks to performed research, physicians have improved their understanding of how differential stiffness in Achilles tendons based on gender and sport specificity can refine diagnostic accuracy, ensuring that anomalies are not just dismissed as sport- or gender-related norms. By being aware of the normal stiffness ranges for different groups, clinicians can more effectively identify individuals who might be at increased risk of injuries or other tendon pathologies. For interventions such as physiotherapy or surgical procedures, a clear understanding of typical stiffness values can guide treatment modalities and expected outcomes, ensuring optimum patient care.Study  providesThe analysis of the differential muscle deformation and force at various ankle angles can guide rehabilitation exercises, strength training, and sport-specific training to optimize performance and reduce injury risks. The identification of increased force generation at dorsiflexion ankle angles due to higher fiber cross-section deformation asymmetry and higher shear strains can guide clinicians in prescribing exercises or interventions, ensuring that the foot’s position is optimized to achieve specific therapeutic goals.Study  aimed toIt was demonstrated that TS provides improved sensitivity in detecting emerging or enlarging ectopic bone lesions, especially in conditions like fibrodysplasia ossificans progressiva (FOP). This can facilitate earlier intervention or treatment adjustments. By leveraging the augmented ability to detect changes over time using TS, physicians can make more informed decisions regarding treatment plans, allowing tailored interventions based on the progression of the condition. By comparing changes over time in one set of images, physicians can quickly identify areas of concern without having to manually compare previous and current scans.Study  was desiPhysicians can provide evidence-based recommendations on pillow choice to patients presenting with forward head posture (FHP) based on their preferred sleeping position. This can enhance the therapeutic interventions designed for patients with neck or spine issues. Understanding the relationship between pillow material, sleeping position, and spinal alignment enables physicians to tailor advice and treatments for individual patients, optimizing outcomes.Study  sought tThe study resulted in the authors understanding the kinematic differences between injured and non-injured female futsal players that physicians must consider. They can identify at-risk players by observing their motor patterns during specific movements. This allows early intervention strategies, possibly preventing further injuries. For players recovering from knee injuries, the findings can guide physiotherapy and rehabilitation interventions, emphasizing the importance of achieving more physiological positions during movement to avoid the valgus collapse mechanism.Percutaneous plasma disc decompression (PPDD) serves as a minimally invasive intervention strategy for discogenic lumbar pain and symptoms related to disc herniation . Yet, thUnderstanding the potential role of epidurography as an outcome predictor can aid clinicians in making better-informed treatment decisions. If a patient demonstrates epidurographic improvement, they may be more likely to benefit from PPDD. Using epidurography as a predictive tool, physicians can better identify which patients are more likely to benefit from the procedure, leading to higher treatment success rates. By recognizing the potential end-point of the PPDD procedure through epidurography, doctors can avoid over- or under-treating, leading to optimized results and reduced patient discomfort or risk of developing a worsened condition.The diminished thickness of the temporal muscle (TMT) has been identified as an adverse prognostic factor in patients with brain tumors . SeparatThe Identification of temporal muscle thickness (TMT) as a potential prognostic indicator can help physicians to quickly stratify patients based on the risk of poor outcomes. Understanding which patients are more vulnerable allows more informed clinical decision-making. Understanding the association between reduced TMT and outcomes such as hematoma volume and post-operative performance can guide surgeons in their approach, post-operative care, and setting realistic expectations for patients and their families.The primary goal of this research was to scrutinize and juxtapose ultrasonographic findings in the nails and entheses of patients diagnosed with psoriasis and psoriatic arthritis . DispariThe use of ultrasonography for the examination of nails and entheses can assist in the early detection of abnormalities in patients with psoriasis and psoriatic arthritis. This is vital for making