High precision is necessary during percutaneous transcatheter heart valve implantation. The precision of the implantation has been established by increasing the heart rate  to the point of significantly reduced cardiac output and thus minimizing valve movement. Routinely, this tachycardia is induced by rapid pacing. Here we report a case of failure to pace during valve-in-valve (VIV) Edwards Sapien XT implantation in the tricuspid valve position. Transient cardiac arrest was induced by intravenous adenosine injection enabling accurate valve implantation. Transcatheter valve-in-valve (VIV) procedures are relatively new procedures performed increasingly in degenerative bioprosthetic valves as an alternative to surgical replacement. The procedure has challenging technical aspects and requires high level of accuracy. During valve implantation, accuracy is achieved by rapid pacing, which reduces cardiac output and minimizes involuntary valve movement. For this reason, a temporary electrode is placed in the right ventricle.For tricuspid VIV procedures, pacing may be induced by an electrode placed either in the left ventricle or in the coronary sinus. An attempt may also be made to deploy the valve without pacing due to the low flow velocity in the right ventricle outflow tract.This is a case of failed rapid pacing during tricuspid VIV implantation. Adenosine was used as an alternative to create temporary heart block, enabling accurate valve deployment during the cardiac arrest period. Adenosine inhibits atrioventricular (AV) node conduction, leading to a short-acting AV block and temporary cardiac asystole .A 63-year-old female with a medical history of rheumatic heart disease, ischemic heart disease, chronic atrial fibrillation, past stroke, and cerebral palsy, who underwent mechanical mitral valve replacement and biological tricuspid valve replacement  at the age of 55, was currently admitted with shortness of breath and severe pitting leg edema. Echocardiography revealed moderate aortic stenosis (mean gradient 30 mmHg), good function of the mechanical mitral valve, severe (free) tricuspid valve regurgitation, and significant tricuspid valve stenosis Figures  and 1. TCardiac movement might influence the height of implantation in relation to the aortic annulus and increase the probability of paravalvular leak and atrioventricular conduction disturbances, which, in turn, may negatively influence the prognosis of the patient. These movements mainly have an effect on balloon expandable valves, and therefore rapid pacing is considered mandatory during such procedures. Adenosine administered intravenously can induce transient cardiac arrest by inhibiting AV nodal conduction. Having a half-life from 10 to 30 seconds, its effect is achieved rapidly after injection (10–15 seconds) and lasts for several seconds (the drug is cleared from the plasma within 30 seconds). Thus, it has suitable pharmacological features for potential use to induce heart arrest during percutaneous cardiac interventions. The adverse effects are self-limiting, and during the procedure there was no case of bronchospasm.The literature reveals adenosine being successfully used to enhance accurate deployment of stent grafts in the thoracic aorta , 3 and i


Temporary mechanical circulatory support device without sternotomy has been highly advocated for severe cardiogenic shock patient but little is known when coupled with amniotic stem cell therapy.This case reports the first dual therapy of temporary left ventricular extracorporeal device CentriMag with distal banding technique and human amniotic stem cell injection for treating a severe refractory cardiogenic shock of an 68-year-old female patient. A minimally-invasive off-pump LVAD was established by draining from the left ventricle and returning to the right axillary artery with distal arterial banding to prevent right upper extremity hyperperfusion. Amniotic stem cells were injected intramyocardially at the left ventricular apex, lateral wall, inferior wall, and right subclavian vein.The concomitant use of the temporary minimally-invasive off-pump CentriMag placement and stem cell therapy not only provided an alternative to cardiopulmonary bypass and full-median sternotomy procedures but may have also synergistically enhanced myocardial reperfusion and regeneration. Severe refractory cardiogenic shock (RCS) can be defined as significant left or right ventricular dysfunction resulting in sustained hypotension and hypoperfusion of end-organs. Treatment for RCS would include one or more modalities like pharmaco-agents (inotropes and vasopressors), intra-aortic balloon pump (IABP), revascularization in the case of myocardial infarction, and ultimately mechanical circulatory support (MCS) system to hemodynamically unload the heart and restore circulation. One of such MCS system is the centrifugal pumps like CentriMag , Rotaflow , or Sorin Revolution . These temporary ventricular assist devices (VAD) have been widely used as bridge-to-decision or bridge-to-recovery in patients with refractory cardiogenic shock , 2. HoweMost of patients who require this therapy fall into INTERMACS  profile1. Conventionally, the temporary left VAD implantation has been performed through median sternotomy with or without cardiopulmonary bypass (CPB) support. These critically ill patients tend to bleed more during and after surgery for pre-operative liver dysfunction . EspeciaPatients with VAD may also be benefited from stem cell therapy (SCT), which has been shown to potentially increase circulatory perfusion , 6, promTo recover the heart, a minimally invasive approach with stem cell therapy was applied to reduce surgical insult, avoiding CPB pump and median sternotomy. We cannulated at the apex of the left ventricle and returned through the right axillary artery with distal banding technique to avoid hyperperfusion. We then administered a bimodal delivery of amniotic stem cells with the intention of initiating cellular myocardial recovery.A 68-year-old female patient with past medical history of, two previous coronary artery bypass grafts, hypertension, chronic kidney disease, and diabetes mellitus, presented to a local hospital with chest pain and shortness of breath following an ST-elevation myocardial infarction. The patient was placed on an IABP and underwent a cardiac catheterization with the placement of five stents in the left anterior descending artery and saphenous vein graft. However she developed postoperative cardiogenic shock and multi-organ hypoperfusion despite her IABP and increased pressor requirements. She was then transferred to our institution for possible ventricular assist device placement.Preoperative transesophageal echocardiography (TEE) demonstrated EF of 10% with apical akinesis, mild aortic insufficiency, moderate mitral and tricuspid valve regurgitation. Right heart was functional prompting for a CentriMag LVAD placement as Bridge-to-Decision/Recovery.3 of PalinGen Kardia Flow, Amnio Technology, Phoenix, AZ, USA) and into the anterior, lateral, and inferior walls of the LV .The patient was placed supine position. The position of Left ventricular (LV) apex was confirmed by transthoracic echocardiography. A 5 cm mini-thoracotomy at 5th intercostal space was made. A pericardial well was created and A Thoratec 34 Fr inflow cannula  was brought to the field. The Thoratec cuff was sewn into the left ventricular apex using plegetted 3–0 Ethibond sutures followed by a running 3–0 Prolene suture. The right axillary artery was exposed. Activated clotting time guided heparin was confirmed to be more than 200 s. An 8 mm Dacron graft was sewn into the axillary artery in end-to-side fashion using a 4–0 Prolene running suture. A 20 Fr EOPA cannula was passed through the graft with the tip extending to the level of the anastomosis. Silk ties were used to secure the cannula to the graft. The distal axillary artery was banded with a vessel loop. Banding prevented arterial and right axillary artery distal from over perfusion and ensured adequate cerebral perfusion. Remaining off-pump, the 34 Fr Thoratec inflow cannula was passed into the left ventricle. The position was confirmed by TEE. The cannula was secured to the cuff and was de-aired and connected to the CentriMag device Fig. . The CenHer end organ function recovered during the support. Transthoracic Echocardiography (TTE) was conducted which showed LV recovery, EF 30% with 1.5 LPM of LVAD flow at post op day 13. At post op day 20, fibrin clots developed in both the inflow and outflow cannula connectors prompting for an urgent decannulation at post op day 21. Upon off-pump LVAD removal, a subsequent IABP was placed and inotropic support was started in an effort to increase coronary perfusion. A head CT scan showed evidence of a small right sided ischemic cerebral infarct possibly due to clots dislodgement from the support/plumbing system or thrombotic occlusion of the right brachiocephalic trunk, right common carotid, right internal, and right vertebral arteries resulting in left sided hemiplegia. Extubation, IABP removal, and BiPAP administration was performed on post-explant day three. The patient was discharge to rehabilitation facility.With regard to implantable LVAD, off pump placement has been reported . HoweverOne of the potential disadvantages of this approach was hyperperfusion of the right arm and right carotid artery. We were able to avoid the latter complication by tightening the axillary artery distal to the anastomosed site via a tourniquet such that the right radial pressure matched the left radial pressure upon stable support.From the hemodynamic point of view, mechanically unloading the heart has been shown to increase survivability and promote differentiation of cardiac stem cells injected in the myocardium of an infarcted animal heart ; inhibitThe concomitant use of SCT and LVAD have been previously reported by Dib et al.  and Paga


