Tumor-associated vascular endothelium comprises a specialized and diverse group of endothelial cells that, although not cancer themselves, are integral to cancer progression. Targeting the tumor vasculature can have significant efficacy in reducing tumor burden, although loss of efficacy due to acquisition of resistance mechanisms is common. Here we review mechanisms by which tumor endothelial cells (TEC) utilize chemokine receptors to support tumor progression. We illustrate how chemokine receptors support and may serve as functional markers of the diverse TEC population. We focus on ACKR1 (DARC), ACKR3 (CXCR7), CXCR4, and CCR2, as these are the best studied chemokine receptors in TEC; and suggest that targeting these receptors on the tumor vasculature may prove efficacious in slowing or reversing tumor growth. We also mention CXCR2 and CXCR3 as important mediators or tumor angiogenesis, given their distinct roles with angiogenic and angiostatic chemokines, respectively. The endothelium consists of a network of endothelial cells (ECs) that form the inner lining of blood and lymphatic vessels. Endothelium is present only in vertebrates, including the hagfish, the oldest of extant vertebrates , 2. The In the context of cancer, endothelial cells form the inner lining of the blood vessels that make up part of a growing tumor. Compared to normal endothelial cells, tumor endothelial cells (TEC) become morphologically and phenotypically dysregulated at the cellular and molecular level, much like the tumor itself. TEC retain their ontological endothelial identity, remain distinct from cancer cells, and are not immortal. TEC support is, however, a major component of the tumor microenvironment, not only irrigating the tumor with nutrients, but also affecting the immune cell infiltrate and stromal composition of the tumor , 4. The Misconceptions regarding the origin of TEC have been clarified in the last few years with the advent of improved technologies that have enabled a detailed compositional analysis of these cells and uncovered a vast repertoire of functional activities and associated markers. Key misconceptions included that (i) tumor endothelial cells were derived from the tumor, (ii) TECs were similar to their normal counterparts; and (iii) targeting only vascular endothelial growth factor (VEGF) would be sufficient to destroy the tumor they were a part of. Interestingly, the heterogeneity of TECs is such that it is extremely challenging to pinpoint a single overall function or modus operandi that defines the TEC population. Tumors hijack otherwise normal homeostatic or developmental vascular endothelial processes, such as angiogenic sprouting or vasculogenesis; or engage in vessel co-option or other mechanisms, such as intussusception (splitting of pre-existing vessels to give rise to daughter vessels), and parasitize the host's vascular system to promote tumor survival, growth, and dissemination –8 Figur.Tumor angiogenesis results from growth factor and chemokine-dependent EC proliferation. Classic EC proliferation is stimulated by VEGFs . DependiGiven the conflicting evidence on whether or not there exists bone marrow-derived precursors that are bona fide endothelial progenitors cells (EPC), we adopt a more general definition of vasculogenesis as the process of new blood vessel formation assisted by pro-angiogenic bone marrow-derived precursors, if not actual EPC . Tumors less likely to respond to antiangiogenic therapy. Ronca et al.  signaling blockade. Despite initial optimism, the efficacy of anti-angiogenic pharmaco-monotherapies is typically short-lived, and drugs such as Bevacizumab  have failed to deliver the promise of a cure for cancer. Improvements in patient survival are limited by acquired refractoriness and drug resistance –28. DespIn this review, we aim to illustrate how chemokine receptors support and serve as functional markers of the TEC population. We also discuss several studies that demonstrate the role of chemokine receptors within the heterogeneous TEC population and how these receptors may be relevant and appropriate targets for the treatment of cancer.Chemokine receptors maintain a classic seven transmembrane (7-TM) family structure. An important feature of 7-TM receptors is that they have a conserved disulfide bond between two cysteines, and part of what determines the large diversity of these families is how many amino acids separate those two cysteines . 7-TM prChemokine receptors are well-known as leukocyte-expressed homing receptors that guide white blood cell localization throughout the body . Certain3C) based on the position of conserved cysteine motifs (where X represents any non-cysteine residue). CXC chemokines are further divided into two groups with defined biological activities. The first set contains the ELR motif that induces chemotactic activity, inducing selectin-dependent leukocyte rolling on activated endothelium, followed by integrin mediated firm adhesion and transendothelial migration to inflamed sites  . Tumor mIn general, upon binding to their ligands, chemokine receptors undergo conformational changes that allow the binding of G proteins to intracellular loop epitopes and the carboxy terminal tail of the receptors. This initiates a signaling cascade of activated second messengers that lead to cell motility and multiple other functional effects in the target cells. Major cellular processes are influenced significantly by chemokines via their receptors. Cancer cells can hijack the chemokine receptor system to enhance their survival and proliferation. Epithelial cells, stromal cells, and normal cells secrete chemokines that attract tumor cells overexpressing chemokine receptors and thus increase metastatic dissemination. Increased chemokine receptor expression can also support angiogenesis that feeds tumor growth and gives tumor cells additional survival signals or a survival advantage.+ CXC chemokines , also known as Duffy antigen receptor for chemokines (DARC) binds more than 20 different chemokines, and is expressed in cerebellar neurons, venular ECs, and erythrocytes . ACKR1 iemokines , whereasemokines .in vitro , also known as CXCR7, has a modification in its DRYLAIV motif that does not allow it to bind heterotrimeric G-proteins after binding its ligands CXCL11 or CXCL12. Instead, it preferentially signals via the beta-arrestin pathway. ACKR3 is known to play a critical role in guiding progenitor cell migration during embryo- and organo-genesis . But folin vitro .ACKR3 is upregulated in tumor endothelial cells, where it is induced under hypoxic and acidic conditions, distinctive features of the tumor microenvironment. CXCL12 secreted by TECs promotes ACKR3-mediated angiogenesis via ERK1/2 phosphorylation but not normal endothelial cells (NECs), indicating an autocrine/paracrine loop affects TEC proangiogenic properties . TherefoCXCR4 is the most common chemokine receptor overexpressed in human cancers and is implicated in over 25 different types of cancers , 60. CXCCXCR4 is expressed by EPCs and is responsible for their maintenance in the bone marrow via CXCL12. VEGF/VEGF-R, which upregulates MMP9, and CXCL12/CXCR4 are considered the key pathways regulating bone marrow-EPC mobilization –66. On tHER2/neu transgenic mice)  . A similnd, CCL2 . EPC expnd, CCL2 . EPC devhenotype . ChemoCehenotype , 72 havehenotype .+ CXC-chemokines  known to possess angiogenic activity and promote neovascularization  gamma-induces CXCL9/10/11 expression in endothelial cells, where the chemokines play an important role in the vascular recruitment of IFN-gamma-producing T cells to atherosclerotic plaques  could lead to tumor vascular disruption and neoplastic necrosis. CXCR4 is also present on anti-tumoral leukocytes and synergistically attracts leukocytes with other chemoattractants. Thus, the outcome of CXCR4 inhibition might differ depending on the tumor type or even individual patient. For example, since CXCR4 is upregulated on immune suppressive regulatory CD4+ T cells /MET signaling and enhanced autocrine signaling through VEGF and platelet-derived growth factor (PDGF). As the TECs developed within the tumor, there was loss of normal EC function and markers including MAdCAM-1 that control lymphocyte homing. Changes in adhesive properties on tumor endothelial cells also showed decreased expression of lymphocyte-attracting chemokines CXCL16, CXCL13, CXCL12, CXCL9, CXCL10, and CCL19 . This stTECs and NECs isolated from human breast cancer tissues and reduction mammoplasty tissues were analyzed by single cell RNA sequencing (scRNA-seq) to characterize and compare their global gene expression profiles. Not surprisingly, chemokines and the GPCR pathways, which include the chemokine receptors, were some of the most differentially expressed genes and correlated with breast cancer . One limIn another study evaluating tumor endothelium by scRNA-seq analysis, the authors isolated TEC and NECs from xenografts of human colon carcinoma and successfully re-capitulated previously identified markers for tip and stalk cells. Most interesting was the effect of anti-angiogenic therapy on the TEC populations. The authors used either aflibercept (VEGF inhibitor), anti-Dll4 (Notch inhibitor), or a combination to treat the colon carcinoma xenograft model. Blockade of VEGF rapidly inhibited cell cycle genes and reduced the proportion of endothelial tip cells in tumors. In contrast, blockade of Dll4 promoted endothelial proliferation as well as tip cell markers while blockade of both pathways inhibited endothelial proliferation but preserved some tip cells . While tCurrent technologies are allowing us to decipher at the single cell resolution the heterogeneity and functionality of the tumor endothelium. This will provide profound insight into mechanisms governing tumor leukocyte infiltration and functional activation via the quantitative analysis of adhesion molecule, chemoattractant, and costimulatory molecule expression. Single cell analysis of the endothelium may also help identify escape mechanisms from current anti-angiogenic and vascular disrupting agents and lead the way to effective countermeasures .Understanding which chemokine receptors are responsible for the early development of the tumor EC but change as the TECs progress along with the rest of the tumor, will help us understand the dynamics of this heterogeneous population and identify appropriate targets for treatment. In the near future, we should seek to identify the characteristics of TECs at the single cell level to understand the transcriptional controls that are altered in NECs, EPCs, and/or cancer-stem-like cells that give rise to TECs in the tumor microenvironment. Understanding how to control this developmental switch will allow us to do what we cannot do today: control the position, abundance, and physical properties of tumor blood vessels. For example, in poorly-vascularized tumors, we may seek to increase the abundance and permeability of tumor vascular endothelium to allow better irrigation of a tumor with a drug or cellular treatment in a patient. In other cases, we may seek to optimally disrupt existing tumor-associated vascular endothelium by targeting key chemokine receptors for therapeutic purposes. As we enter the era of personalized medicine, sequence and expression analysis of neoplastic cells, and supporting TEC will guide the selection of optimal treatments. Given the role of TEC-expressed chemokine receptors in tumor progression, it is likely that chemokine receptor-targeted drugs will play a prominent role in most combination treatment strategies to treat cancer.NS organized the research topic, wrote, and edited the manuscript. BZ wrote and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 76-year-old woman who experienced sinusitis for years was presented to the emergency department complaining of left orbital pain, eyelid swelling, and reduced visual acuity. She was nonfebrile, and she reported no recent trauma nor any violent Valsalva maneuver.Ophthalmological examination showed a proptosis and a limitation of eye movements, particularly in the up gaze Figure  as well Non-contrast computed tomography (NCCT) revealed a biconvex well-defined 41 × 31 × 17 mm collection with layering hyperdense blood products in the roof of the orbit, displacing superior oblique and rectus muscles, causing exophthalmia and deformity of the eye. No obvious bone erosion was visualized  and isointense to hyperintense signal on T1-weighted images  indicated an acute to subacute hematoma with hypointense signal on T2/FLAIR-weighted images . The visual field showed an altitudinal inferior defect with a macular sparing.Orbital MRI control performed one month postoperatively was unremarkable.Most cases of orbital subperiosteal hematoma (OSH) typically result from the rupture of blood vessels in the setting of trauma. Non-traumatic OSH is uncommon and typically associated with a sudden increase in cranial venous pressure, as in emesis, bleeding diathesis or chronic sinusitis . OSH ariBecause the possibility of orbital infection, surgical drainage is recommended. An anterior orbital approach is preferred. Early detections and treatment are necessary to prevent compressive optic neuropathy and to ensure the best prognosis. Antibiotic coverage is recommended.While computed tomography performs well to show sinusitis, possible bone changes, and the presence of blood collection or abscess, an MRI is superior for evaluating intraorbital structures, especially the optic nerve.