a timely and accurate diagnosis. Understanding the variations in ultrasonographic findings between psoriasis and psoriatic arthritis allows physicians to design more tailored treatment plans based on the specific condition and its severity.Intraoperative CT-navigation (iCT-navigation) has shown efficacy in enhancing the precision and safety of transpedicular screw insertion during primary spinal operations . NonetheThe study illustrates that iCT-navigation can enhance the precision of screw placements, even in revision sites, which are traditionally more challenging due to the disrupted anatomy. The utilization of iCT-navigation appears to reduce the risk of complications, as evidenced by the lack of neurological injuries in the patients studied. The iCT-navigation allows the instantaneous identification of unaccepted screws, permitting their immediate adjustment during the same operation, potentially reducing the need for further revision surgeries.Titanium trabecular cages (TTCs) have been developed as promising implants with the intent to ensure both immediate and long-lasting spinal stability via rapid osseointegration . HoweverThe study provides clinicians with valuable insights into the reactive bone behavior adjacent to titanium trabecular cages (TTCs) used in lumbar interbody fusion surgeries. This knowledge may aid in better understanding the osseointegration process and inform surgical planning, potentially leading to improved patient outcomes. The use of 18F sodium fluoride (18F-NaF) PET/CT as a tool to assess metabolic–reparative reactions offers clinicians a scientifically rigorous approach to evaluate the success of implantation. This evidence-based assessment can guide clinical decisions related to patient management and treatment adjustments.Study  introducThe introduced schema serves as an additional support tool for radiologists in COVID-19 diagnosis. It assists radiologists by offering a structured method for evaluating X-ray images and potentially reducing the workload associated with manual image interpretation. The lightweight nature of the approach allows the quick processing and analysis of X-ray images. This speed can significantly expedite the diagnostic process, enabling doctors to promptly make informed decisions about patient care.An innovative technique for conducting cervical interlaminar epidural steroid injections (CILESIs) guided via ultrasound (US), which eliminates the reliance on the loss-of-resistance approach for identifying the epidural space, was presented in .The employment of this novel ultrasound-guided technique for cervical interlaminar epidural steroid injections (CILESIs) offers physicians increased accuracy and precision during the procedure. The direct visualization of anatomical structures aids in precise needle placement, minimizing the risk of complications and optimizing treatment outcomes. The use of ultrasound imaging allows physicians to monitor the administration of injectable substances in real time, ensuring that the medication is delivered accurately and without causing inadvertent damage to surrounding tissues. This heightened level of safety can lead to a decrease in adverse events and complications associated with cervical epidural injections.Antegrade intra-medullary (IM) nailing remains the typical treatment for femoral shaft fractures, yet non-union rates remain high for infra-isthmal femoral shaft fractures based on this approach . Thus, aThe results of this retrospective case–control study provide physicians with valuable insights into the radiographic risk factors associated with non-union after antegrade intra-medullary (IM) nailing for infra-isthmal femoral shaft fractures. Armed with this knowledge, physicians can make more informed treatment decisions by considering these risk factors and tailoring their approach to reduce the likelihood of non-union. By understanding the radiographic elements that contribute to non-union, physicians can adopt strategies to mitigate these risks during the treatment process. This proactive approach can lead to improved patient outcomes, reduced complications, and enhanced recovery rates, thereby bolstering the physician’s reputation and patient satisfaction.We hope that all readers will appreciate this Special Issue and that the collection of the articles will be useful in a clinical or scientific way, as well as inspire further investigations into the domain of musculoskeletal imaging. We would also like to encourage doctors to use various quantitative image processing and analysis methods and expand cooperation with computer scientists and biomedical engineers in this area. New information obtained thanks to such analyses will improve the efficiency and repeatability of the diagnostic process.