Research on commensal microbiota and its contribution to health and disease is a new and very dynamically developing field of biology and medicine. Recent experimental and clinical investigations underscore the importance of gut microbiota in the pathogenesis and course of stroke. Importantly, microbiota may influence the outcome of cerebral ischemia by modulating central nervous system antigen-specific immune responses. In this review we summarize studies linking gut microbiota with physiological function and disorders of the central nervous system. Based on these insights we speculate about targeting the gut microbiome in order to treat stroke.The online version of this article (doi:10.1007/s13311-016-0475-x) contains supplementary material, which is available to authorized users. The way we perceive microorganisms and their role in health and disease has changed substantially over the last few decades. It has long been recognized that human–microbial synergy in the gut promotes digestion and contributes to infections when the host–bacterial interaction is disturbed. Recent discoveries, however, have enabled a deeper understanding of the sophisticated interconnection between commensal microbial populations and the host, demonstrating that microbial communities not only refine host metabolism, but also modulate immunity and even contribute to organ developmentBacterium coli commune, today known as Escherichia coli and “the work horse of molecular biology”  . HoweverIn another report antibiotic-induced gut dysbiosis with significantly decreased α-diversity of gut microbiota (diversity within particular habitat ) improveInterestingly, similar mechanisms were suggested to explain the effects of high-fat diet on the pathogenesis of type 2 diabetes and obesity. A high-fat diet induced dysbiotic changes in the gut microbiota, impaired function of antigen presenting cells, and decreased number of IL-17 producers, RORγt CD4+ T cells, in the intestine. These alterations preceded the onset of metabolic disease . ObesityOur group investigated the outcome of experimental stroke in C57BL/6 mice after extensive microbiota depletion with broad-spectrum antibiotic pretreatment . We obseFurthermore, model-specific changes in the microbiota after murine MCAo and mild traumatic brain injury were described very recently. In MCAo animals alterations in Peptococcaceae and Prevotellaceace correlated with infarct severity. Additionally, inducing focal cerebral ischemia in mice increased noradrenaline release in the gastrointestinal tract (cecum), and reduced the number of mucoprotein-producing cells and goblet cells. Increased noradrenaline levels and changes in goblet cell function may directly affect the gut microbial community after stroke .Clostridium butyricum in ischemia/reperfusion-induced brain injury after bilateral common carotid artery occlusion. Treatment with C. butyricum decreased neuronal injury and improved the cognitive functions [A study in diabetic mice identified beneficial effects of supplementation with unctions Clinical data on the brain–gut microbiota connection are still scarce Table . HithertFirst clinical reports on the role of gut microbiota indisorders of the nervous system investigated alterations in the composition of the gut microbiome with neurological disease but did not provide a causative link. It was consequently conjectured that gut microbiota plays a role in such different conditions as PD, visceral pain, Guillain–Barré syndrome, stroke, and psychiatric diseases , 43, 71.Spinal cord injury is another CNS disorder where the composition of microbiota has recently been investigated. Patients with spinal cord injury have fewer butyrate-producing bacteria in the gut; the consequences of this has not yet been clarified . MoreoveChanges in the composition of microbiota in the course of stroke were already reported , but morA recent clinical study compared microbiome composition in patients diagnosed with asymptomatic atherosclerosis, stroke, and transient ischemic attack. The trial data also included patient TMAO plasma levels. Surprisingly, the asymptomatic atherosclerosis group with and without carotid plaques had similar levels of TMAO and comparable gut microbiota composition. In contrast, patients with stroke and transient ischemic attack differed substantially from the asymptomatic subjects regarding microbiome composition, but their TMAO levels were lower than those of the asymptomatic group .–/–; mouse model of atherosclerosis [–/– animals, however, lack an important enzyme cholesteryl ester transfer protein, which transfers cholesterol ester between lipoproteins of high and low density. Interestingly ApoE–/– transgenic mice overexpressing human cholesteryl ester transfer protein supplemented with L-carnitine had decreased aortic atherosclerotic plaque formation and high TMAO levels [–/– mice, the same transgenic animals housed under GF conditions developed severe atherosclerosis when fed a low cholesterol diet [In another study, serum levels of carnitine and its metabolite γ-butyrobetaine—rather than TMAO and trimethyllysine—were elevated in patients with carotid atherosclerosis. Serum levels of gamma-butyrobetaine and trimethyllysine were also associated with cardiovascular death . Conflicclerosis ) when thclerosis . ApoE–/–O levels . Moreoverol diet .These data suggest that metabolites of the microbiome might also provide a certain level of protection from the development of disease. It should be noted that gut microbiota studies in the clinical settings are more challenging than experimental studies in animals. Study populations in humans are usually more heterogeneous, as they are influenced by multiple factors independent of the disorder under investigation. These confounders might affect the composition of the intestinal microbial community as well . FurtherClostridium difficile colitis. In a more sophisticated approach, TMAO production has been successfully inhibited by 3,3-dimethyl-1-butanol, a structural analog of choline and an antagonist for the microbial trimethylamine lyase [Gut microbiota could be a potential therapeutic target for diseases that constitute risk factors for stroke and/or for complications after cerebral ischemia Fig. . Experimne lyase .Fig. 1MoStreptococcus pneumoniae showed higher mortality, more severe organ damage, increased spread of the pathogen, elevated inflammatory markers, and limited alveolar macrophages functions than did untreated mice. Transfer of fecal microbiota from untreated animals reduced bacterial counts in the lungs and normalized inflammatory markers. [Further, microbiome-based therapy appears to be a promising approach for the treatment of poststroke complications. Complications after cerebral ischemia comprise, among others, bacterial infections, cognitive impairment, and depression , 96. In markers. . Whethermarkers. .In current practice patients with stroke are often treated with antibiotics in the acute course of the disease due to poststroke infections. Certainly, antibiotic treatment will target not only pathogens in lung and urinary tract, but also the commensal bacterial populations in other organs such as the gut. Antibiotics induce rapid and long-lasting changes in the microbiome . TreatmeInvestigations in an animal model , as wellStroke survivors often suffer from neuropsychiatric complications, mainly poststroke depression . It has The abovementioned relations are largely speculative but ultimately testable. They provide examples for how gut microbiome might serve as target to treat or even prevent conditions that pose risk factors for stroke or poststroke complications.Principally, there are two strategies for manipulating microbiota: 1) target a defined microorganism by direct elimination, modification, or triggering of the immune response via vaccination with a specific epitope; and 2) manipulate whole communities either individually or by combinations of antibiotics, probiotics, prebiotics, synbiotics, or fecal transplant .Targeting specific microbiota is promising when a causal link has been demonstrated between a particular microorganism and a disease. The approach of targeting whole communities appears to be a shot in the dark: the outcome of such a therapy is not only unpredictable, but might also have more severe adverse effects, in particular when the entire microbial community is profoundly influenced. As already discussed, antibiotic treatment might shift the gut microbiome incurring detrimental outcome, in particular in immune compromised patients with stroke. In contrast, several probiotics have been shown to exert beneficial effects on the human immune system , while dC. difficile colitis. At that time the causative agent had not even been identified [C. difficile enteritis that is nonresponsive to standard therapies; however, the legal status of FMT is still being debated [Ever since 1958, transfer of a whole microbiota community from a healthy donor, so-called fecal microbiota transplantation (FMT), has been established in the treatment of patients with severe entified . The effentified . Howeverentified . Deliverentified . Howeverentified . Moreoveentified . Thus, e debated . Further debated , 126.High expectations for developing new microbiota-based therapies are pinned on the microbial interplay with the immune system and the metabolic capacity of the microbiome. Gut microbiota possesses metabolic capacities comparable with those of a human liver . ProductBacteroides species) has proved to be indispensable for efficacy of certain anticancer drugs , which are unsuccessful in GF or antibiotic-treated mice [Bifidobacterium promoted success of antitumor therapy with anti-programmed cell-death-ligand 1 by boosting T-cell responses [In an experimental mouse study, nonlethal inhibition of bacterial β-glucuronidases, which reactivate the colon cancer drug CPT-11 (Irinotecan), lead to alleviation of the drug's toxicity . These eted mice . Bifidobesponses .Taken together, composition of gut microbiota might influence treatment success of certain drugs through its microbial metabolic functions or by modulating the immune response. This field of research certainly needs to be followed up to disentangle the therapeutic potential of the commensal microorganisms and help to predict individual responses to certain therapies. It appears very likely that many commonly used drugs, not investigated in the context of gut microbial composition, might exert their effects, at least in part, on microorganisms of the gut.One of the main obstacles in current microbiome-based treatment research is the definition of measurable and clinically relevant microbiota-related endpoints for predicting the success of the therapy . There iIn summary, gut microbiota research is a flourishing field with novel and often surprising discoveries about the role of commensal microorganisms in health and disease. Thanks to the advances in sampling and sequencing techniques, the detailed characterization and profiling of microbiome is now feasible. Although the concept of gut microbiota–brain communication seems to be established now, investigations are still needed to characterize the mechanistic connections between changes in the gut microbiota and neurological diseases. This would be the prerequisite for developing successful microbiota-based therapies in CNS disorders, the effectiveness and safety of which would need to be tested in experimental studies and large clinical trials. Although most of this research has been done outside neurosciences, we provided examples, which we believe to be instructive for stroke research.ESM 1(PDF 1225 kb)Below is the link to the electronic supplementary material.