The resulting spinal-evoked oculomotor behavior produced conjugated eye movements that were in phase opposition with the mid-caudal part of the tail. This time adjustment is independent of locomotor activity in the more caudal spinal parts of the tail. Altogether our findings demonstrate that locomotor feed-forward spino-extraocular signaling produce conjugate eye movements that compensate specifically the undulation of the mid-caudal tail during active swimming. Finally, this study constitutes the first extensive behavioral quantification of spino-extraocular motor coupling, which sets the basis for understanding the mechanisms of locomotor-induced oculomotor behavior in larval frog.In larval xenopus, locomotor-induced oculomotor behavior produces gaze-stabilizing eye movements to counteract the disruptive effects of tail undulation during swimming. While neuronal circuitries responsible for feed-forward intrinsic spino-extraocular signaling have recently been described, the resulting oculomotor behavior remains poorly understood. Conveying locomotor CPG efference copy, the spino-extraocular motor command coordinates the multi-segmental rostrocaudal spinal rhythmic activity with the extraocular motor activity. By recording sequences of xenopus tadpole free swimming, we quantified the temporal calibration of conjugate eye movements originating from spino-extraocular motor coupled activity during pre-metamorphic tail-based undulatory swimming. Our results show that eye movements are produced only during robust propulsive forward swimming activity and increase with the amplitude of tail movements. The use of larval isolated  Ior (CPG) . In partor (CPG) . Such unor (CPG) . The delin vitro preparation to record the corresponding spinal and extraocular motor nerve activity during spontaneous swimming episodes, either in natural or fictive swimming experimental conditions. Our results demonstrate that the locomotor-induced oculomotor behavior, elicited by an internal efference copy signaling from rostral spinal motor networks, is specifically tuned to produce conjugate eye movements that compensate the mid-caudal tail undulatory pattern during propulsive swimming.To address this question, we used intact animals as well as semi-intact preparations at pre-metamorphic larval stages to record tail and eye movements, or isolated X. laevis obtained from the Xenopus Biology Resources Centre in France (University of Rennes 11). Animals were maintained at 20–22 °C in filtered water aquaria with a 12:12 h light/dark cycle. Developmental stages were sorted according to external body criteria  were placed in an aquarium (20 × 40 cm) filled with filtered water to a depth of 3 cm. In these behavioral conditions, larvae were able to produce unobstructed swimming sequences up to 20 tail swim cycles. In these experiments, only uninterrupted episodes of swimming with at least 10 consecutive undulatory cycles were analyzed. Video sequences were recorded with a digital camera  positioned above the aquarium. A wide-angle lens (Fujinon 16 mm 1:1.4) was used to monitor tail movements throughout free-swimming episodes. Image acquisition frequencies were of 250 fps. Video sequences were collected on computer through a USB3 interface and stored using the AVI video file format with the Pylonviewer5 software (Basler). Subsequent data analyses were performed using a homemade macro from free Fiji  Ringer solution . The temperature of bathing solution was controlled and maintained around 18°C. Viscera and telencephalon were removed and animals were fixed dorsal side up to a Sylgard-lined Petri dish. Brainstem was exposed to Ringer solution perfusion. To avoid any visuo-vestibular sensory inputs, the optic nerves were transected bilaterally and the semi-intact preparation was placed in a special chamber where the head was firmly secured to the Sylgard with pins. The tail was free in a deeper compartment to allow unrestrained swimming undulatory movements  and spinal ventral roots (Vr) innervating the 5th, 15th, and 20th myotomes .For video image processing, traces of angular movements from eyes and/or tail sections were first filtered with a 25 Hz low-pass filter. Tail swimming cycles were defined based on angular excursion of the 1st tail section and the null angle excursion of the 1st tail section determined the cycle start. Then maximum angle values of tail sections and eyes (peak sinewave) were detected in each individual swimming cycle. These peak markers were used to calculate instantaneous peak frequency, peak-to-peak latency from the 1st tail section (sct) or eye, and the temporal relationship of consecutive tail sections relative to the 1st tail section or eye.Electrophysiological recording signal of each motor nerve was rectified about 0 mV and smoothed  to obtain an integrated signal. Fictive swimming cycle was determined from the 5th rostral ventral root (Vr-5) bursting discharge. Then an event was generated for each detected peak in Vrs and LR bursts in each fictive swimming cycle. Frequency, latency and temporal relationships were calculated in Dataview. 1st sct or Vr-5 signals were used as the phase marker in phase relationship analysis shown in Figure U-test, and Kolmogorov–Smirnov test to compare distribution. To compare several values, non-parametric Kruskal–Wallis test was processed with a Dunn’s multiple comparisons test. Circular data analysis was performed with Oriana 4.02 software . The temporal relationships between eye and tail sections angular excursion, or in the Vrs and LR in different preparations were assessed by circular phase analysis of pooled data. The mean vector ‘μ’ and its length ‘r’ indicated the preferred phase and the strength of coupling, respectively. To test if the distribution of mean angle values was non-uniform with a specified mean direction, data was processed with a V-test and an expected mean. For non-uniform distributions , mean phase values of each animal were plotted as the grand mean of the individual means of phase relationship between tail section/Vrs and eye/LR. They were expressed as . Preferred direction of grand mean vector was tested by Moore’s Modified Rayleigh test and the difference on phase relationships between means was evaluated by using the Watson–Williams F-test. Linear regression (r2) was proceeded to evaluate the kind of correlation between amplitude of angular excursion of eye and tail section, or between burst area of LR and Vrs. Slope (s) of these regression expressed the gain between the two factors tested. Regression results were expressed as . Differences between results values were taken to be significantly different at p < 0.05 . All mean numerical values are given in a After signal processing in Dataview, data were analyzed using Prism7 . A normal distribution was verified , and thus the results were expressed as the means ± SEM, unless stated otherwise. For swimming parameters (frequency and amplitude) and integrated electrophysiological signals, differences between two results were tested using the unpaired two-tailed Mann–Whitney in vitro preparation.Before analyzing tail and eye movements coordination, a fine description of the sinewave undulation of the tail  as well in vitro brainstem-spinal cords, the mean bursting frequency measured from spinal ventral roots was lower  in free swimming compared to head-fixed preparations  of several spinal segments during fictive swimming sequences  oscillates in phase opposition with the rostral part of the tail (1–7th myotome segments). As the locomotor CPG rhythmic activity exhibits a constant latency between rostro-caudal segments, the temporal relationship between rostral and mid-caudal tails directly depends on the swimming frequency.Altogether these results demonstrate that head fixed semi-intact preparations and isolated ii, gray squares). Similar to the in vivo swimming behavior, the recruitment of more or less rostro-caudal spinal segments fluctuated in isolated in vitro preparations  Ringer solution (not shown). In this condition, we observed the same linear relationship for the phase shift and the latency between LR and Vr-5 as described above  determine the intersegmental rostro-caudal delay that set the timing of the undulatory swimming pattern. Therefore, those rostral swimming CPGs elicit ascending commands to extraocular motoneurons with a temporal calibration that produce conjugated eye movements counteracting specifically the undulation of the mid-caudal tail region, which is the most biomechanically efficient region to produce propulsive forward swimming.in vitro approaches showed compensatory eye movements in phase with the hindlimb extension phase (One may wonder why the signals for spino-extraocular coupling arise principally from rhythmically active CPG networks in the rostral region and not directly from those innervating the myotomes of the middle part of the tail compensated by conjugate eye movements. We can notice that the rostral segments involved in the spino-ocular coordination are the only ones that remain after metamorphosis, when the tadpole changes into a frog and the tail disappears. Indeed, we have recently shown that the efferent copy is still present in the postmetamorphic animal, although adapted to the new mode of locomotion of the animal . We can on phase .in vitro fictive swimming sequences and in vivo unrestrained swimming behavior. First, the frequency range was lower in fictive compared to free swimming conditions. Second, the phase shift between the LR motor nerve and rostral Vrs were reduced in isolated preparation compared to free swimming condition. Sensory feedback from the tail undulatory movement normally comprises spinal proprioceptive inputs from myotome contraction, lateral line neuromast inputs from water flow detection and central canal fluid movement