Among the complications of orthodontic treatment, mucogingival problems with gingival recession in the mandibular anterior teeth are challenging for clinicians. Mucogingival problems can lead to esthetic deficits, thermal hypersensitivity, tooth brushing pain, and complicated plaque control. Herein, we present a case of a 16-year-old female with gingival recession in the left mandibular central incisor after orthodontic treatment. The preoperative clinical findings showed a thin soft tissue biotype with root prominence in the mandibular anterior area. The interdental area was relatively depressed. After reflection of the full-thickness flap, root coverage using a bone graft substitute and subepithelial connective tissue graft obtained from the palatal mucosa was performed. The 6-month and 5-year postoperative clinical findings showed improved soft tissue phenotype. The cross-sectional CBCT scans 5 years after surgery showed a well-maintained labial bone plate in the mandibular incisors. Within the limitations of this case report, for patients with gingival recession in the mandibular incisors after orthodontic treatment, a successful biotype modification can be achieved with a combined procedure using subepithelial connective tissue graft with bone graft substitutes. Gingival recession is associated with attachment loss and exposure of the root surface to the oral environment . GingivaVarious techniques including a free gingival graft, a subepithelial connective tissue graft, and a coronally advanced flap have been introduced for increasing the width of keratinized mucosa or covering the denuded root surface ,12. In rAlthough various techniques have been used for the treatment of gingival recession after orthodontic treatment ,20, to tA 16-year-old female sought esthetic improvement of the mandibular anterior area. She was referred to our clinic to treat gingival recession of the lower anterior teeth. Clinically, a severe gingival recession on the lower left central incisor was observed. The patient had no history of systemic diseases. She had an orthodontic treatment to resolve mandibular anterior crowding. She had undergone orthodontic treatment for about 2 years.The preoperative clinical findings showed a thin soft tissue biotype with root prominence in the mandibular anterior area. The interdental area was relatively depressed a. GingivSigns of slight inflammation with supragingival plaque and calculus were observed before surgery a. Under The clinical outcomes 6 months after surgery showed reduced gingival recession of the lower left central incisor. In addition, soft tissue phenotype was improved. Color discrepancy was not observed, but some interdental space with supragingival plaque and calculus was observed a. The 5-The cross-sectional CBCT scans 5 years after the surgery showed well maintained labial bone plate at the midfacial side of the lower right and left central incisors a,b. On tThe present case showed a successful clinical outcome of a subepithelial connective tissue graft and bone graft procedure performed on the lower incisors with thin periodontal biotype and gingival recession after orthodontic treatment. In addition, the cross-sectional CBCT scans showed that the interdental concavity was augmented with bone graft substitutes combined with a subepithelial connective tissue graft.Gingival recessions in the lower anterior teeth after orthodontic treatment are challenging for periodontists. Gingival recession may compromise outcomes of orthodontic treatment and adversely affect dentofacial esthetics or cause tooth hypersensitivity . Animal In addition, Wennström emphasized the importance of proper plaque control before, during, and after orthodontic treatment . In the In several root coverage procedures, a coronally advanced flap with a subepithelial connective tissue graft is considered the gold standard ,13. In aWe did not perform a root conditioning procedure before using a subepithelial connective tissue graft with bone substitute. Various root modifiers including different root conditioners, lasers, EMD, recombinant human growth factors, and platelet-rich plasma have been used to improve the healing process and increase the success rate of root coverage . There iIn addition, bone graft substitutes were used to reduce interproximal concavity. For dehiscence-type defects, an animal study showed that biphasic hydroxyapatite + beta tricalcium phosphate (ß-TCP) or deproteinized bovine bone mineral may provide an osteoconductive scaffold to support guided bone regeneration procedures . In addiWithin the limitations of the present case report, for patients with thin soft and hard tissue phenotype of the mandibular anterior region and gingival recession that occur due to complications of orthodontic treatment, a successful periodontal phenotype modification can be achieved with a combined procedure using a subepithelial connective tissue graft with bone graft substitutes. In addition, interdental concavities between the lower incisors were also improved.