Asymmetry of symptom onset in Parkinson’s disease (PD) is strongly linked to differential diagnosis, progression of disease, and clinical manifestation, suggesting its importance in terms of specifying a therapeutic strategy for each individual patient. To scrutinize the predictive value of this consequential clinical phenomenon as a neuromarker supporting a personalized therapeutic approach, we modeled symptom-side predominance at disease onset based on brain morphology assessed with magnetic resonance (MR) images by utilizing machine learning classification. The integration of multimodal MR imaging data into a multivariate statistical model led to predict left- and right-sided symptom onset with an above-chance accuracy of 96%. By absolute numbers, all but one patient were correctly classified. Interestingly, mainly hippocampal morphology supports this prediction. Considering a different disease formation of this single outlier and the strikingly high classification, this approach proves a reliable predictive model for symptom-side diagnostics in PD. In brief, this work hints toward individualized disease-modifying therapies rather than symptom-alleviating treatments. Although the origin of a unilateral symptom prevalence still remains enigmatic, this has sparked much interest in studying symptom-side predominance.2 While the clinical definition of a side predominance is not trivial with respect to the individual course of the disease, the determination at disease onset seems consistent.3Parkinson’s disease (PD) is one of the most common neurodegenerative diseases resulting in motor as well as in non-motor dysfunctions. Despite its heterogeneous clinical manifestation and course, the asymmetry of motor symptoms at the time of diagnosis is a pathological hallmark indicating PD ) that clinically helps to differentiate from atypical forms of PS.4 Support vector classification involving data from quantitative magnetic resonance imaging (MRI) approaches, such as diffusion tensor imaging (DTI), has been recently applied to distinguish between PD patients and a group of patients with PD-mimicking conditions.5 Various white matter microstructural changes associated with PD6 thus reveal a significant hint at DTI as a valuable tool when investigating this pathology. In fact, decoding methods on morphological markers from various MRI methods have changed the culture of clinical cohort analysis to the extent that they putatively reveal underlying neurobiological mechanisms, hence supporting to move beyond descriptive phenomenological categorization.7To date, numerous studies have employed multivariate decoding methods such as support vector machines to classify disease entities; rather infrequently these methods were applied to predict a treatment outcome or prognose disease progression at an individual subject level. With respect to PD, decoding methods have been used to delineate, e.g., essential tremor with rest tremor from tremor-dominant PD patients.8 Using this approach, we deemed to identify specific morphological markers between disease forms unraveling the enigma of variety in clinical pattern of disease.Following this rationale, one might argue that despite the lateralization of dopaminergic deficit, wide-spread structural differences reflecting the asymmetry of PD can be systematically found. Therefore, we introduced a multimodal approach to model symptom side at disease onset in brain morphology based only on different aspects of diffusion MR parameters and multi-kernel support vector classification.Methods and any associated references are available in the Post hoc inspection of the medical records of this one misclassified patient (red circle) revealed a suicide attempt with carbon monoxide poisoning, which differentiates him from all other patients.We used segregated brain gray  and white  matter images of 24 male idiopathic PD patients to predict left- and right-sided symptom onset of motor signs. Remarkably, this framework yielded an above-chance accuracy of 96%. Classification performance is demonstrated by means of the receiver operating characteristics (ROC) curve with an area under the ROC curve of 0.9 . The deccf.9 Since predominantly the pattern for explaining right-sided symptom onset  occurred in this region, this finding might indicate relatively higher mean diffusivity in the right-sided symptom onset group as compared with the left-sided group.When mapping the MRI relevant voxel that drive prediction results onto the neuroanatomical space cf., the lar1 Notably, post hoc mapping of most relevant regions revealed an aspect of the posterior head of the right hippocampus.9 One might speculate, that right-sided onset patients exhibit relatively more microstructural alterations in this area as compared with left-sided onset patients. This discriminative region is especially intriguing given the hippocampal role in spatio-temporal orientation and mnestic function.9 This also resonates with previous findings, where patients with a right-sided symptom onset were associated with a more favorable outcome regarding cognitive impairment, and a left-sided symptom onset appeared to be associated with a more favorable outcome in terms of motor progression.1–3 Here, our sole outlier attempted suicide by carbon monoxide poisoning 3 years prior to our study. As hippocampal damage is one of the typical pathological features of carbon monoxide poisoning,10 we argue that this is a reasonable explanation for his misclassification.We demonstrate a strikingly high prediction of symptom-side predominance in iPD patients that especially benefit from a novel multimodal whole-brain approach (due to the combination of white and gray matter segregations of different images). Our multi-kernel decoding algorithm discriminates body-side asymmetry with an accuracy of 96%, indicating excellent statistical performance. Apart from one outlier, this predictive model yields a remarkable precision of 100%. The exact determination of symptom-side prevalence at disease onset is of major interest since it has recently been linked to disease progression.10 Given that (i) our framework is based on segments of DTIs and (ii) our major classification pattern was identified in the hippocampus, even subtle changes in this one patients’ hippocampus could have misled the model to predict the wrong body side.We explicitly chose the utility of diffusion-weighted brain imaging data here since these data are susceptible for the neurodegenerative aspects of PD. In particular, we used a combination of fractional anisotropy (segregated white matter), as well as mean diffusivity (segregated gray matter) images to investigate both the integrity of the fiber architecture and cortical differences at the same time . Especially the use of diffusion-weighted images enables the detection of subtle anomalies, as well as restricted diffusion in white and gray matter in patients suffering from carbon monoxide poisoning.In conclusion, because of the excellent performance and group separability, we are convinced this proves a reliable predictive model for symptom-side diagnostics in iPD patients based solely on parameters from DTIs. We consider these results a major step in further predictive clinical models of PD incorporating the many clinical aspects that determine individual prediction of progression, as well as of a personalized sustainable therapeutic approach. We propose that the described asymmetry parameter should be incorporated as a covariate when striving for a comprehensive and particularly generalizable future model of this disease.