detection from mechanosensory neurons. These sensory signals are known to ensure a multimodal control of locomotion (in vitro preparations could be due to the absence of sensory feedback inputs normally originating from tail undulation and its interaction with the aquatic environment. Indeed, proprioceptive and lateral line sensory signals might play a role in the adjustment of the temporal calibration and the strength of the spino-extraocular motor command in response to the swimming frequency variation.Swimming kinematic parameters as well as spino-extraocular temporal parameters were comparable between all experimental conditions used to quantify the locomotor-driven oculomotor behavior and its electrophysiological correlates. Nonetheless some variability was observed between comotion . In manycomotion , sensorycomotion . TherefoThis study brought a quantified behavioral supply to our previous work focused on the understanding of the central pathways responsible for locomotor efference copy gaze stabilizing mechanism . It setsJB-C performed the experiments, acquired and analyzed the data, designed the figures, and wrote the manuscript. GC contributed to the software conception and testing for video tracking. MB conceived the idea and wrote the manuscript. FL conceived the idea, performed the experiments, acquired the data, designed the figures, and wrote the manuscript. DC conceived the idea and wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The best treatment for patients with ischemic heart failure (HF) is still ondebate. There is growing evidence that coronary artery bypass graft (CABG)benefits these patients. The current recommendations for revascularization inthis context are that CABG is reasonable when it comes to decreasing morbidityand mortality rates for patients with severe left ventricular dysfunction(ejection fraction <35%), and significant coronary artery disease (CAD) andshould be considered in patients with operable coronary anatomy, regardlesswhether or not there is a viable myocardium (class IIb). Percutaneous coronaryintervention (PCI) does not have enough data to allow the panels to reach aconclusion. The Korean Acute Heart Failure registry (KorAHF) had its datareleased recently, showing that patients with acute HF who underwent CABG hadlower death rates, more complete revascularization and less adverse outcomescompared with patients treated with PCI. Recent ESC/EACTS guidelines onmyocardial revascularization clearly recommended CABG as the first choice ofrevascularization strategy in patients with multivessel disease and acceptablesurgical risk to improve prognosis in this scenario of left ventriculardysfunction. However, a high peri-procedural risk must be compared with thebenefit of late mortality, and pros and cons of each strategy (either PCI orCABG) must be weighed in the decision-making process. Spurred on by thepublication of the above-mentioned article and the release of new guidelines, wewent on to write an overview of the current practice of state-of-the-artcoronary revascularization options in patients with HF. However, this study was underpowered and, further,larger trials were required to settle this issue.One of the first pieces of evidence was the Heart Failure Revascularization(HEART) trial compared the outcomes of patients propensitymatched to obtain comparable subgroups with CAD and left ventricular dysfunctionundergoing CABG (n=718) versus PCI (n=718). The analysisidentified that CABG was significantly associated with lower rates of repeatrevascularization and better survival compared with PCI at 1, 5, 10 and 15years.The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease(APPROACH) identified 3,584 patients with3-vessel and/or left main disease of 15,939 patients undergoing first myocardialrevascularization, and 908 with LVEF <50%. In both patients with moderate andsevere left ventricular systolic dysfunction, the risk of cardiac death afterPCI was significantly greater than after CABG. Similarly, the risk of all-causedeath tended to be higher after PCI than after CABG in both patients withmoderate and severe left ventricular systolic dysfunction. CABG was associatedwith better 5-year survival outcomes than PCI in patients with LVEF <50% withcomplex CAD in the era of drug-eluting stents.The CREDO-Kyoto PCI/CABG Registry Cohort-2, 1,212 patients with CAD and LVEF ≤35%were randomized to medical therapy or CABG. Patients with LM disease wereexcluded, 17% of patients on medical therapy underwent CABG and 6% of patientsunderwent PCI by the end of the follow-up period. In the intention-to-treatanalysis, all-cause mortality was not significantly lower with CABG than withmedical therapy; however, all-cause mortality or hospitalization forcardiovascular causes occurred less frequently among patients undergoing CABG.The results with respect to all other secondary clinical outcomes also favoredCABG. In addition, CABG was associated with a reduced risk for the primaryoutcome (death) in the "as-treated" analysis, which compared the outcomes of 592patients treated with medical therapy throughout the first year afterrandomization with those of 620 patients who underwent CABG-either as aconsequence of randomization or crossover-and reported significantly lowerall-cause mortality in favor of CABG.In the Surgical Treatment Ischemic Heart Failure (STICH)trial, which was conducted to evaluate the long-termeffects of CABG in patients with ischemic cardiomyopathy. The rate of death fromany cause over 10 years was lower by 16% among patients who underwent CABG inaddition to receiving medical therapy than among those who received medicaltherapy alone. Overall, CABG was associated with an incremental median survivalbenefit of nearly 18 months and prevention of one death due to any cause forevery 14 patients treated and of one death due to a cardiovascular cause forevery 11 patients treated. CABG was associated with more favorable results thanisolated medical therapy across all clinically relevant long-term outcomesevaluated by the authors. These findings were directionally similar to thosereported earlier. The choice between CABG and PCI should be made by the heartteam after careful evaluation of the patient's clinical status and coronaryanatomy, including SYNTAX Score, comorbidities and expected completeness ofrevascularization. A specialist in heart failure should be consulted.In 2016, the authors reported the results of the STICH Extension Study(STICHES)versus PCI among patientswith reduced ventricular function and multivessel CAD. For example, the NorthernNew England Cardiovascular Disease Study Group (NNECDSG) is a voluntaryregional consortium of 7 hospitals in New Hampshire, Vermont, and Maine thatprovide the majority of PCI and cardiac surgery in the region. The authorsexamined all patients undergoing primary isolated coronary revascularizationfrom 2004 to 2014. To simulate a real-world STICH-like population, the inclusionand exclusion criteria for the STICH trial were applied. Specifically, wereincluded in the analysis patients who had EF ≤35% and 2- or 3-vessel CAD.The final study cohort was 955 CABG and 718 PCI patients. The median duration offollow-up was 4.3 years. CABG was associated with improved long-term survivalcompared to PCI after risk adjustment. Although CABG and PCI had similar 30-daymortality rates, CABG was associated with a higher frequency of cerebrovascularaccidents and acute kidney injury, whereas PCI was associated with a higherincidence of repeat revascularization. The authors concluded that, amongpatients with reduced ejection fraction and multivessel disease, CABG wasassociated with improved long-term survival compared with PCI and should bestrongly considered in patients with ischemic cardiomyopathy and multivesselcoronary disease.Because PCI has become an established treatment option for selected patients withCAD and the STICH trial did not include a PCI arm, some groups sought to assessthe comparative effectiveness of CABG  enrolled patients with reduced left ventricularsystolic function, defined as a LVEF <50%, who had PCI with drug-elutingstent (DES) or CABG from the Cardiovascular Catheterization and SurgeryDatabases of Samsung Medical Center. There was no statistically significantdifference in all-cause death in the follow-up (median duration of 32 months).In the propensity score matching analysis performed in 141 patient pairs, thelong-term cumulative mortality rate was not significantly different between thegroups. However, the rate of major adverse cardiac and cerebrovascular eventswas higher in the DES group than the CABG group, which was explained by thehigher incidence of repeat revascularization in the DES group.Yang et al. selected patients with multivessel disease andLVEF ≤35% who underwent either PCI with everolimus-eluting stent (n=1063)or CABG (n=1063) with propensity score matching from the New York StatePercutaneous Coronary Intervention Reporting System. In the short term, PCI wasassociated with a lower risk of stroke in comparison with CABG. At long-termfollow-up (median of 2.9 years), PCI was associated with a similar risk ofdeath, a higher risk of myocardial infarction, a lower risk of cerebrovascularaccident, and a higher risk of repeat revascularization. Completeness ofrevascularization played a major role in this study, such that, in patients inwhom complete revascularization was achieved with PCI, there was no differencein myocardial infarction between PCI and CABG.Bangalore et al.Although it seems clear that patients with severe left ventricular dysfunctionbenefit most from revascularization, nothing is set in stone yet. A highperi-procedural risk must be balanced against late mortality benefit and prosand cons of each strategy (either PCI or CABG) must be weighed up in thedecision-making process.