Wide-awake local anaesthesia, no tourniquet (WALANT) has been reported for upper extremity procedures of varying complexities ranging from simple tendon repairs to more complicated soft tissue and bony reconstructions. Hemi-hamate arthroplasty under WALANT has yet to be described in English literature. We report a case of a chronic dorsal PIPJ fracture-dislocation who underwent open reduction followed by Hemi-hamate Arthroplasty under wide-awake anaesthesia. There was adequate visualization during the surgery with no additional anaesthesia required. Active intra-operative range of motion and joint stability testing was possible with no pain experienced throughout the procedure. 10-month post-operative follow-up showed excellent range of motion with occasional tolerable pain during maximal finger flexion and power grip. Wide-awake anaesthesia is a viable and safe alternative for hemi-hamate arthroplasty. Chronic injuries are more often unpredictable and various treatment options combined with open reduction such as bone grafting, volar plate arthroplasty, external fixation, and hemi-hamate arthroplasty have been described2. Wide-awake, local anaesthesia, no tourniquet (WALANT) was popularised by Lalonde3 and has been gaining increasing popularity especially during the time of the COVID pandemic4. Hemihamate arthroplasty using wide-awake anaesthesia has not yet been reported in English literature.Unstable Proximal Interphalangeal Joint (PIPJ) fracture-dislocations are common injuries that pose a unique and complex challenge for the treating hand surgeonWe present a patient who presented with a chronic PIPJ fracture-dislocation who underwent open reduction and hemi-hamate arthroplasty under wide-awake anaesthesia.A 27-year-old male, right-handed office worker came to our clinic for persistent pain and limitation of range of motion of their right middle finger after sustaining an injury during a basketball game 4 months prior. No previous consult was sought.On physical examination, the patient’s right middle finger PIPJ was noted to be slightly swollen with limited arc of motion from 0° to 20°. No neurovascular compromise was noted. Radiographs of the patient’s middle finger revealed a comminuted dorsal PIPJ fracture-dislocation involving approximately 40% of the articular surface . An openThe anaesthetic solution used was a buffered 1% lidocaine with 1:100,000 epinephrine. An ultrasound-assisted median and ulnar nerve block was performed by the surgeon using a wireless linear ultrasound probe  and was done at the mid forearm using 3ml of anaesthetic solution for each nerve. These nerve blocks are optional and may be omitted depending on the surgeon’s preference. Ten (10) ml of the same solution was then used to infiltrate the subcutaneous area and periosteum of the 4th and 5th carpometacarpal joint (CMCJ) followed by an additional 4ml for the volar surface of the middle finger . A total1. The size of the defect of the volar lip of the middle phalangeal base was measured which determined the graft size for the hamate. A longitudinal incision was then done over the dorsal wrist centred over the 4th and 5th CMCJ. The graft was harvested using an oscillating saw and osteotome, trimmed and then fixed using two 1.5mm screws. Proper graft position, implant placement and joint reduction was confirmed with intra-operative radiographs.A modified Bruner incision was utilized and a shot-gun approach to the PIPJ was doneWide-awake anaesthesia allowed for active intra-operative range of motion and stability testing . The pat4. It is also the preferred option during the COVID pandemic since it avoids aerosol-generating procedures such as intubation, reduces needed manpower since an anaesthesiologist is not required, provides adequate pain control, and allows for rapid patient turn-over4.Since its introduction by Lalonde, WALANT has been increasingly popular and has been described in various hand and extremity procedures2. For our patient, we were able to achieve excellent results with near full finger range of motion. However, there was still mild pain during full flexion and power grip, which is also consistent with the previously reported results and could be possibly explained by arthritic changes due to the chronicity of the injury5. Wide-awake anaesthesia also allowed adequate visualisation of the operative field without the need for a tourniquet. This avoids the necessity of performing sedation or proximal nerve blocks to address tourniquet pain4.Hemi-hamate arthroplasty has been reported to have the most consistent outcome for treatment of chronic dorsal PIPJ fracture-dislocations, especially if there is more than 50% joint involvement and comminuted fracture fragments4. Pain control throughout the procedure was satisfactory and there was no need to take opiate analgesics. It allows for dynamic intra-operative stability and range of motion testing after placement of the graft, although this remains to be seen if it has any long-term clinical benefit as most of the previously reported chronic PIPJ reconstructions did not experience any dislocations despite using the conventional anaesthesia5. Also, even though this was done in a chronic injury, this approach is also feasible to use in acute cases. Contraindications to WALANT would include allergy to lidocaine or epinephrine, uncooperative patients, and patient refusal.Advantages of doing the procedure using wide-awake anaesthesia would include obviating the need for preoperative laboratory testing and fasting and reducing overall cost. Although we did this procedure as an in-patient procedure, this could have very well been done in an outpatient setting since WALANT reduces the need for postoperative anaesthesia monitoring, allowing for immediate discharge after the procedureHemi-hamate arthroplasty under wide-awake anaesthesia has not been previously described and is a viable, simple, and safe alternative to conventional regional or general anaesthesia. Considering all the benefits of WALANT, we would recommend the use of wide-awake anaesthesia as the primary anaesthetic technique of choice, unless contraindicated, for hemi-hamate arthroplasty.