BMPR2 and environmental/genetic factors make PAH a heterogeneous disease and it is thus likely that the best approach will be patient-tailored therapies.Pulmonary arterial hypertension (PAH) is a chronic disease characterized by a progressive elevation in mean pulmonary arterial pressure. This occurs due to abnormal remodeling of small peripheral lung vasculature resulting in progressive occlusion of the artery lumen that eventually causes right heart failure and death. The most common cause of PAH is inactivating mutations in the gene encoding a bone morphogenetic protein type II receptor (BMPRII). Current therapeutic options for PAH are limited and focused mainly on reversal of pulmonary vasoconstriction and proliferation of vascular cells. Although these treatments can relieve disease symptoms, PAH remains a progressive lethal disease. Emerging data suggest that restoration of BMPRII signaling in PAH is a promising alternative that could prevent and reverse pulmonary vascular remodeling. Here we will focus on recent advances in rescuing BMPRII expression, function or signaling to prevent and reverse pulmonary vascular remodeling in PAH and its feasibility for clinical translation. Furthermore, we summarize the role of described miRNAs that directly target the BMPR2 gene in blood vessels. We discuss the therapeutic potential and the limitations of promising new approaches to restore BMPRII signaling in PAH patients. Different mutations in  Pulmonary arterial hypertension (PAH) is a chronic disease characterized by a progressive elevation in mean pulmonary arterial pressure mPAP >25 mmHg) leading to right heart failure and death . PAH is 5 mmHg leMore than 70% of patients with familial PAH and 20% of idiopathic PAH show heterozygous mutations in the bone morphogenetic protein type II receptor (BMPRII) –8. BMPRIBMPR2 gene. These mutations target sequences that encode the ligand binding and kinase domain and the long cytoplasmic tail; the mutations compromise BMPRII function   , 61  may be involved in the pathogenesis of the disease . In addiPAH has a complex etiology and pathobiology with many factors contributing to its development . A varieBMPR2 knock-out mice, switchable rodent models have been developed, by means of BMPR2 conditional knock-out, whereby the mutation can be activated after birth [In recent years, second-generation animal models have been established based on the combination of multiple triggers: MCT plus pneumonectomy, MCT plus chronic hypoxia, and SU5416 plus chronic hypoxia. To circumvent the problem of the embryonic lethality of er birth –70. Moreer birth ).BMPR2 gene, non-genetic forms of PAH show a reduction in BMPRII levels and activity [BMPR2 deletion in PAECs and pulmonary artery smooth muscle cells (PASMCs) mimics the PAH phenotype [While hereditary PAH have been linked to heterozygous mutations in the activity . Consisthenotype , 72. Furhenotype , 72.There is strong evidence suggesting that BMPRII signaling has a protective role in the vascular wall by promoting the survival of PAECs, inhibiting PASMCs proliferation and triggering anti-inflammatory responses , 73, 74.BMPR2 encoding virus targets the pulmonary endothelium by binding to the highly expressed pulmonary endothelial angiotensin-converting enzyme (ACE) using a bi-specific conjugate antibody. This BMPR2 adenoviral vector restored BMPRII protein levels in human microvascular PAECs and attenuated the PAH phenotype in a chronic hypoxia model and MCT-treated rats [BMPR2 mutations. It should be noted that adenoviral vectors are only capable of transient gene expression since the delivered gene is not integrated into the host chromosome. Stable integration can be achieved and lentiviral vectors are potentially an attractive vehicle to deliver longer term transgene expression since they integrate into the genome and they can infect non-proliferating cells, when compared to retroviral vectors. An important potential limitation of this approach is that integrating vectors may generate gene mutations upon insertion and newer advances regarding self-inactivating vectors are needed [BMPR2 delivery is a possible therapy for PAH, but further improvements in vector technology are required to translate this approach to the clinic for the treatment of pulmonary vascular disease.One strategy to treat PAH patients is to rescue BMPRII expression through gene therapy targeting ECs. In pre-clinical models, this was explored by Reynolds et al., who administrated a vector inducing BMPRII expression via tail-vein injection. The ted rats , 78. Furted rats . In contted rats . The late needed , 82. Adee needed , 84. TakBMPR2 mutations [BMPR2 expression in vascular cells. In addition, Table BMPR2 in silico.In recent years, there has been an increasing interest in the role of epigenetics in the development of PAH , 86. Epiutations –91). FigCurrently, there are different technologies to inhibit aberrantly overexpressed miRNAs including the use of antisense oligonucleotides, masking, sponges, erasers, or decoys , 93. In The delivery routes mostly used to target lung disease are local intranasal and intra-tracheal administration. These naked miRNAs are directly delivered into the lung with minimal systemic side effects . NeverthBMPR2 mutations (~70%) are non-sense mutations (frame-shift deletions and insertions) generated by the insertion of a premature termination codon (PTC) resulting in truncated reading frames which produce non-functional proteins [Most tations ~0% are noproteins , 101. NMproteins .An approach aimed to correct these types of mutations consists on the induction of PTC read-through. Read-through of truncated mutations by aminoglycoside antibiotics, such as Gentamicin, has been extensively studied and has reached the clinical trial stage for genetic disorders such as cystic fibrosis  and DuchRecently, a high-throughput screening for compounds that suppress non-sense mutations identified a new small molecule named Ataluren (PTC124) which mediates read-through of premature stop codons without acute side effects . Aldred BMPR2 mutations are missense mutations leading to single amino acid substitutions in a conserved domain affecting the overall function of the protein [30% of  protein . Mutatio protein , 116. A  protein –126. Dif protein –129. The protein , 130–133Even though chemical chaperones have the potential to rescue the BMPRII mutants which are retained in the ER, it remains to be investigated whether the amount of BMPRII reaching the plasma membrane is enough to induce a clinically relevant effect. Also, BMPRII with a protein-folding defect expressed at the cell surface may have a dominant-negative activity and adverse effects on BMP signaling . MoreoveITCH expression resulted in increased BMPRII protein levels [The deciphering of mechanisms which regulate cell surface expression levels of BMPRII are of potential clinical importance, particularly those mechanisms that prevent its rapid turnover and thereby restore downstream BMPRII signaling and function. In this context, several studies focused on the potential of targeting the degradation of BMPRII by preventing lysosomal degradation . Durringn levels . Whethern levels . This min levels . Differen levels . Caveolan levels –139. BMPn levels . Recentln levels . Furthern levels  and weren levels . In agren levels . Howevern levels . Even thInterestingly, autophagy has also been found to be involved in PAH. Autophagy  is a highly regulated catabolic process that involves sequestration and lysosomal degradation of cytosolic components such as dysfunctional organelles, misfolded proteins, lipid droplets, and invading pathogens . AutophaAs mentioned previously, BMP signaling in the vascular endothelium is mainly activated by BMP2, 4, 6, 9, and 10 . In partAn additional approach to reverse the effect of mutant BMPRII is use small molecules to enhance signaling of the wild-type functional proteins. Sildenafil is a phosphodiesterase type-5 (PDE5) inhibitor currently used in the clinic for PAH treatment –154. ItsAnother promising strategy is to identify compounds in drug libraries that activate BMP/SMAD signaling. FK506 (Tacrolimus) was identified as the best BMP coactivator among 3756 FDA-approved drugs and bioactive compounds  . FK506 pBMPR2 mutations (~70%) are non-sense mutations, not all patients will benefit from this approach. Nevertheless, further in vivo studies are worth pursuing in the context of PAH. Likewise, clinical trials using chloroquine have to be performed to test its effectiveness in PAH patients. The use of chloroquine has to be carefully evaluated because blocking lysosomal degradation might trigger non-specific off-target effects when used as a long-term treatment. An alternative drug showing significant clinical benefits for PAH is FK506/Tacrolimus. However, it still needs to be monitored for side effects since it is an immunosuppressive drug . Moreover, the effectiveness of FK506 at low doses has to be rigorously tested.Exogenous BMPRII delivery to ECs has been shown to be an effective means to restore BMPRII expression and function , 78. An It is important to highlight that although several drugs showed beneficial outcomes in animal models, most of the drugs have failed in the clinic. In light of this, we should focus on a more personalized approach which takes into account the co-existence of modifier genes, infections, toxic exposure, inflammation, or alterations in estrogen metabolism. Combining treatments which target not only BMPRII signaling but also inflammation and hypoxia should improve outcomes. Lastly, the use of human ex vivo models such as lung or vessel on a chip  could beTaken together, previously discussed data suggest that modulation of BMPRII signaling in PAH is a promising alternative that could prevent and reverse pulmonary vascular remodeling. However, different therapeutic approaches aimed at to increasing the levels of BMPRII signaling are needed, and these approaches will depend on the particular genetic background of each patient. In addition, for more efficient treatments, targeting other genetic and environmental factors that contribute to the disease must be taken into consideration. In this regard, modulators of the inflammatory response and estrogen metabolism could be used to help restore BMPRII signaling.