To compare dosimetric data of the organs at risk (OARs) and clinical target volumes (CTVs) between intensity-modulated proton therapy (IMPT) and volumetric-modulated arc therapy (VMAT) for patients undergoing prostate and elective, pelvic lymph node radiotherapy in the setting of unfavorable, intermediate and high-risk prostate carcinoma.A study of moderately hypofractionated proton therapy (6750 centigray [cGy] in 25 fractions) is in progress for unfavorable, intermediate and high-risk prostate cancer where treatment includes an elective pelvic nodal CTV (4500 cGy in 25 fractions). Ten consecutively accrued patients were the subjects for dose-volume histogram comparison between IMPT and VMAT. Two treatment plans (IMPT and VMAT) were prepared for each patient with predefined planning objectives for target volumes and OARs. The IMPT plans were prepared with 2 lateral beams and VMAT plans with 2 arcs.The CTV coverage was adequate for both plans with 99% of CTVs receiving ≥ 100% of the prescription doses. Mean doses to the bladder, rectum, large bowel, and small bowel were lower with IMPT versus VMAT. Mean femoral head dose was greater with IMPT. The percentage of volumes of rectum receiving ≤ 47.5 Gy, large bowel receiving ≤ 27.5 Gy, small bowel receiving ≤ 30 Gy, and bladder receiving ≤ 37.5 Gy was less with IMPT versus VMAT, largely because of reduction in the low-dose “bath” associated with VMAT.In the setting of prostate and elective, pelvic nodal radiotherapy for prostate cancer, IMPT can significantly reduce the dose to OARs, in comparison to VMAT, and provide adequate target coverage. External beam radiotherapy (RT) has been widely used for the treatment of high-risk, clinically localized prostate carcinoma. Clinical target volumes of RT for high-risk prostate cancer often include the regional pelvic lymph nodes, because of the increased risk of nodal metastasis, along with the prostate and seminal vesicles. In addition, most large, published, randomized trials evaluating the efficacy of RT, with or without androgen-deprivation therapy, approached RT in this manner –6.RT techniques have evolved rapidly with the introduction of intensity-modulated RT (IMRT), including more-recent techniques, such as volumetric modulated arc therapy (VMAT), an arc-based approach to IMRT. Although IMRT provides a more-conformal dose distribution to target volumes in comparison to 3 Dimensional conformal RT, IMRT spreads out the integral dose over a large volume of healthy tissue with significant dose to organs at risk (OARs). Proton therapy may provide an advantage over IMRT in sparing nontarget, healthy tissue while maintaining target coverage, given its characteristic dose distribution and Bragg peak with decreased exit dose. This dosimetric gain of proton therapy may be further amplified when clinical target volumes expand to a larger area increasing the volume of nearby OARs. Such an example is pelvic nodal irradiation for high-risk prostate carcinoma.More recently, intensity modulated proton therapy (IMPT) has been incorporated into clinical practice, in which discrete spot scanning with a proton pencil beam delivers the dose from a highly conformal treatment plan. However, few studies have investigated dosimetric differences between IMPT and VMAT in the setting of elective pelvic nodal coverage for patients undergoing RT for prostate cancer. We aimed to perform such a comparison in a recent cohort of patients treated on a prospective study, NCT02874014 [A study of moderately hypofractionated proton therapy for patients with unfavorable, intermediate or high-risk prostate cancer completed accrual between August 2016 and November 2018. The study was approved by our institutional review board and was registered at clinicaltrials.gov (NCT02874014). Staging work-up included a bone scan and computed tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen and pelvis. Patients with clinical evidence of pelvic nodal or distant metastasis were ineligible for the study. In this single-arm, prospective study, the clinical target volumes (CTVs) included the regional pelvic lymph nodes (CTV low), as well as the prostate and the seminal vesicles (CTV high). The CTV high and CTV low received 6750 centigray (cGy) radiobiologic equivalent (RBE) and 4500 cGy (RBE), respectively. The two dose levels were delivered simultaneously in 25 fractions over 5 weeks. The first 10 enrolled patients provide the basis for this dosimetric study.As part of the standard of care for unfavorable, intermediate or high-risk prostate cancer, patients also received adjuvant androgen deprivation therapy for 6 to 36 months. Androgen deprivation therapy started 2 months before the beginning of RT and consisted of bicalutamide 50 mg by mouth once daily for 2 to 4 weeks and a luteinizing hormone-releasing factor agonist (goserelin or leuprolide).Four carbon fiducial markers were implanted into the prostate gland. These implanted carbon markers were used for daily image guidance. Patients were simulated with a full bladder. A planning CT scan was performed with the patient in supine position. An indexed knee cushion and a custom vacuum-lock bag were used to immobilize the legs and feet. The leg immobilization reduced daily setup variation, particularly variation in foot rotation. A scout CT scan was obtained to adjust rotation and bony alignment of the patient. The patient was then scanned from above the iliac crests to the mid femur with 2-mm slice thickness. Shortly after CT simulation was completed, MRI of the pelvis (MR simulation) was obtained with the same setup described above.Both CT and MRI images were then imported into the Eclipse treatment planning system , and the 2 data sets were fused, with the implanted, intraprostatic carbon markers as references.The CTVs were delineated by the attending radiation oncologist, with MRI images as a supplemental tool for delineating the CTV high. The CTVs were defined according to the consensus guidelines and current protocols of the Radiation Therapy Oncology Group (RTOG) . The CTVTwo sets of plans (IMPT and VMAT) were prepared for each patient with predefined dose-volume histogram (DVH) objectives for target volumes and OAR. Quantitative evaluation of plans was performed by means of a standardized DVH. For CTVs and PTVs, D99% and D2%  were reported as metrics for minimum and maximum doses. To complement the appraisal of D99% and D2%, V100% and V107%  were reported. For OARs, the analysis included the mean dose, the maximum dose expressed as D2cc (Gy), and a set of appropriate volume metrics.An optimized proton plan was generated by the Eclipse treatment-planning system. Spot spacing was set to 3 mm. The planning process involved the inverse optimization of dose distribution generated by a number of pencil beam spots scanning for cloud-covering targets and OARs and the modulating each beam spot with simultaneous tuning of spot energy and weight. Two opposed lateral beams were used in all cases. Plan quality and acceptability were assessed based on DVH parameters of target volumes and OARs.IMRT at our institution is delivered via VMAT. Moreover, VMAT has been widely used to treat prostate cancer, given its demonstrated plan quality and efficiency. An optimized VMAT plan was generated by the Eclipse treatment-planning system. The VMAT plans consisted of ≥ 2 coplanar arcs.Treatment setup for daily proton beam therapy was identical to the simulation setup, including bladder and bowel preparation. Image-guided localization of the prostate was achieved with onboard orthogonal-kilovolt imaging of the intraprostatic carbon markers before treatment of each field.When proton therapy was delivered with a daily setup based on the prostate position (using on-line matching of the intraprostatic carbon markers), there was uncertainty about the dose coverage of the regional pelvic nodes, which can be independent of prostate motion. To assess the adequacy of the CTV coverage during the 5-week course of proton therapy, a verification CT scan was acquired weekly, starting 1 day before the start of proton therapy. The CTV high and CTV low were propagated from the planning CT scan to the verification CT scans by matching intraprostatic carbon markers and pelvic bones, respectively. Coverage of CTVs was then evaluated on the weekly verification CT scans.P < .05. All statistical analyses were performed with the statistical software R .Various dosimetric parameters were compared between IMPT and VMAT plans. Percentage of the volume of the rectum, large bowel, small bowel, bladder, and femoral heads receiving between 10 and 70 Gy were evaluated and compared. The paired 2-sided Wilcoxon signed-rank test was used to compare IMPT versus VMAT plans. The level of statistical significance adopted was Table 1 shows the mean values with standard deviations for the mean (cGy) dose, D99% (%), D95% (%), D2% (%), V95% (%), V100% (%), and V107% (%) of CTV high and CTV low for IMPT versus VMAT. The coverage of CTVs was adequate for both plans with > 99% of CTVs receiving the prescription doses. The mean values with standard deviations for the same DVH metrics of PTV high and PTV low are shown in Table 2. In both Tables 1 and 2, an asterisk is used to denote a statistically significant difference between IMPT and VMAT values on a Wilcoxon signed-rank test (P < .05). Figure 1 depicts the median DVH values of the CTV high and CTV low at various dose points for each modality.Table 3, including the rectum, large bowel, small bowel, and bladder. The mean dose to the femoral heads was significantly higher with IMPT in comparison to VMAT. Table 3 also displays various DVH metrics with statistical comparison of IMPT versus VMAT. Figures 26 graphically depict DVHs of the rectum, large bowel, small bowel, bladder, and femoral heads, respectively, at various dose points for each modality.IMPT had significantly lower mean doses for most OARs in comparison to VMAT, as depicted in Table 3 and Figures 2 through 6, the DVH metrics favored IMPT over VMAT, except for the femoral heads. In general, IMPT plans did not produce the typical low-dose “bath” to the pelvis seen with VMAT plans. For the femoral heads, the mean dose and percentage of volumes receiving 11.25 to 30 Gy were greater with IMPT plans. Those higher DVH metrics were primarily a by-product of 2 opposed lateral beams used for a typical IMTP plan.As shown in For high-risk prostate cancer, radiation treatment volumes often include elective pelvic lymph nodes because of an increased risk of occult lymph node metastasis. The efficacy of pelvic lymph node coverage for unfavorable, intermediate or high-risk prostate cancer remains an open question, currently being investigated by RTOG 0924 (NCT01368588). Recent evidence in the setting of salvage RT showed a significant benefit for biochemical free survival with the addition of pelvic nodal radiation .There have been no prospective studies reported to date, to our knowledge, evaluating the efficacy and toxicity of proton beam therapy in the setting of unfavorable, intermediate or high-risk prostate cancer in which target volumes are expanded to cover the regional pelvic lymph nodes. Recently, Chuong et al  reportedFigures 2 through 6. Although VMAT can deliver highly conformal, high-dose target coverage, this is achieved by spreading out the low-to-medium dose over a larger volume of nontargeted tissues. In contrast, IMPT is able to reduce the dose to nontargeted tissues significantly and deliver equally conformal, high-dose target coverage because of its distinct advantage of having minimal dose distal to the targets.IMPT spared more OARs in the pelvis than the VMAT did in our study. The mean doses to the rectum, large bowel, small bowel, and bladder were significantly decreased with IMPT as compared with VMAT. Additionally, the volumes of those OARs receiving low-to-medium radiation doses were significantly smaller with IMPT plans compared with VMAT plans. That difference is readily evident in the shapes of the DVH curves for each OAR, shown in It is plausible that this large-dose reduction in the pelvic organs by IMPT can translate into lower gastrointestinal and genitourinary toxicity. In our cohort, the mean dose to the rectum was decreased by 36%, and the percentage volume receiving ≤ 45 Gy was significantly reduced with IMPT. In the dose-escalation study by the MD Anderson Cancer Center, DVH metrics revealed a continuous dose effect for rectal toxicity, and differences in the lower-dose region were more predictive of rectal morbidity than the higher-dose region . The smaThe unresolved question is whether a large reduction in low-to-medium doses to the pelvic organs by IMPT actually reduces gastrointestinal and genitourinary toxicity, in comparison with IMRT. A prior comparative effectiveness study  found noOf note, in our study, the mean dose and the percentage volume of the femoral heads receiving 20 to 30 Gy were higher with IMPT plans. In addition, maximum point doses were generally greater for IMPT compared with VMAT. These higher DVH metrics were primarily a byproduct of 2 opposed lateral beams used for a typical IMTP plan. This disparate effect of IMPT can be eliminated by adding another beam in a different direction (such as a posterior oblique beam). Furthermore, the clinical effect of the increased dose to the femoral heads in the IMTP plans may not be significant because the mean dose to the femoral heads (1821 cGy) was well below the 45 Gy generally considered a clinically acceptable dose.A limitation of our analysis is that all photon plans were generated specifically for this dosimetric study. However, the quality of all photon plans was reviewed by radiation oncologists specializing in the treatment of genitourinary malignancy, met departmental criteria, and all were planned by dosimetrists using standardized departmental methodology. Additionally, the dosimetric differences observed here with IMPT are in the setting of 2 opposed lateral fields for each IMPT plan. More sophisticated IMPT approaches, including the use of additional anterior or posterior oblique beam(s) could result in even greater differences in this cohort between IMPT and VMAT plans. Nevertheless, even with opposed lateral fields alone, as these patients were treated, significant differences in dose to OARs were noted.In summary, the dosimetric data presented here provide achievable dose constraints for whole-pelvic radiation therapy with IMPT as a reference for future studies, and the comparative results provide further rational for the prospective evaluation of IMPT versus IMRT, especially in the setting of elective pelvic lymph node coverage.Intensity-modulated proton therapy can significantly reduce low-to-medium doses to the rectum, large bowel, small bowel, and bladder, in comparison with VMAT. This dosimetric advantage of IMPT may translate into a decreased risk of gastrointestinal and genitourinary toxicity for patients receiving pelvic lymph node irradiation. Further study is warranted to correlate a dosimetric advantage of IMPT with clinical outcomes.