The mortality rate of epithelial ovarian cancer (EOC) remains the first in malignant tumors of the female reproductive system. The characteristics of rapid proliferation, extensive implanted metastasis, and treatment resistance of cancer cells require an extensive metabolism rewiring during the progression of cancer development. EOC cells satisfy their rapid proliferation through the rewiring of perception, uptake, utilization, and regulation of glucose, lipids, and amino acids. Further, complete implanted metastasis by acquiring a superior advantage in microenvironment nutrients competing. Lastly, success evolves under the treatment stress of chemotherapy and targets therapy. Understanding the above metabolic characteristics of EOCs helps to find new methods of its treatment. BRCA1/2 or homologous recombination deficiency in EOC patients are only about 24% [EOC accounts for about 2.5% of all female malignant tumors, but its mortality rate ranks the first in malignant tumors of the female reproductive system. During the past two decades, the overall mortality rate of all cancers decreased by about 29% with the advancement of screening and treatment modalities . Howeverbout 24% . Immune bout 24% . HoweverCarcinogenesis is a multistep process and needs a set of functional capabilities which include sustaining proliferative signaling, evading growth suppressors, resisting cell death, enabling replicative immortality, inducing/accessing vasculature, activating invasion and metastasis, reprogramming cellular metabolism, and avoiding immune destruction . Of thesTherefore, we summarize the metabolic rewiring of HGSOC cells to meet the uncontrolled sustain proliferation, implanted metastasis, and evolution under treatment stress to ultimately provide new strategies for its treatment.Rapid proliferation is the first hallmark of HGSOC cells which need a large amount of energy supply and carbon to rebuild biomasses, such as bio-membrane, nucleic acids, and proteins. Reprogramming of glucose, lipids, and amino acids is the well-known hallmark of tumor metabolism which provide the basis of its proliferation .The first feature of metabolism in malignant tumor cells is the distinct glucose metabolic mode from normal cells see Fig. A. The paPyruvate dehydrogenase kinase (PDK) isoforms 1–4 and pyruvate dehydrogenase complex (PDC) regulate the metabolic shift between aerobic glycolysis and OXPHOS. PDC is a gatekeeper of glucose oxidation which converts pyruvate to acetyl-CoA and bridges glycolysis with the Krebs cycle . The gatSalt-inducible kinase 1–3 (SIK1-3) are serine/threonine kinases belonging to the AMP-activated protein kinase family which also play important roles in the regulation of HGSOC metabolisms . SIK1-3 in the first step of glycolysis [Besides PDK/PDC and SIKs, hexokinase-2 (HK2) is another rate-limiting enzyme that catalyzes the production of glucose-6-phosphate ycolysis . Pyruvatycolysis –40. Pyruycolysis . Changinycolysis , 43.Augmented glycolysis and increased uptake of glucose are significant metabolic alterations of EOC cells , 45. RecGenomic landscape and cell signaling were considered key drivers of cancer cell metabolism. The genomic rewiring ranges from oncogenic mutations, and key kinases to signaling pathways on nutrients sensing, uptake/acquisition, and biosynthesis in tumor cells. Activation of oncogenes and loss of tumor suppressors promote metabolic reprogramming , resultiAlterations of lipid metabolism are critical to the proliferation and metastasis of ovarian cancer cells see Fig. B.β-oxidaThe de novo lipogenesis of FAs relies on the intermediates of glucose and amino acids. Cytosolic citrate resulting from glutamine metabolism and the citric acid cycle turns into a series of saturated FAs through ATP-citrate lyase , Acetyl-Enzymes in the fatty acid synthesis pathway are also found to have increased expression levels across various cancer types and this increased expression correlates with worse survival outcomes. SCD1 is the rate-limiting enzyme converting saturated FAs to unsaturated FAs and is upregulated in various cancers . UnsaturAmino acids are of utmost necessity for cancer cell proliferation. Proliferating cancer cells often engage in amino acid production more proactively and biosynthesis of non-essential amino acids (NEAAs) see Fig. C. ActiveTumor cells rewired their metabolic program to actively acquire amino acids from the extracellular space to sustain biomass accumulation. The