Charcot-Marie-Tooth (CMT) disease is a peripheral hereditary neuropathy associated with motor and sensory impairment and can result in profound sensorineural hearing loss (SNHL). Currently, the role of cochlear implantation in the setting of CMT and other progressive peripheral neurodegenerative disorders is not well established.  Case report and review of the English literature.  A 70-year-old male with CMT was referred for evaluation of progressive asymmetric SNHL and reported a 15-year duration of deafness involving the left ear. Audiometric testing confirmed profound SNHL in the left ear, while the right ear exhibited moderate-to-severe SNHL. Left-sided cochlear implantation was performed using a conventional length lateral wall electrode. Intraoperative device testing found normal impedance levels throughout the array; however, electrically evoked auditory potentials were absent on all electrodes. Upon initial activation 3 weeks after surgery, the patient reported excellent access to sound in the cochlear implant-only condition. He has made good progress at each subsequent visit; speech perception testing after seven months showed improvement from 0% to 32% on AzBio sentence and 53% on CNC phoneme testing in the cochlear implant-only condition.  We report the third case of cochlear implantation in a patient with CMT. SNHL in CMT is hypothesized to result from disruption of synchronous activity of the cochlear nerve. In patients with CMT, cochlear implantation may reconstitute synchronous neural activity by way of supraphysiological electrical stimulation. Our results corroborate two earlier reports that cochlear implantation is a viable option for rehabilitation of SNHL in this unique subset of patients. Charcot-Marie-Tooth (CMT) disease is a clinically and genetically heterogeneous group of disorders affecting the peripheral nervous system. The disease can manifest in profound SNHL, hypothesized to result from disruption of synchronous activity of the cochlear nerve. Given that CMT affects the retrocochlear auditory pathway, there have been theoretical concerns that CI is incapable of providing meaningful auditory stimulation. Two previous cases of CI in patients with CMT have been described in the world literature; thus, the role of cochlear implants in auditory rehabilitation of CMT-associated SNHL is poorly defined , 2. We pA 70-year-old male with CMT was referred for evaluation of progressive asymmetric SNHL and reported a 15-year duration of deafness involving the left ear. He was initially a bilateral hearing aid user but subsequently stopped using his hearing aid in the left ear several years prior due to experiencing progressive audiometric decline. Audiometric testing confirmed profound SNHL in the left ear, while the right ear exhibited moderate-to-severe SNHL. Information regarding the subtype of his CMT is unavailable at our tertiary care facility; prior workup was performed at another institution.Left-sided cochlear implantation was performed using a conventional length lateral wall electrode. The electrodes were introduced without resistance, and a full insertion was achieved using the MED-EL™ Synchrony Flex® 28 cochlear implant. Intraoperative device testing found normal impedance levels throughout the array; however, electrically evoked auditory potentials were absent on all electrodes. Upon initial activation 3 weeks after surgery, the patient reported excellent access to sound in the cochlear implant-only condition. He has made good progress at each subsequent visit; speech perception testing after seven months showed improvement from 0% preoperatively to 32% on AzBio sentence and 53% on CNC phoneme testing in the cochlear implant-only condition. At an 18-month phone follow-up, he reports improving subjective benefit and consistent usage of the device.PMP22, MPZ, GJB1, and MFN2. CMT types 1 and 2 represent by far the largest proportion of patients; these classifications are based off features of demyelinating (CMT1) or axonal (CMT2) dysfunction. Motor weakness is the predominant symptom, typically arising in the first or second decade of life. The majority of treatment options are directed towards alleviation of motor deterioration; there have been few reports describing the management of hearing loss in patients with CMT [Charcot-Marie-Tooth disease is the most commonly occurring hereditary motor and sensory neuropathy. CMT can be classified as types 1 to 7, X, and intermediate, with many subtypes. CMT is genetically heterogeneous with more than 30 genes identified to date. Despite this, the vast majority of cases are attributed to mutations in just four of these genes: Hearing loss in patients with CMT is associated with point mutations or deletions in the peripheral myelin protein (PMP) 22 gene, a myelin regulatory gene . Neural Traditionally, retrocochlear disease affecting the auditory pathway has been considered a contraindication to CI. In patients with auditory neuropathy spectrum disorder (ANSD), there is an absence of auditory brainstem responses despite the intact outer hair cell function. ANSD results in poor speech discrimination while general awareness of speech is often retained. The resultant severe impairment in temporal processing ability was originally thought to be unchanged by CI; however, over the last decade, we have seen several disease processes that have challenged this notion. Specifically, it is well documented that many patients with auditory nerve hypoplasia, auditory neuropathy, and acoustic neuroma with an intact cochlear nerve gain significant benefit from CI , 8. In pTwo prior cases of cochlear implantation in patients with SNHL attributed to CMT have been reported in the world literature , 2. EachWe report the third case of cochlear implantation in a patient with CMT. Improvement of speech discrimination in this unique subset of patients has been shown to occur at a more gradual rate of progression. While no definitive recommendations concerning the efficacy of CI in patients with CMT have been established, our results corroborate two earlier reports that cochlear implantation is a viable option for rehabilitation of SNHL in CMT patients. Future study should be performed in an attempt to further define the role of CI in the setting of CMT.


The imbalance between effector and regulatory T (Treg) cells is crucial in the pathogenesis of autoimmune arthritis. Immune responses are often investigated in the blood because of its accessibility, but circulating lymphocytes are not representative of those found in inflamed tissues. This disconnect hinders our understanding of the mechanisms underlying disease. Our goal was to identify Treg cells implicated in autoimmunity at the inflamed joints, and also readily detectable in the blood upon recirculation.We compared Treg cells of patients with juvenile idiopathic arthritis responding or not to therapy by using: (i) T cell receptor (TCR) sequencing, to identify clonotypes shared between blood and synovial fluid; (ii) FOXP3 Treg cell-specific demethylated region DNA methylation assays, to investigate their stability and (iii) flow cytometry and suppression assays to probe their tolerogenic functions.We found a subset of synovial Treg cells that recirculated into the bloodstream of patients with juvenile idiopathic and adult rheumatoid arthritis. These inflammation-associated (ia)Treg cells, but not other blood Treg cells, expanded during active disease and proliferated in response to their cognate antigens. Despite the typical inflammatory-skewed balance of immune mechanisms in arthritis, iaTreg cells were stably committed to the regulatory lineage and fully suppressive. A fraction of iaTreg clonotypes were in common with pathogenic effector T cells.bona fide synovial Treg cells readily accessible from the blood and selectively expanding during active disease, paving the way to non-invasive diagnostics and better understanding of the pathogenesis of autoimmunity.Using an innovative antigen-agnostic approach, we uncovered a population of  Certain therapies, such as those relying on anti-TNF, can re-establish normal Treg cell counts and function.bona fide, antigen-stimulated and suppressive Treg cells expands during active autoimmunity in JIA. Investigation of their TCR repertoire through next-generation sequencing demonstrates that these Treg cells are enriched in synovial clonotypes, some of which were shared with pathogenic Teff cells. Our work uncovers an easily accessible pool of synovial Treg cells in the circulation that might be used as a novel non-invasive diagnostic tool, and proposes an innovative antigen-agnostic approach to shed light on pathogenic mechanisms of autoimmune disease and unresponsiveness to therapy.In this work, we demonstrate that a subset of in silico translation. The similarity between samples was calculated either using the Chao-modified Jaccard index, which varies from 0 (complete dissimilarity) to 1 (complete similarity), or by repeated random subsampling at equal sample size . The median percentage of clonotype overlap resulting from 200 subsamples was then plotted. Hierarchical clustering with single linkage and t-SNE dimensionality reduction of TCR repertoires were performed using the Chao-modified Jaccard index.TCRβ CDR3 sequencing was performed by Adaptive Biotechnologies. Statistical analysis of TCR repertoire datasets is described in detail in previous reports.Additional methodological details are available as online 10.1136/annrheumdis-2015-208992.supp1Supplementary dataWe investigated the phenotype of Treg cells in peripheral blood samples of patients with JIA, collected before (T0) and after (Tend) therapy,+ Treg cells was identical between ID and NO ID patients, irrespective of the time point analysed Treg cells in NO ID patients as compared with ID patients at Tend  within the Previous reports indicate that HLA-DR expressing Treg cells from HD are endowed with early contact-dependent suppressive function.Altogether, these findings support the notion that iaTreg cells are genuinely tolerogenic and functionally competent.Based on the observation that iaTreg cells expand during active autoimmunity and are fully suppressive in vitro, we hypothesised that these cells increase in numbers in an attempt to restrain deranged effector mechanisms. To address this hypothesis, we first characterised their migratory potential by looking at chemokine receptors. Compared with the other Treg cells, a larger fraction of iaTreg cells expressed the inflammatory tissue-homing receptor CCR5, as opposed to the lymph node-homing receptor CCR7 A. This pAltogether, our data suggest that iaTreg cells have recently proliferated and become activated upon cognate antigen encounter, and that they can recirculate between the blood and the inflamed peripheral tissues.To obtain conclusive evidence that blood iaTreg cells are indeed migrating to (or escaping from) the synovium, we investigated their TCR repertoires through next-generation sequencing of CDR3 regions within the TCRβ chains  and nucleotide sequences, both yielding similar results  or the regulatory lineage. To this aim, we compared the TCR repertoires of blood and synovial Teff and Treg cells. Blood Treg cells were segregated in iaTreg and other Treg cells. Blood Teff was similarly segregated in circulating pathogenic-like lymphocytes (CPLs) or other Teff.Given the large differences across patients, we then visualised similarities across cell subsets within each subject by plotting all the pairwise distances between TCR repertoires as a heatmap. By far, the greatest similarity was observed between iaTreg cells and synovial Treg cells, and between CPLs and synovial Teff, respectively  and the activated CD45RA−FOXP3hi Treg cell subsets, are stable over the course of treatment, iaTreg cells selectively persist in NO ID patients. Thus, abnormal features arising in disease may be overlooked when focusing on unsegregated populations, as the signal from  relevant subsets would be diluted by a large pool of clinically irrelevant cells. This issue is critical, as most studies perform bulk measurements  on whole blood Treg cells. In light of our data, we express concern that these efforts may be unfruitful until the cell target is redefined.First, while Treg cells as a whole, as well as the naive  is expanded in this very same cohort of patients resistant to anti-TNF therapy.Interestingly, iaTreg cells are actively proliferating upon TCR triggering in the absence of overt infection, as indicated by high prevalence of Ki67, reduced TCR repertoire diversity and Nur77 upregulation. In addition, although iaTreg cells are ontogenically related to Treg cells, they show some degree of TCR repertoire overlap with arthritis-associated synovial Teff and blood CPLs. This finding fits into the accepted paradigm whereby modestly self-reactive TCRs escaping negative selection give rise to either tolerogenic Treg cells or effector clonotypes poised for autoimmunity.