The epithelial layer creates a chemical and physical barrier at the forefront of intestinal mucosa, and immune cells beneath the surface epithelium are poised to react to extrinsic factors, to maintain tissue homeostasis. Importantly, the nexus of epithelial–immune responses at mucosal surfaces is dexterously modulated by intrinsic stromal–mesenchymal cells. First, organogenesis of lymphoid tissues, including Peyer's patches, requires dynamic interplay between lymphoid cells and stromal cells, which have become known as “lymphoid organizers.” Second, correct spatiotemporal interaction between these cell populations is essential to generate the infrastructure for gut immune responses. Moreover, immune cells at the intestinal barrier are functionally modulated by stromal cells; one such example is the stromal cell–mediated differentiation of innate immune cells, including innate lymphoid cells and mast cells. Ultimately, mucosal stromal cells orchestrate the destinations of epithelial and immune cells to maintain intestinal immune homeostasis. The single layer of epithelial cells at the intestinal mucosa creates both a chemical and physical barrier to protect the body. Overlying the epithelial surface of the digestive tract are mucin-containing layers, which play an important role in preventing commensal bacteria from attaching directly to gut epithelium. A single layer of mucus covers the small intestinal epithelium, whereas two layers (inner and outer) overlay the epithelium of the stomach and colon . Mucus iTo efficiently absorb nutrients from the ingested diet, the intestine contains a huge number of villi. The gut epithelial cells overlying these villi create a physical barrier by sealing the spaces together with other epithelial cells [reviewed in ]. These In this review, we highlight current knowledge regarding the crucial and complex roles of stromal cells from intestinal epithelial homeostasis to surface immune responses.in vitro co-culture of ISEMFs and epithelial cells or intestinal organoids  composed of epithelial cells shows that ISEMFs are critical for epithelial proliferation  receptor α, and the WNT agonist R-spondin 3 . These c+ cell populations, including telocytes, abolishes the proliferation of stem and transit amplifying cells , predicted as its involvement in epithelial barrier formation   .+ subset of colonic goblet cells support intestinal epithelial stem cells via secretion of Wnt, indicating that activation of cryptal stromal cells due to danger signaling leads to both protection and maintenance of the stem cell niche through dual pathways (directly and indirectly through secretory cell–derived Wnt)  . IL-33, ved Wnt) .highCCL19high fibroblasts, may strongly influence on the function of macrophages and Th17 cells leading chronic inflammation. So that, regulation of the function of this fibroblast population will be useful therapy for IBD.However, increase of IL-6 in colonic tissues, produced by continuously activated CD74Stromal cells located the sub-epithelial compartments of PPs are required for the development of specific epithelial cells, including antigen-sampling M cells. M cells are considered to be “gatekeepers” of the mucosal immune system and serve as entry sites for luminal antigens and bacteria . M cellsOverall, current knowledge supports that—as determinants of epithelial integrity and sentinels of mucosal immune responses—sub-epithelial and cryptal stromal cells play indispensable roles in the barrier function of the intestinal mucosa.In addition to epithelial regulation, another important role of stromal cells is their biologic contribution to lymphoid organogenesis [reviewed in ]. The or+ LTo cells in gut +CD3−CD4−IL-7Rα−CD11c+ cells —must be present before clustering of and interaction between LTo and PPi cells can occur at the site of PP organogenesis  needs to be investigated.Lymphoid tissue contains 3 types of stromal cells: fibroblastic reticular cells, follicular dendritic cells, and marginal reticular cells . Analysis in gut . The LTiogenesis –57. RET ogenesis , 58. In ogenesis . Importahigh and ICAM-1high stromal cells . Iniewed by . Furtheriewed by .Taking these findings together, stromal cells are involved in and are necessary for mucosa-associated lymphoid organogenesis. However, the nature and fate of various organizer cells  have not yet been elucidated and merit further research. The possible heterogeneity of LTo cells particularly ought to be investigated, given that the local tissue microenvironment  may influence this characteristic.The seminal influence of stromal cells on the immune system occurs not only in mucosa-associated inductive or organized sites  but also at effector or diffused sites . Precise investigations of the immune cells in peripheral tissues revealed the direct interaction between stromal and immune cells . In thisSeveral cascades of stromal cell-mediated immune regulation have been reported but remain poorly characterized as yet . For exa+ T cells reduced the production of IFNγ by this T cell population –programmed cell death protein 1 (PD-1) pathway . PD-1–mepulation . In addipulation . Stromalpulation , suggestpulation , thus gepulation . Togethe− and PDGFR+ stromal cells through IL-33 and as yet unknown mediators, respectively , anatomic , and functional  characteristics of each stromal cell subset , stromal cells are important for maintaining the integrity of the intestinal mucosal barrier. In contrast, during inflammation, stromal cells exacerbate the pathologic conditions in fibrosis and carcinoma . Itl subset , 82. Howl subset , 84. FurAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


McCune-Albright syndrome (MAS) is a rare genetic disorder characterized by café-au-lait macules, polyostotic fibrous dysplasia and multiple endocrinopathies. Liver involvement, although described, is a rare complication. We review the case of a child with MAS whose initial presentation was characterized by severe neonatal cholestasis. The case demonstrates a severe phenotype of persistent cholestasis in MAS requiring liver transplantation. This phenotype has been previously considered to be a more benign feature. This case highlights the importance of consideration of MAS as an uncommon but important cause of neonatal cholestasis. Early diagnosis may allow for prompt recognition and treatment of other endocrinopathies. What is already known on this topic?Hepatic disease is a rare but described feature of McCune-Albright syndrome (MAS). Previous descriptions of cholestasis in MAS have detailed a benign phenotype with gradual improvement and resolution over time.What this study adds?This case demonstrates a presentation of severe cholestasis in McCune-Albright syndrome with significant associated morbidity, ultimately leading to liver transplantation.Classically, McCune-Albright syndrome (MAS) is characterized by café-au-lait macules, polyostotic fibrous dysplasia and multiple endocrinopathies, including precocious puberty. The condition presents with different tissue involvement depending on the location of the postzygotic somatic mutations, resulting in wide phenotypic variability. Understanding the diverse manifestations of this rare diagnosis is important as it is associated with potentially significant complications including short stature, fractures, facial deformity and hearing and vision loss.The index patient is a female infant born following an uncomplicated pregnancy. She was delivered at 40 weeks gestation with a birth weight of 2020 g and presented at two weeks of life with significant neonatal cholestasis. She had persistent jaundice and mild hepatomegaly with laboratory investigations showing evidence of conjugated hyperbilirubinemia  and marked elevation of liver enzymes . Further investigations revealed normal coagulation parameters  and albumin levels [41g/L ]. The patient underwent a comprehensive panel of investigations to determine the cause of the hepatobiliary dysfunction, but no clear diagnosis was identified. She had a normal TORCH screen, hepatitis B and C serologies, alpha-1-anti-trypsin level, galactosemia screen, metabolic and mitochondrial studies, urine bile acids and negative genetic testing for Niemann-Pick type C, Alagille syndrome and progressive familial intra-hepatic cholestasis. Imaging of the liver revealed mild hepatomegaly with non-specific mild heterogeneity and no evidence of biliary obstruction. A liver biopsy was performed at one month of age and showed significant liver damage with cytoplasmic and canalicular cholestasis, broad areas of resolving hepatocellular necrosis, giant cell transformation and abundant extramedullary hematopoiesis.She experienced ongoing severe cholestasis with secondary complications, namely significant fat malabsorption and failure to thrive requiring placement of an enterostomy tube. The patient experienced episodes of recurrent respiratory infections and sepsis. She also sustained a non-traumatic femur fracture, which was thought to be related to metabolic bone disease in the setting of profound cholestasis and poor nutrition. As a result of these progressive complications, she was listed for liver transplantation and underwent a living related donor transplant at the age of 10 months. Histologic examination of the liver explant showed severe cholestatic liver disease with intrahepatic cholestasis, focal bile cannalicular plugs, mild to moderate focal peri-portal and sinusoidal fibrosis, yielding no definitive cause for the liver disease.At 14 months of age, she presented with a five-day history of vaginal bleeding. She was otherwise well, with no history of fevers, discharge or abdominal pain. Physical examination was significant for sexual precocity including Tanner stage 2 breasts and pubic hair with an estrogenized vulva. Dermatological examination revealed multiple ragged-edge café-au-lait macules in the lumbosacral area and bilaterally on her legs.Laboratory investigations revealed undetectable follicle-stimulating hormone and luteinizing hormone (<0.1/<0.1 IU/L), an elevated estradiol , a suppressed thyroid-stimulating hormone  and elevated free T4 . Cortisol level was normal . An initial bone age assessment after the episode of vaginal bleeding, revealed a slight advancement (by 4 to 10 months). However, follow up radiography performed at 21 months of age revealed an advancement of 21 months, with a bone age of 42 months. Skeletal survey revealed evidence of lesions in the femur and humerus suggestive of polyostotic fibrous dysplasia . A routiWritten informed consent was obtained from the parents of the patient.GNAS1 (adenylate cyclase stimulatory