mechanistic target of rapamycin complex 1 (mTORC1) is a central coordinator of amino acid availability and allocation . Its actBesides the active uptake of amino acids, cells can specifically adjust the levels of certain amino acids by modulating the expression of selective transporters and/or by regulating de novo biosynthetic pathways. When PI3K -AKT signaling is activated, TSC2 is dislocated from RHEB and results in the activation of mTORC1 kinase activity. Concerted AKT and mTORC1 kinase activation induce and sustain cell surface expression of amino acid transporters . mTORC1 Macropinocytic scavenging of proteins has been demonstrated to be a crucial opportunistic amino acid source to support cell proliferation, especially in cancer. The initiation of macropinocytosis is characterized by membrane ruffling and macropinosome formation and is normally stimulated by growth factor signaling and PI3K activation , 79. OncExcept for amino acid uptake, tumors are capable of synthesizing NEAAs with the metabolites of glycolysis and the TCA cycle. When cells sense a decrease in amino acid levels through general control nonderepressible 2 (GCN2), activating transcription factor 4(ATF4) can directly lead to the upregulation of enzymes involved in NEAA synthesis, such as asparagine synthetase (ASNS) in asparagine synthesis , and phoAberrant glutamine metabolism, with overexpression of glutaminase (GLS), was associated with poor survival in EOC patients and platinum resistance in EOC cellular models . AlteratThe multi-omics studies of glycoproteome, transcriptome, and proteome of HGSOC have revealed that the glycans conjugated on glycosylation sites are associated with tumor subtypes and intact glycopeptides information from a combination of glycosylation sites and site-specific glycosylation provide survival predictors beyond the protein and transcription levels, which provide significant clues for the treatment of HGSOC .As the proliferation rate of ovarian cancer is fast, the NEAA acids and FAs provided from external sources for the endogenous synthesis do not meet the increased needs of the highly proliferating cancer cells . HoweverProlonged amino acid starvation in ovarian cancer cells can be sensed by the mTOR kinase and triggers the expression of several autophagy genes . OvarianCancer cells located in hypoxic niches use aerobic glycolysis for energy supply . AerobicTumor cells also reprogram the surrounding stromal cells by paracrine growth factors, cytokines, and other signaling molecules, such as platelet-derived growth factors and VEGF, to create a favorable environment for continuous proliferation. Besides, the levels of major carbon and nitrogen sources such as glucose, and glutamine affect their metabolic reprogramming and metabolic phenotype. In low glucose conditions, tumor cells could not maintain cellular ATP levels after metformin blocks mitochondrial oxidative metabolism . When glEnzymatic activity involving metabolism is delicately balanced and regulated. Besides upstream regulation, the compartmentalization of competing reactions into different membrane-bound organelles, also called Liquid–liquid phase separation (LLPS), is another important regulation. LLPS is a dynamic and reversible process that includes two distinct phases, the dense and dilute phase , 117. ThActivating invasion and metastasis and avoiding immune destruction compromised the basis of EOC invasion and metastasis. Omentum and peritoneum implantation is the hallmark of advanced-stage EOC. Tumor growth and metastasis require a special microenvironment , commonlTumor-associated stromal cells include different cell types: CAFs, CAAs, or cancer-associated endothelial cells . ContrarOmentum is comprised of adipocytes which are the preferred metastatic site of ovarian cancer cells . CAAs reFABP4 was a lipid chaperone protein in EOC cells and also highly upregulated in metastatic EOC cells. FABP4 interacts with the transmembrane domain of CD36 to facilitate the import of free FAs from the extracellular space. Once inside the cell, FAs remain bound to the cytosolic part of FABPs until their delivery to the destination site. FABP4 promotes the colonization of tumor cells in the lipid-rich TME, and its targeted inhibitor inhibits the adaptation of tumor cells to colonization in the TME . FABP4 aThe peritoneum is another preferred metastatic site of ovarian cancer cells compromised with fibroblast cells. Further studies have found that