Loss of skeletal muscle myofibrillar protein with disease and/or inactivity can severely deteriorate muscle strength and function. Strategies to counteract wasting of muscle myofibrillar protein are therefore desirable and invite for considerations on the potential superiority of specific modes of resistance exercise and/or the adequacy of low load resistance exercise regimens as well as underlying mechanisms. In this regard, delineation of the potentially mechanosensitive molecular mechanisms underlying muscle protein synthesis (MPS), may contribute to an understanding on how differentiated resistance exercise can transduce a mechanical signal into stimulation of muscle accretion. Recent findings suggest specific upstream exercise-induced mechano-sensitive myocellular signaling pathways to converge on mammalian target of rapamycin complex 1 (mTORC1), to influence MPS. This may e.g. implicate mechanical activation of signaling through a diacylglycerol kinase (DGKζ)-phosphatidic acid (PA) axis or implicate integrin deformation to signal through a Focal adhesion kinase (FAK)-Tuberous Sclerosis Complex 2 (TSC2)-Ras homolog enriched in brain (Rheb) axis. Moreover, since initiation of translation is reliant on mRNA, it is also relevant to consider potentially mechanosensitive signaling pathways involved in muscle myofibrillar gene transcription and whether some of these pathways converge with those affecting mTORC1 activation for MPS. In this regard, recent findings suggest how mechanical stress may implicate integrin deformation and/or actin dynamics to signal through a Ras homolog gene family member A protein (RhoA)-striated muscle activator of Rho signaling (STARS) axis or implicate deformation of Notch to affect Bone Morphogenetic Protein (BMP) signaling through a small mother of decapentaplegic (Smad) axis. Skeletal muscle contractile properties can be negatively affected with prolonged inactivity and/or muscle wasting disease, leading to severe deteriorations in muscle myofibrillar mass, muscle strength, and mobility Clark, . ConsequIntriguingly, mechanical force changes inherent of resistance exercise are assumed to exert regulatory action on mechanisms involved in MPS. With regards to resistance exercise, this immediately advance questions such as; (a) how mechanical force changes inherent of resistance exercise is sensed; (b) how resistance exercise-induced mechano-sensing molecules can affect biochemical signaling to directly activate MPS and; (c) how resistance exercise-induced mechano-sensing can exert influence on MPS by means of regulating net supply of muscle myofibrillar gene transcripts to the ribosomal machinery.in vitro or animal models, whereas less information exists from human resistance exercise studies. Consequently, most of the findings presented, originate from non-human studies. However, human studies that provide support for the implication of similar mechanisms in human skeletal muscle are included, with attention on the influence of resistance exercise modality and intensity.Below, we will first summarize the burden of proof that advocate for the significance of mechanotransducing mechanisms. We will then summarize some emerging knowledge on how force changes with resistance exercise may be sensed by mechanosensitive molecules to activate biochemical signaling for MPS and/or muscle myofibrillar gene transcription. Most of the current knowledge on mechanotransduction has been retrieved through employment of Mechanistic target of rapamycin complex 1 (mTORC1) is regarded as a nodal point for integration of various stimulators, such as growth factors, nutrients and mechanical forces, to activate downstream signaling for muscle protein translation initiation  seem to provide a stronger proxy of signaling for resistance exercise-induced MPS, than mTORC1  , sarcolemmal , focal adhesion , costamere  and/or Z-disk  proteins  by the enzyme phospholipase D (PLD). In the unstimulated state, α-actinin (in the z-band of the sarcomere) associates with and inhibits phospholipase D (PLD)  is a GTP-binding protein that expresses GTPase activity  and polymeric/filamentous (F-actin) forms  and the striated muscle activator of Rho signaling . Both proteins can activate actin-associated proteins following mechanical signals, with activation of STARS or RhoA leading to G-actin polymerization and SRF-mediated gene transcription  family of ligands, such as Myostatin/TGFβ, has been shown to negatively affect the regulation of muscle mass due to receptor-mediated activation of a class of effector molecules known as small mother of decapentaplegic (Smad) proteins (Lee and McPherron, Interestingly, transmembranal protein Notch has been shown to increase in response to high frequency electrical stimulation and has been suggested to possess a negative regulatory effect on TGFβ signaling by inhibiting Smad 2/3, thereby allowing Smad 1/5/8 signaling for hypertrophy (MacKenzie et al., A present, little is known on how resistance exercise may favor activation of the Smad1/5/8-Smad4 complex, but transcriptome analysis from our own previous analysis serve to support that certain BMP and Smad isoforms are transcribed in adult human skeletal muscle and that certain isoforms exhibit differential expression with differentiated exercise (Vissing and Schjerling, in vitro or animal models. The advantages of such models are that they offer genetic homogeneity, manipulation through genetic engineering and easy use of compounds such as wortmanin and rapamycin. On the other hand, the stimulation protocols utilized in those studies typically do not ideally mimic resistance exercise regimens as they are genuinely practiced in humans. In this regard, animal models that can render voluntary resistance exercise possible would offer an experimental advantage. Moreover, animal models that employ surgical ablation models and electrical stimulation likely impose non-exercise related stressors and/or omit true stressors inherent of voluntary human resistance exercise. In this regard, non-intervention control models would improve the ability to deduce potential separate effects of invasive procedures and/or dietary premises inherent of stimulation protocols that potentially obscure interpretation of results. Human studies offer volitional resistance exercise, but imply genetic heterogeneity and a similar need to for non-intervention control models to control for e.g., systemic effectors. Furthermore, loss of function and/or overexpression manipulation is difficult to apply to human studies. Consequently, results from human studies are often most quite descriptive unless of comprehensive comparative designs. However, comparative studies introduce difficult considerations on sample size and whether/how to match exercise protocols for volume, intensity and/or whether exercise is performed to a state of fatigue. In this regard, increased use of administration of rapamycin and wortmanin in future human resistance exercise studies might help provide more causal information.Most of the knowledge on potential mechanotransduction mechanisms summarized in the current review is derived from As previously suggested, the ability to address these challenges would benefit from a multi-site consortium of scientists, to facilitate translational studies through use of non-human and human model systems (Neufer et al., All authors listed, have made 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.