G protein) gene that has been associated with the MAS phenotype  in exon 8 of the henotype .Over the next six months, the patient continued to develop recurrent episodes of vaginal bleeding with evidence of an advancing bone age. She was initiated on a trial of an aromatase inhibitor for management of precocious puberty. She sustained recurrent fractures of her femur and received a course of bisphosphonate therapy. She has required intermittent treatment with methimazole for thyroid over-activity. She is receiving ongoing clinical surveillance of bone lesions and screening for other comorbidities of MAS.G protein a stimulatory subunit (GNAS) gene (MAS is caused by activating somatic mutations within the AS) gene . These mAS) gene . One casAS) gene . LumbrosAS) gene  presenteAS) gene ,5. To ouAS) gene .The underlying mechanism by which the constitutive activity of the G protein leads to cholestasis is unclear, however it has been suggested to play a role in bile metabolism . G proteHepatobiliary lesions and hepatic adenomas have been identified in adult patients with MAS, further supporting the concept of persistent liver involvement as a pathologic feature of the syndrome . Less coThe reported patient was started on letrozole for treatment of precocious puberty. Aromatase inhibitors have been associated with mild liver abnormalities among women taking it as an adjuvant treatment for breast cancer and rarely it has been associated with more significant hepatoxicity . LongituThe case reported here exhibits a severe phenotype of persistent cholestasis in MAS which has been previously considered to be a more benign feature. While this is a rare finding, we propose that MAS should be considered in the differential diagnosis of unexplained cholestasis. Occurring in the neonatal period, the presence of cholestatic liver disease may provide an early clue to the underlying diagnosis of MAS. In turn, prompt diagnosis may allow for screening, recognition and treatment of other endocrinopathies and bone disease.


Sirtuin (SIRT) [FOXO [KLOTHO (KL) [KL is 116 kDa. Yet, Western blotting studies in vascular cells report smaller molecular weights of KL without demonstrating specificity of the bands with, for example, siRNA knockdown experiments [Aging is an independent risk factor for cardiovascular, neoplastic, and neurodegenerative diseases. Several genes have emerged as important regulators of signal transduction pathways and gene programs linked to longevity, including members of the n (SIRT)  and FOXOT) [FOXO  gene famTHO (KL) . The acceriments . Commerceriments , the esteriments . Even moclustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) system [www.synthego.com) to a specific sequence in the genome where a protospacer adjacent motif (PAM) exists. Upon contacting the PAM and contiguous complementary sequence recognized by the sgRNA, Cas9 creates a DNA double-strand break that undergoes rapid mending by the cell’s endogenous repair machinery. In the presence of a repair template, typically a single-strand oligonucleotide (ssODN), precise sequences – even single base substitutions – become incorporated into the newly repaired segment of the genome. This astonishing technology has been a huge game-changer for biomedical research, to say nothing of the therapeutic potential [Myocd are transcriptionally active [Myocd allele CRISPR-tagged with a unique peptide . This offers further experimental rigor in detecting MYOCD whether in a cell or bound to other macromolecules.Meanwhile, new advances in genome editing were evolving, most notably the revolutionary ) system . This teotential . Accuratotential . Mass spotential . Since by active , it shouOnly about 1% of the CRISPR literature pertains to aging. What are some important considerations and how might CRISPR-tagging of proteins assist in further elucidating the biology of aging? Before CRISPR-tagging a gene locus in the mouse, investigators should determine what tag to incorporate. If, for example, eGFP is desired for live cell imaging, then a larger repair template will be required . It should be noted that unless a cell type is impossible or difficult to culture in vitro, CRISPR-tagging mice is preferred over cell lines since a mouse model affords both in vivo and in vitro experimentation and the time to generate such a mouse is remarkably fast (~5-6 weeks). Another important factor in CRISPR-tagging is ascertaining whether the tag should be placed at the amino or carboxy terminus of a protein. For example, tagging the carboxy terminus will often capture all splice variants of a protein. Preliminary experiments would be necessary to ensure protein activity and localization are not altered with the position of the tag. Apart from demonstrating the accurate molecular weight and true cellular localization of a longevity protein, CRISPR-tagging with 3xFLAG or 3xHA will allow for rigorous ChIP-seq of highly related proteins such as those of the FOXO family . By usin


Modulation of telomerase maintenance by gene therapy must meet two polarizing requirements to achieve different therapeutic outcomes: Anti-aging/regenerative applications require upregulation, while anticancer applications necessitate suppression of various genes integral to telomere maintenance . Patients suffering from aging-associated illnesses often exhibit telomere attrition, which promotes chromosomal instability and cellular senescence, thus requiring the transfer of telomere maintenance-related genes to improve patient outcomes. However, reactivation and overexpression of telomerase are observed in 85% of cancer patients; this process is integral to cancer immortality. Thus, telomere-associated genes in the scope of cancer gene therapy must be inactivated or inhibited to induce anticancer effects. These contradicting requirements for achieving different therapeutic outcomes mean that any vector-mediated upregulation of telomere-associated genes must be accompanied by rigorous evaluation of potential oncogenesis. Thus, this review aims to discuss how telomere-associated genes are being targeted or utilized in various gene therapy applications and provides some insight into currently available safety hazard assessments. The eukaryotic nuclear genome is packaged into discrete linear chromosomes, and this poses a unique biological problem: The ends of linear chromosomes must be distinguished from breaks to avoid unnecessary repair processes that may promote end-to-end fusion of chromosomes . To thisThe telomere attrition of linear chromosomes is solved in most eukaryotes by specialized telomeric nucleic acid-protein complexes: Telomeric DNA with a repetitive G-rich sequence composed of 5′-TTAGGG-3′ can be synthesized de novo by a complex composed of a catalytic subunit known as telomerase reverse transcriptase (TERT) and telomerase RNA component (TERC) that serves as a template. Additionally, a shelterin complex, which is a protein complex composed of three core subunits (telomeric repeat-binding factor (TRF)1, TRF2, and protection of telomeres protein (POT)1), is also critical for maintenance of telomere stability, as it enables DNA damage response machinery to distinguish telomeres from sites of genomic DNA damage [Despite these potential benefits of telomerase gene therapy, constitutive telomerase activation may lead to oncogenesis, since cancer cells frequently reactivate and upregulate telomerase activity to achieve immortalization ,5. Cancehttps://bioviva-science.com/blog/new-telomere-length-results-a-2018-update-by-liz-parrish/), there are increasing amounts of experimental evidence from other researchers supporting the transfer of the essential genes of telomere maintenance as a promising strategy to combat aging and restore cellular regenerative function for therapeutic benefits.Telomere attrition causes a wide range of age-related diseases. To this end, transfer of genes essential for telomere maintenance can be a promising strategy to combat these illnesses and restore the regenerative capacity of aging tissues. The first human use of telomerase gene transfer was reported in 2015, but the test was quite unorthodox, as self-experimentation was performed on the CEO of a company developing experimental adeno-associated virus (AAV) expressing human TERT. Despite the skepticism surrounding the results reported by the company, which have not been published in any peer-reviewed academic journal to date and are only available on the company website  vector expressing murine TERT improved the longevity of both adult (1-year-old) and old (2-year-old) mice . AAV9 waTRF1 gene, which is an essential part of the shelterin complex for telomere replication and protection, using AAV9 [TRF1 overexpression in adult mice, as their previous work demonstrated that constitutive TRF1 overexpression in TG mice led to telomere shortening through telomere cleavage by XPF nuclease [TRF1 gene was expressed in a number of organs, including the liver, heart, muscle, and brain. Ectopic TRF1 expression induced by AAV9 did not increase the cancer incidence rate in mice, further supporting the notion that transient expression of core telomere maintenance genes does not necessarily lead to carcinogenesis. Interestingly, induction of TRF1 expression only improved the longevity of old mice (2 years old at treatment), whereas it failed to improve the lifespan of adult mice (1 year at treatment), suggesting that TRF1 overexpression, unlike TERT, can only increase life expectancy when administered during a shorter therapeutic window. Additionally, TRF1 overexpression by AAV9 failed to alter telomere length significantly with respect to those observed following treatment with control AAV9 lacking the TRF1 gene expression cassette. This finding is intriguing, as it means that the authors successfully addressed XPF nuclease-mediated telomere shortening (observed in constitutively TRF1-overexpressing TG mice [Similar improvements in the longevity of aging mice were achieved by transfer of the ing AAV9 . The autnuclease . Similar TG mice ), yet leCollectively, the available literature on telomerase gene therapy for anti-aging applications properly highlights the promising future and provides exciting evidence to support that transient upregulation of essential telomere maintenance genes does not necessarily translate into carcinogenesis. However, the limited number of available studies means that more extensive exploration of this subject is necessary in the future to clarify what happens when these genes are transiently upregulated in younger mice (less than 1 year of age) and if other gene vectors, either