the Warburg effect of the tumor occurs in the surrounding myofibroblasts, rather than in the tumor cells themselves. Tumor cells can induce the surrounding CAFs to proceed with aerobic glycolysis through which these CAFs generate high energetic metabolites (such as lactic acid and pyruvic acid). Those metabolites can be taken up by adjacent tumor cells for further mitochondrial OXPHOS which plays a crucial role in tumor genesis, invasion, and metastasis through the systemic interaction of energy metabolism with the tumor at all stages of its evolution . CAFs arThe immune cells of TME include the innate immune response cells  and the adaptive immune response cells (such as CD4 + T cells and CD8 + T cells). Nature killer cells and CD8 + T cells are classified as cytotoxic lymphocytes which offer a natural defense against tumor progression through the specific killing of tumor cells after identifying the tumor antigens. CD4 + T cells support  or repress (Treg) the activity of cytotoxic lymphocytes. When T cells interact with an antigen and induce signaling through the T cell receptor (TCR), a cascade of signaling events is initiated that trigger rapid metabolic remodeling . The funHighly proliferative activated T cells and cancer cells both rely heavily on glucose metabolism and compete for energy nutrients like glucose and amino acids. Cancer cells can inhibit the CD8 + T cell infiltration and proliferation through several mechanisms . GlycolyAside from glucose, amino acids have now also been identified to drive and fuel T cell function and differentiation , 144. AsLike T cells, tumor-associated macrophages (TAMs) also compete with ovarian cancer cells for glucose. However, the TAMs have two phenotypes that play an opposite function in tumor growth. M2 macrophages have a pro-tumoral function through secretion of growth-promoting cytokines and local immunosuppression, whereas M1 macrophages can directly limit primary tumor growth .Several factors regulate the polarization of TAMs towards an M1 or M2 phenotype: genetic background, surrounding soluble factors , and cell metabolism –153. GlyLactate produced by tumor cells has a critical function in signaling and TAM polarization. Specifically, lactate induces a pro-tumoral M2 phenotype by inducing VEGF through HIF1α stabilization  and throThe reaction of cancer cells after treatment remains different. Cancer cells may adapt to the different metabolic modes when undergoing metabolically challenges.The relapse of EOC is mainly attributable to late diagnosis and the development of chemoresistance . IncreasThe pentose phosphate pathway (PPP) is elevated in tumor cells. PPP usually occurs in the cytoplasm. The intermediates of PPP are phosphate, including NADPH, pentose phosphate, and fructose 6-phosphate. NADPH can reduce the level of active oxides, like free radicals, caused by radiotherapy and chemotherapy, maintain redox homeostasis, and protect tumor cells from oxidative damage. Pentose phosphate is involved in ribonucleotide biosynthesis. Moreover, PPP is also involved in fatty acid synthesis and glycolysis . ActivatOvarian cancer cells also produce high levels of ROS, likely due to defective signaling pathways. Mitochondria-associated granulocyte colony-stimulating factor stimulating protein (Magmas) is a ROS scavenger, that is also overexpressed in ovarian cancer cells. Magmas inhibitor was able to sensitize an ovarian cancer cell line to carboplatin .In a study with-depth, single-cell phenotypic characterization of HGSOC, patients with poorer outcomes had an increased frequency of cell type that co-expressed vimentin, HE4, and c-Myc. Low c-Myc/HE4 expressed cells were sensitive to continuous exposure to carboplatin. However, cells with a high c-Myc/ HE4 expressed subgroup were sensitive to c-PARP treatment, not carboplatin . These HOne of the targeted therapies for EOC is anti-angiogenic therapy. One significant characteristic of ovarian cancer is angiogenesis induced by low oxygen. In ovarian cancer xenografts, a remarkable alteration occurred in tumor lipidomic profile after the anti-VEGF treatment with bevacizumab, including increased levels of triacylglycerols and reduced saturation of lipid chains. Further transcriptome analysis revealed up-regulated metabolism pathways accompanied by increasing accumulation of lipid droplets both in vitro and in vivo assays. After treatment with liver x-receptor agonists GW3965, this phenomenon could be selectively counteracted