Prostate cancer is histologically and molecularly heterogeneous. Clinically significant disease is often driven by dominant intra-prostatic lesions (IPLs). Prostate cancers cluster into molecular phenotypes with substantial genetic heterogeneity making pathway-based molecular analysis appealing. MRI/ultrasound fusion biopsy provides a unique opportunity to characterize tumor biology of discrete lesions at diagnosis. This study determined the feasibility of pathway-based gene expression analysis of prostate biopsies and characterized cancer pathway deregulation.Thirteen patients had prostate cancer diagnosed by MRI/ultrasound fusion biopsy and either Gleason 6 or Gleason ≥8. Gene expression profiling was performed on 14 biopsies using >700 genes representing 13 cancer pathways. Pathway-based analysis compared gene expression among samples based on clinical, pathological, and radiographic characteristics. Pathway-based gene expression analysis was successful in 12 of 14 (86%) samples. Samples clustered based upon deregulation of DNA Repair and Notch, Chromatin Modification and Cell Cycle, or all other pathways, respectively. DNA Repair demonstrated the greatest differential deregulation. Lesions with Gleason ≥8, PSA ≥10, or intense dynamic contrast enhancement (DCE) had significantly higher DNA Repair deregulation than those with Gleason 6, PSA <10, or low to moderate DCE. Alterations in DNA Repair gene expression were diverse with upregulation of markers of DNA damage and down-regulation of DNA Repair proteins. This study demonstrates the feasibility of pathway-level gene expression analysis of discrete intra-prostatic lesions sampled by MRI/ultrasound fusion biopsy. IPLs cluster into distinct molecular phenotypes, the most significantly altered being DNA Repair. Despite decades of advancement in prostate cancer management, distinguishing men with aggressive, clinically-significant disease at the time of diagnosis remains challenging. Many men with low-risk, indolent prostate cancer have historically been over-treated. Even in the modern era of risk stratification and advanced treatment options, men with high-risk disease continue to develop recurrence, symptomatic progression, or die of their disease. Diagnosis of prostate cancer classically relies on digital rectal examination (DRE), serum prostate-specific antigen (PSA) levels, and pathologic evaluation of standard biopsy samples. The current management approach relies very little on understanding tumor biology and there is significant heterogeneity in disease behavior within current risk stratification groups –3. PersoThe standard extended-sextant prostate biopsy technique is essentially a systematic, but otherwise random sampling of various regions of the prostate gland. Prostate cancer is an extremely heterogeneous spectrum of disease, and the majority of men with prostate cancer harbor multiple foci of disease –6. HowevEmerging data supports the clustering of large proportions of prostate cancer into molecular phenotypes, similar to the well-known molecular phenotypes used to describe breast cancer . Many emThirteen patients with fourteen discrete IPLs were identified who had undergone targeted MRI/TRUS fusion biopsy and were found to have GS (Gleason score) 6 (7 IPLs) or GS ≥8 (7 IPLs) disease with tumor involving at least 20% of the tissue in the biopsy core. One patient had two discrete IPLs, each with GS 6 disease. Table Gene expression analysis was performed using the Nanostring platform. Two 14%) samples had inadequate RNA to perform gene expression analysis, and both were GS ≥8. Gene expression and pathway analysis was performed on 12 specimens (7 GS 6 and 5 GS ≥8). Canonical cancer pathway-based gene expression analysis demonstrated significantly higher deregulation of the DNA Repair pathway in GS ≥8 IPLs compared to GS 6  and castration-resistant prostate cancers (∼30%) driven by DNA repair defects , 15. HowInformation about tumor biology at the time of biopsy would be most beneficial in guiding management, and the techniques used in this study represent a next-generation approach to prostate cancer diagnosis and risk stratification . IdentifHigh risk radiographic features, PI-RADS score and intensity of DCE, also strongly correlated with pathway deregulation. When interpreting these findings, it is important to note that high-risk imaging features are known to be associated with high-risk pathological features. One benefit of prostate MRI is increased detection of high risk lesions and decreased detection of low risk lesions. An important future goal of prostate MRI is to have imaging that highly correlates with pathological findings to avoid the need for biopsy in the setting of surveillance . One purThis study is limited by its retrospective, exploratory nature and the small sample size. With a small sample size, the genomic heterogeneity of prostate cancer and potential inclusion of outlier mutations could potentially influence the results. However, the findings of DNA repair deregulation are consistent with findings of larger studies. Also, we focused on pathway, as opposed to specific gene, analysis to partially account for expected genomic heterogeneity. Small sample size also limits the interpretation of associations among clinical, radiographic, and molecular findings with multivariate analysis. In particular, many of the clinical and radiographic findings are known to be associated, such as high Gleason grade with PIRADS score and contrast enhancement or elevated PSA with high Gleason grade. The small sample size precludes more extensive statistical analysis that would be needed to demonstrate independent associations among various clinical and radiographic features and the molecular findings.In conclusion, this study demonstrates the feasibility of obtaining detailed information about the molecular biology of discrete IPLs using mpMRI, MRI/TRUS fusion biopsy, and targeted gene expression and pathway analysis. Using this technique, we found significantly higher deregulation of DNA repair in high-grade lesions. We also found strong clinical and radiographic correlates of these underlying molecular changes. These techniques can be used in larger clinical trials to personalize definitive therapy and improve outcomes for clinically significant prostate cancer.Investigation has been conducted in accordance with the ethical standards and according to the Declaration of Helsinki and according to national and international guidelines and has been approved by the authors’ institutional review board. Patients who had targeted MRI/TRUS fusion-guided biopsy of IPLs with pathology demonstrating either low-risk (GS 6 and PSA < 10) or high-risk (GS ≥ 8 with any PSA) prostate cancer between December 2014 and December 2015 were identified. Because the purpose of this study was to determine the feasibility of detecting changes in cancer biology in a small sample size, only low-risk and high-risk histologies were compared in order to increase the likelihood of detecting a difference. Furthermore, Gleason 7 disease is known to be heterogeneous in both clinical and biological behavior. Multi-parametric prostate MRIs were reviewed by a multidisciplinary team of urologic oncologists and MRI radiologists to determine the risk of a lesion. IPLs with suspicious T2-weighted, diffusion-weighted, and dynamic contrast enhanced MR imaging were identified and a PI-RADS v2 score  was assigned [http://www.uab.edu/medicine/radonc/en/nanostring)). The Reporter probe carries the fluorescent signal specific to each gene, and the Capture probe allows the complex to be immobilized on a cartridge for data collection. After hybridization, the samples were loaded into the nCounter Prep Station where excess probes were removed and the samples were aligned in order to be read properly in the nCounter Digital Analyzer.All cases were reviewed by a single, fellowship trained genitourinary pathologist. Tumor foci from the MR/TRUS fusion biopsy specimens were identified and given a Gleason score. The pathologist determined if adequate tissue was available for molecular analysis. In cases where patients also had standard extended-sextant biopsy or subsequent radical prostatectomy, those tissue samples were not included in the analysis in order to demonstrate the feasibility of this technique using targeted biopsy samples only. RNA was isolated from FFPE prostate tumor tissue as previously described . BrieflyThe raw data was analyzed using a cancer pathway-based gene expression profiling platform. We then performed an advanced analysis of gene expression and cancer pathway signature data using the nSolver advanced analysis package. The primary outcome was differences in pathway deregulation scores for GS 6 and GS ≥8 IPLs calculated by the advanced gene expression analysis software using the t-test. Secondary outcomes were differences in pathway deregulation scores and correlation of scores with clinical and radiographic characteristics. Pathway deregulation scores were correlated with pre-biopsy serum PSA and PI-RADS score assigned to the specific IPL based upon pre-biopsy mpMRI. Pathway deregulation scores were also compared between IPLs with PI-RADS score 3-4 and 5, no/moderate and intense DCE, and central gland versus peripheral zone anatomic location in the prostate using the t-test and the built-in statistical software of the gene expression analysis platform.