nonintegrative or integrative, could achieve similar results without increasing the risk of carcinogenesis. Despite the potential risks of telomere gene therapy, which hold true for any newly emerging technology, the available results suggest that it is a promising candidate with substantial benefits to combat age-associated illnesses in an aging society with increasing average life expectancy.In clinical studies, short leukocyte telomere length has been associated with cardiovascular risk factors, such as smoking, obesity, and hypertension : This isA telomerase-deficient TG mouse with telomere attrition developed cardiomyopathy and exhibited impaired cell division, greater cardiomyocyte death, and cellular hypertrophy, leading to various cardiac dysfunctions . Based oTRF1 overexpression, rather than elongation of telomeres, was associated with the longevity of mice [A recent clinical study using autologous cell transplantation of peripheral blood-derived CD34+ cells in 43 patients with cardiomyopathy highlighted that higher expression levels of TERT in cell therapeutics improved their therapeutic effect against cardiovascular illnesses , suggest of mice . Additio of mice . Althougn = 2509) demonstrated that telomeres were not extensively shortened in individuals with familial history of cardiovascular illnesses [Despite the presented cases providing strong evidence of potential applications of telomerase gene therapy for cardiovascular illnesses, there are some concerns that require careful consideration during future studies. A study using endothelial cells isolated from patients suffering from coronary artery disease (CAD) demonstrated that cellular senescence in these patient samples was independent of telomere length and was instead dependent on oxidative damage , suggestllnesses , thus callnesses , suggestllnesses , an assollnesses , future Extensive accumulation of damages in the tissues will cause severe shortening of telomeres during the regenerative processes to promote proliferation and differentiation of cells to replace senescent cells with functional copies. Importantly, the chronic damaging of various tissues eventually promotes improper tissue regeneration, resulting in aberrant scarring and fibrosis.−/− TG mouse model, ultimately resulting in improved liver function and alleviation of cirrhotic pathology [−/− mice with aberrantly short telomere lengths, TERC-expressing adenovirus was systemically administered via the tail vein before liver ablation. TERC-expressing adenovirus effectively transduced the liver tissues, inducing robust transgene expression  to closely recapitulate the molecular pathogenesis of clinical IPF, involving both continuous damage and telomere shortening [Idiopathic pulmonary fibrosis (IPF) is a rare disease that scars the lungs; the symptoms progressively worsen over time. Similar to liver cirrhosis, telomere shortening following continued wear and tear of the lungs leads to permanent damage accumulation and uncontrolled scarring. Despite few Food and Drug Administration (FDA)-approved drugs currently available for IPF, these drugs only slow disease progression, but are not curative ,41. To tortening . Their fTelomere attrition is a major contributor to several other age-related diseases. This section of the review will discuss how telomere gene therapy is being applied to treat these illnesses.TERC, DKC1 (responsible for production of dyskerin that maintains telomeres), or poly(A) ribonuclease (PARN) can lead to reductions in TERC expression levels, and dysregulation of these genes are often observed in patients suffering from severe forms of dyskeratosis congenita (DC) or IPF [Genetic mutations to ) or IPF ,45,46,47) or IPF . Their fDegenerative disc disease (DDD) is characterized by progressive loss of human nucleus pulposus (HNP) cells and extracellular matrix (ECM) . As HNP TRF1 gene in BM by the CreLox system or constitutive silencing of TERT in TERT−/− to induce telomere shortening) [TRF1 in the BM of TG mice led to rapid telomere shortening, replicative senescence, BM failure, and a poor survival rate  in the absence of any TERT gene transfer, whereas mice receiving TERT-expressing AAV9 showed a greatly improved survival rate (87%) due to the lower incidence rate of aplastic anemia . Impressively, TERT gene transfer led to a drastic improvement in telomere length maintenance, as the length was retained at a level similar to that prior to deletion of TRF1 by the CreLox system, whereas the group treated with the empty AAV9 vector exhibited a 12-kb decrease in telomere length. This is important, as the degree of telomere shortening was positively correlated with the incidence rate of aplastic anemia. Similar anti-anemic effects were observed following TERT gene transfer by AAV9 in the TERT−/− model; this was evidenced by higher erythrocyte and platelet counts in the gene transfer group compared to the empty vector-treated group. Collectively, these findings showed that telomere attrition, which causes BM dysfunction and aplastic anemia in patients, can be effectively treated by TERT gene transfer.Aplastic anemia is a potentially life-threatening heterogeneous disorder, where bone marrow (BM) cannot produce sufficient quantities of new blood cells due to a sharp decline in the quantity of immature hematopoietic stem and progenitor cells (HSPC) . The disrtening) . Upon syIn most cases, cancer is an age-related genetic disease that occurs with persistent accumulation of genomic instability over time . Cancer The immortality of cancer is maintained by constitutive TERT expression, which means that the intracellular environment is rich in various factors that activate TERT promoters, while the promoter remains largely inactive in most normal cells. This allows TERT promoter-driven gene expression to occur in a cancer-specific manner in the majority of cancers, as ~85% of all cancers exhibit overexpression of TERT. This pan-cancer applicability of the human TERT promoter is important when considering that most other cancer-specific promoters are only capable of selectively targeting a small subset of cancers in a tissue-specific manner. For example, human alpha fetoprotein, carcinoembryonic antigen, and MUC1 promoter can only target subsets of hepatocellular carcinoma, colorectal and lung cancers, or breast cancer, respectively . The mosMany of the pioneering works (from the early 21st century) utilizing human TERT promoter focused on adenovirus-mediated delivery of suicide genes ,64 or apDuring the past decade, technological breakthroughs have increased the practicality of genome editing. The most recent adaptation to the field is CRISPR/Cas9, which is a simple RNA-guided platform with highly efficient and specific genome editing in diverse organisms . Thus, tSimilar to the application discussed in Despite numerous reports showing that human TERT promoter can endow cancer specificity to gene therapeutics, the promoter induces relatively weak transgene expression. This shortcoming remains a major challenge toward achieving an optimal therapeutic index with a TERT promoter-based gene expression system. To this end, Kim et al. developed a modified human TERT (mTERT) promoter to drive the replication of oncolytic adenovirus and compared its antitumor efficacy with that of unmodified human TERT promoter-driven oncolytic adenovirus . Their fIn 2018, two different modification approaches were reported to improve mTERT promoters further. The first approach generated a hybrid cancer-specific promoter by combining E2F and mTERT promoters with several copies of hypoxia response elements (HRE) to generate two variations of hypoxia-responsive and cancer-specific promoters (HEmT or HmTE) ; HEmT shCollectively, these studies illustrated that human TERT promoter can endow cancer specificity to the oncolytic adenovirus through transcriptional regulation of the E1A gene, and that the potency of these vectors can be further improved through genetic modification of the human TERT promoter.Alternative applications within the scope of gene therapy exploiting constitutive activation of TERT in cancer utilize silencing or inhibition of TERT or TERC activity ,77,78. FThe earliest works in the scope of the silencing of TERT or TERC were achieved by direct delivery of antisense oligonucleotides or siRNA with transfection reagents ,91. A reOne promising strategy to circumvent the poor biological stability and short-term silencing effect mediated by RNA interference therapeutics in the nucleotide form is to deliver short hairpin RNA (shRNA) via an expression vector. Unlike siRNA treatment, where 99% of duplex siRNA is degraded within 48 h of cellular delivery, shRNA transcription in the nucleus by an expression vector is continuous and leads to more durable gene silencing than siRNA . In suppAlthough RNA interference is the most commonly investigated gene therapy strategy to disrupt the telomerase function in cancer, there are several other approaches being investigated. One of these approaches utilizes a vector-mediated expression of hTERTC27 to cause telomere dysfunction . hTERTC2A C>T single-nucleotide mutation at either the -124 or -146 position (with respect to the ATG site of TERT) of the TERT proximal promoter region is frequently observed in various types of tumors . This muCollectively, these studies demonstrate that gene therapeutics with variable modes of telomerase inhibitory effects can be promising candidates to treat a wide range of tumor types in the future.Upregulation and downregulation of telomerase-related genes have shown promising therapeutic results for anti-aging/regenerative and anticancer applications, respectively. Furthermore, the preliminary safety hazard assessments for vector-mediated expression of telomerase-related genes in anti-aging or regenerative applications suggest that nonintegrative expression of these genes does not promote oncogenesis. Importantly, the transfer of telomere maintenance-related genes improved longevity and tissue regeneration to combat aging and age-related diseases. Alternatively, the strategies that silence or disrupt telomerase activity in cancer cells or endow cancer specificity to gene therapeutics via utilization of the human TERT promoter have rapidly evolved since their conception and development in the beginning of this century, ultimately improving the therapeutic potency and safety profile of cancer gene therapy. Collectively, these reports illustrate that telomere-associated genes are attractive candidates for gene therapy with multidimensional therapeutic benefits and wide applicability toward numerous disease targets.