which resulted in the therapeutic effects of bevacizumab being enhanced and the viability of tumor cells inhibited .GLS is an enzyme that converts the amino acid glutamine into glutamate. ARID1A is a part of the SWI/SNF protein complex, which inhibits the widely expressed GLS gene. Inactivation of ARID1A increases glutamine utilization and metabolism through the TCA cycle to support aspartate synthesis. In ovarian clear cell carcinoma (OCCC), GLS inhibitor CB-839 suppresses the growth of the tumor with ARID1A mutation, but not wildtype, and significantly reduces the tumor burden and prolongs the survival in patient-derived xenografts. In addition, glutamine metabolism regulates the function of immune lymphocytes in the TME. The glutamine antagonism in effector T cells can be used as a "metabolism checkpoint". Hence, "metabolism checkpoint blockade" GLS inhibitor CB-839 could further enhance the therapeutic effectiveness of immune checkpoint inhibition anti-PD-L1 .Targeting cancer cell metabolism has been an attractive therapeutic target in various cancers. In ovarian cancer, targeting the metabolism of cancer stem cells through inhibition of lipid metabolism resulted in the elimination of cancer stem cells and decreased tumor development in mouse models. However, targeting cancer cell metabolism in the clinic has been largely unsuccessful either due to a lack of efficacy or safety . This isBased on the metabolic characteristics of ovarian cancer cells, multiple pathways may be the target of future ovarian cancer therapy. First, adjust the dietary structure to reduce tumor-specific raw nutrient intake. For example, removal of serine through dietary changes or pharmacological pathways shows potential in P53 deficient tumors. De novo serine synthesis appears essential to cancer cells with PHGDH overexpression. Inhibition of the de novo synthesis pathways of FAs and amino acids  is important. Cancer cells may actively adapt to the utilization of varieties of surrounding nutrients, particularly during metastasis as they invade new territories that are metabolically challenging. Nutrient uptake and utilization are direct results of extracellular stimuli and maintaining glucose influx and metabolism are essential to sustain cell survival and growth. Targeted drugs inhibit the uptake of specific sugars, FAs, and amino acids through selective inhibition of their transporters.Besides, proliferation exceeds the ability of the existing vasculature to supply sufficient oxygen and nutrients when in nutrient and energy crises. Also, autophagy is a critical catabolic process whereby cells salvage intracellular constituents under the conditions of nutrient scarcity. The treatment of cells in rapid proliferation needs the combination of several targets, such as the combination of anti-angiogenesis and elements starvation with anti-mTORC1.In the last, the sense and regulation of metabolism also involve several balances, such as ROS, ratios of ATP/ADP, nutrient supply, and microenvironment adaptation. The first balance is ROS (KEAP1-NRF2 axis) which is regulated by NADH-NAD + balance and PI3K. Local high NADH to NAD + ratio, thioredoxin system, and the glutathione system, reducing equivalent of NADPH to NADP + , therefore contributing to cellular redox balance by serving as an electron acceptor and increasing the ROS level, can stimulate cell growth and inhibit cancer metastasis. Next is the ratio of ATP/ADP, when cells rapidly undergo apoptosis as the reduction in mitochondrial membrane potential and cellular ATP level. Opportunistic modes of nutrient acquisition from the TME meet the needs of cancer cells proliferation and invasion. Interruption of the above balances is also the underlying treatment target of ovarian cancer.The metabolism alterations involve the proliferation, metastasis, and treatment resistance of epithelial ovarian cancer, especially high-grade serous ovarian cancer. EOC cells satisfy their rapid proliferation through the accelerated uptake of glucose, amino acids, and lipids. Ovarian cancer cells complete their implanted metastasis by utilizing the nutrients and interacting with other cells of the special microenvironment. Lastly, the cancer cells evolve through metabolism rewiring under the treatment stress of chemotherapy and target therapy. However, there are no systematic studies on metabolic homeostasis imbalance and metabolic remodeling during the development of EOC. Further studies are needed.