The habenula is a complex nucleus composed of lateral and medial subnuclei, which connect between the limbic forebrain and midbrain. Over the past few years, the lateral habenula has received considerable attention because of its potential roles in cognition and in the pathogenesis of various psychiatric disorders. Unlike extensively studied lateral habenula, anatomically and histologically distinct medial habenula remains largely understudied. The medial habenula can be further subdivided into a dorsal region containing excitatory neurons that express the tachykinin neuropeptide substance P and a ventral region containing dense cholinergic neurons. Although the medial habenula is the source of one of the major cholinergic pathways in the brain, relatively few studies have been conducted to understand its roles. Recently, however, the medial habenula cholinergic system has attracted more attention because of its potential to provide therapeutic targets for the treatment of nicotine withdrawal symptoms, drug addiction, and various mood disorders. Here, we discuss the role of the medial habenula cholinergic system in brain function. The habenula is part of the epithalamus and is divided into medial and lateral subregions, each with a unique gene-expression profile . Over thin situ hybridization against ChAT mRNA both show that habenula cholinergic neurons are restricted to the MHbV . Since choline acetyltransferase (ChAT) is the only enzyme responsible for the biosynthesis of acetylcholine (ACh) , it is fthe MHbV , 24. Habthe MHbV , and by the MHbV . Accordithe MHbV , 28. Altthe MHbV .Genome-wide association studies suggest that specific single-nucleotide polymorphisms associated with an increased risk of nicotine dependence and nicotine addiction are located within a specific gene cluster on human chromosome 15 that encodes the α5, α3, and β4 nAChR subunits –34. Sincet al. demonstrated that acetylcholine and nicotine-evoked responses in the IPN neurons were markedly reduced in α5-null mice . Understanding how nicotine cessation and blockade of acetylcholine signaling after chronic nicotine exposure induce activation of GABAergic neurons in the MHb–IPN pathway will require a sophisticated examination of the connections between MHb cholinergic neurons and IPN neurons, the neural circuits within the IPN, and the connections between IPN GABAergic neurons and midbrain serotonergic neurons.Many studies have shown that nicotine withdrawal reduces levels of dopamine and serotonin , 44. In The habenula has also been linked to drug addiction more generally through a series of rodent experiments and human genome-wide association studies , 43, 46.Nicotine abuse prompts axonal neurodegeneration in the central region of the fr, and this axonal neurodegeneration is also observed following chronic exposure to various other drugs such as D-amphetamine, methamphetamine, MDMA, and cocaine. Nicotine and other drugs induce neurodegeneration of the central core region and external sheath region of the fr , 15. A rThe bed nucleus of the anterior commissure (BAC) and the triangular septum (TS) mainly project to the MHbD and MHbV, respectively , 7. UsinB receptors in cholinergic neurons increased the expression of conditioned fear  from MHb neurons by injecting Cre recombinase expressing AAV into the MHb of CB1-floxed mice reduced strongly the freezing response in cued and contextual fear conditioning , but did not attenuate the increased immobility time in the FST, in accord with the cholinergic hyperactivity theory of depression . The rel+ cell populations containing highly enriched genes, Amigo1 and Epyc, both of which encode cell-surface adhesion proteins. α5-Epyc neurons project locally whereas α5-Amigo1 neurons send long projections to raphe and LDTg nuclei. Neuron-specific silencing via prevention of neurotransmitter release by cre-dependent membrane-tethered Ca2+-channel toxin showed that silencing Amigo1-cells prevented place preference for nicotine, whereas silencing Epyc-cells had no effect . These ligand-dependent activity-modulating receptors may be useful targets for the treatment of various psychiatric disorders associated with malfunctioning habenula cholinergic neurons. For example, anhedonia-like behavior due to reduced habenular cholinergic signaling is not reversed by chronic administration of the standard antidepressant fluoxetine (As described above, habenula cholinergic neurons are closely tied to a variety of brain functions. Pharmacological approaches are needed to control the activity of these neurons. Interestingly, habenula cholinergic neurons express pharmacologically controllable GPCR proteins such as the GABAuoxetine . Thus, eSY and JK led the literature search and HL drafted the manuscript. HK provided substantial contributions to the intellectual content of the manuscript. All authors approved the final version of manuscript to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although China is undergoing rapid economic development, it is facing an ageing population. No data exists on malnutrition risks of older adults in an affluent Chinese society. The aim of this study is to examine these risks and identify their associated factors among home-living older Chinese adults in Hong Kong.This is a cross-sectional study, to which home-living subjects aged 60 or above were recruited, between May and September 2017, from a non-governmental community organisation located in three different districts of Hong Kong. Nutritional status was assessed by the Mini Nutritional Assessment (MNA), and its associated factors examined included socio-demographic characteristics, lifestyle, health status and diet. Multivariable logistic regression analysis was performed to identify factors associated with malnutrition risks (MNA < 24).n = 179) were at risk of malnutrition. By multivariable logistic regression, subjects (1) whose vision was only fair or unclear, (2) with poor usual appetite and (3) with main meal skipping behaviour had significantly higher malnutrition risk .Six hundred thirteen subjects  completed the survey. Nearly 30% (In this affluent Chinese society, the malnutrition risk in older adults is close to the global average, which is a matter for much concern. Interventions are therefore warranted that target vulnerable groups with poor vision, appetite, and meal skipping behaviour.Not applicable. Malnourished older people have poorer functional status –3, longePrevious literature has identified various risk factors of malnutrition in the community of older adults. Certain socio-demographic characteristics are associated with that risk: older age –17, femaBecause of the one-child policy , China iThis is a cross-sectional survey of the home-living old-age population in Hong Kong. Subjects were recruited through a large registered charitable non-governmental organisation (NGO), in three districts covering nearly one-seventh of the population in Hong Kong. The eligible criteria were (1) aged 60 or above , (2) livThis study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong. During the recruitment, eligible subjects were contacted by the NGO staff to ensure confidentiality. They received an information sheet with the details of the study, their rights regarding participation and withdrawal at any stage. They were informed that the survey would be completed anonymously. Those who were interested in participating were requested to sign the consent form. Approval for the use of certain instruments in the study was obtained before data collection.The survey comprised five sections: nutritional status, socio-demographic characteristics, lifestyle choices, health status and dietary factors.The MNA was used to assess the global nutritional staus , as recoData on socio-demographics characteristics were collected: age, sex, marital status, educational level, employment status, monthly household income, receipt of comprehensive social security assistance (CSSA), a financial assistance scheme provided by the Hong Kong government , and infHealth status was assessed by comorbidity using the Charlson Comorbidity Index (CCI), and other conditions common in older adults such as visual or hearing abilities, use of dentures, difficulty in chewing food and appetite. The presence of any disease was reported by participant who had the condition diagnosed by their physicians. CCI classifies comorbid conditions, with a weighed score of 1,2,3 or 6 assigned to each condition associated with a death risk . The totAs for dietary factors, the usual consumption of five major food groups  were assessed using culturally specific food frequency list adopted from the Hong Kong Department of Health . Locallyp-value < 0.25 in the univariate analyses were selected as candidate independent variables for backward multivariable logistic regression to identify factors independently associated with at-risk or malnourished status. The results of the final multivariable logistic regression model for the nutritional status outcome were presented by the odds ratios (OR) and their associated 95% confidence intervals (CI) of the significant factors identified. All statistical analyses were performed using IBM SPSS 24.0 . All statistical tests were two-sided with the level of significance set at 0.05.Data was presented as means (SD) for continuous variables and frequency (%) for categorical variables. The nutritional status of the participants was dichotomised to (1) normal and (2) at risk or malnourished based on MNA. Socio-demographic and lifestyle characteristics, health status and dietary factors were presented and compared between participants with normal nutritional status (MNA ≥ 24) and at risk or malnourished (MNA < 24) by independent t-test for continuous variables and chi-square test for categorical variables. Binary logistic regression was used to perform univariate analysis of socio-demographic and lifestyle characteristics, health status and dietary factors associated with at-risk or malnourished nutritional status. Those factors with a A total of 613 subjects completed the survey without missing data on MNA were included in the study (response rate = 52.0%)   Table .Fig. 2Nup-values < 0.25 in the univariate analysis revealed that (1) visual ability, (2) usual appetite and (3) main meal skipping behaviour were significantly and independently associated with at-risk or malnourished status (Table p = 0.020) and those with weak ability had an even higher odds . Older adults with a good usual appetite had a decreased odds of being at risk or malnourished , whereas those with little usual appetite had an increased odds , when compared with those who reported a normal usual appetite. Older adults skipping one or more main meals per day had an increased odds of being at risk or malnourished  compared with those without main meal skipping behaviour.The results of the univariate analyses of socio-demographic and lifestyle characteristics, health status and dietary factors associated with at risk or malnourished nutritional status are to be found in Table It has long been believed that malnutrition is an important health issue only in less developed economies where food insecurity and infectious disease prevail . Given tBy multivariable logistic regression, the high malnutrition risk was found to be associated with (1) fair and poor visual ability, (2) lack of appetite and (3) meal skipping behaviour. Our study found the poorer the visual ability, the higher the odds of being at risk or malnourished. This is consistent with a previous study’s finding that poor vision was associated with higher malnutrition risk among older assisted-living residents . Since pOur findings on the relationship between poor appetite and high malnutrition risk are consistent with a Netherlands prospective cohort study , indicatIn our study, subjects with meal skipping behaviour had a higher malnutrition risk, matching the findings of other studies , 13. SkiThe strengths of our study include the use of MNA, which is a well-validated and frequently used nutrition screening tool specifically intended for older adults , 51, andTo conclude, this study found that a significant proportion of the home-living older adults were at risk of malnutrition in an affluent Chinese community, which causes much concern and deserves attention, revealing a need to examine the impacts of disparity between rich and poor on nutrition in older adults. The results of the multivariable logistic regression analysis found that, fair or poor visual ability, lack of appetite and meal skipping behaviour are associated with high malnutrition risk. Eye care services improvement is vital to reduce the problem of visual impairment and thus malnutrition. The sensory perception of flavour, wide variety and traditional types of food can improve the appetite of older adults. Older people’s canteens can be developed to allow interaction among older adults to enhance social support, while providing nutritionally balanced meals at low cost.