Virus infected host cells serve as a central immune ecological niche during viral infection and replication and stimulate the host immune response via molecular signaling. The viral infection and multiplication process involves complex intracellular molecular interactions between viral components and the host factors. Various types of host cells are also involved to modulate immune factors in delicate and dynamic equilibrium to maintain a balanced immune ecosystem in an infected host tissue. Antiviral host arsenals are equipped to combat or eliminate viral invasion. However, viruses have evolved with strategies to counter against antiviral immunity or hijack cellular machinery to survive inside host tissue for their multiplication. However, host immune systems have also evolved to neutralize the infection; which, in turn, either clears the virus from the infected host or causes immune-mediated host tissue injury. A complex relationship between viral pathogenesis and host antiviral defense could define the immune ecosystem of virus-infected host tissues. Understanding of the molecular mechanism underlying this ecosystem would uncover strategies to modulate host immune function for antiviral therapeutics. This review presents past and present updates of immune-ecological components of virus infected host tissue and explains how viruses subvert the host immune surveillances. The immune ecosystem of a virus-infected host can be defined as the systemic interaction between the virus and the host immune system, resulting in either viral clearance or immune-mediated host tissue injury ,2. RemarThe immune system is continuously under viral assault, and to counter the invasion threat, it is well known that mammalians have developed a strong innate immune system and an intricate and specialized adaptive immune system to counteract the highly evolving virus infections. Immune system evolution occurs in all hosts from unicellular to vertebrates, for example, viral infection in protozoa leads to viral replication without apoptosis, while in multicellular organisms, apoptosis occurs during viral infection and vertebrate’s response is more complex leading to long term immunity against the invading virus ,5,6. WitIn spite of the existence of several correlative host defense lines to neutralize invasive pathogens or restrict the viral life cycle, viruses have evolved and adapted diverse counter strategies to evade the host immunity, sustaining continuous replication and endurable infection in the host using avoidance and escape tactics. Some viruses have developed highly complicated mechanisms such as viral growth in immunologically privileged sites, e.g., herpes virus establishes a latency in sensory neurons to avoid immune surveillance ; antigenIn this review, we make a comprehensive overview of virus-host interactions, especially immune ecosystem of virus-infected host. We also highlight the virus subversion mechanisms against host immune responses.Host immune response is first activated by sensing the viral infection through PRRs . The hosThe immune response differs according to type of virus and route of infection . For insIn multicellular organisms, cells are actively working as a single fundamental unit countering the viral infection. Once the virus attaches to host cells, the host cells starts a series of events to alert the neighboring cells against the invader and trigger the effector cells and pro-inflammatory response. This happens via the production of cytokines which help the neighbor cells to produce some inhibitory effects on viral infection and replication, e.g., IFNs; a potent neutrophil chemoattractant, e.g., CXCL8; other cell chemoattractants  e.g., CCL2, CCL3, CCL4, and CCL5; or other cytokines that lead to the acute-phase viral removal, e.g., interleukin (IL)-6 ,33. Know+ cells were reported to express perforin and granzyme B after treatment with IL-15 . Pr. Pr73]. TLRs are innate immune recognition receptors acting as the primary sensors of various pathogens . RNA virAlthough TLRs are the primary host defense sensors to combat viral invasion, viruses have evolved to subvert TLR-medicated antiviral immunity. Xagorari and Chlichlia  reviewedAs described above, TLR are mostly endocytic viral nucleic acid sensors . Yet, TLRIG-I like receptors (RLRs) are cytosolic intracellular key receptors, classically responsible for sensing non-self RNA signatures. Yet, several studies suggested that RIG-I is required to sense the DNA viruses for the induction of type I IFN ,95,96. TRIG-I plays an important role in the detection of orthomyxoviruses, rhabdoviruses, and arenaviruses, and MDA5 preferentially detects picornaviruses. Additionally, many other viruses such as flaviviruses, paramyxoviruses, reoviruses, and others are sensed by both RIG-I and MDA5 . Upon deViruses show a variety of strategies to evade RLR-mediated immune responses. Importantly, the NS1 protein of the influenza A virus inhibits the functional RIG-I and RIG-I dependent activation of NF-κB . Z proteNLRs are cytosolic PRRs. They detect diverse PAMPs or damage associated molecular patters (DAMPs) produced by viral infection. The human genome encodes 22 NLRs. Of them, nucleotide-binding oligomerization 2 (NOD2) and multi-protein inflammasome complex ) are well studied for sensing the viral infections. NOD2 was reported to induce IFNs production following ssRNA transfection and respiratory syncytial and influenza A virus infection, whereas NLRP3 inflammasome activation was reported in viral infections such as IAV, encephalomyocarditis virus, and HCV ,110. RegInterferons (type I to III) are critical immune-ecological components produced by virus-infected cells; they function as antiviral molecules and immune-modulators. Roles of type I IFNs (IFN-α and IFN-β) are well characterized and intensively explored. IFNs bind to their respective receptors to activate the Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway that governs antiviral defense . IFNs-acActivated JAK1 also activates other members of the STAT family (STAT1-6)  and induAlthough IFNs act as critical immune components, still, viruses can perturb the IFN-mediated immune barriers. The balance of immune ecosystems is always unsteady. Supportive and virtual host immunity is always perturbed by certain types of viruses . RecentlCM) and effector memory T cells (TEM). TCM is capable of the production of interleukin (IL)-2 and reproduces extensively, while TEM is capable for the production of effector cytokines like IFN-γ [The primary adaptive immune response usually takes several days and starts with the binding of an antigen with its specific receptor on the T cells or B cells. Migration of the pathogen stimulates dendritic cells of the draining lymph nodes. This is followed by several steps that ends with the release of lymphocytes embracing the antigen-specific receptors and the production of effector and memory cells. The adaptive immune response to viral infection has two-main arms: humoral immunity and cellular immunity. Humoral immunity consists of the antibodies secreted by plasma cells that can neutralize the native extracellular viruses. The cellular immunity is driven by α-β T cell receptors expressed by T lymphocytes that recognize the antigen processed peptide bound to MHC molecules on the surface of infected cells ,135. Aftke IFN-γ . This meke IFN-γ ,138.+ TH cells, resulting in a serious immune suppression due to cellular lysis [+, and CD8+ memory T cells and monocytes, resulting in immune suppression that lasts for several weeks after the virus invasion [Various viruses have evolved to invade the effector cells to evade the adaptive immunity. For example, HIV can infect the CD4ar lysis . Measlesinvasion . Epsteininvasion . In addiinvasion  and muriinvasion . On the invasion ,145. Theinvasion  leading invasion . HBV caninvasion . Many otinvasion . Herpes invasion ; retreovinvasion ; and sominvasion , arenaviinvasion , and polinvasion ,155.Dynamic interaction between the virus and host immune system results in the formation of a complex immune ecosystem involving intermolecular signaling webs for their synergistic or antagonistic fitness and survival. The host cell modulates intracellular components to clear the virus away, but viruses hijack host cell components, simultaneously. To guarantee successful and durable defense mechanisms against virus infection, hosts have evolved a highly intricate, sophisticated, and adaptable immune system to protect against continuously emerging threats and mutated viruses. Antiviral immune responses comprise complex networks of innate and acquired defenders, some of them are specific to certain pathogens and some of them are nonspecific to counteract any state of stress or immunogenic particle. It is well known that innate immunity provides the rapid nonspecific response, while adaptive immunity is only developed after the initial virus exposure. The interplay between the innate and adaptive immunity will provide the desirable immune ecosystem that can challenge the virus infection and demolish the infected cells.On the other hand, viruses also evolve. Viruses have co-evolved with their hosts to produce remarkable strategies to counteract the host defenses. These strategies include the rapid shutdown of host molecular synthesis, evasive strategies of viral antigen production, interference with MHC class I and class II antigen presentation, impairing NK cell function, suppression of antiviral cytokine signaling, and blocking apoptosis. It is recognized that health can be compromised in are remarkable way by highly mutative viruses. Viruses are ever evolving and being transmitted to susceptible hosts from animal or environmental sources to cause diseases, such as often catastrophic emerging and adventitious diseases. Virus fitness inside a host is critically reliant on the host immune ecosystem and its strategies to counter the immune ecosystem. Approaches in the understanding and management of host immune ecosystem and virus-host community would further develop novel antiviral therapeutics.


Anatomic imaging utilizing both CT (computed tomography) and MRI (magnetic resonance imaging) limits the assessment of cancer metastases in lymph nodes and distant organs while functional imaging like PET (positron emission tomography) scan has its limitation in spatial resolution capacity. Hybrid imaging utilizing PET-CT and PET-MRI are novel imaging modalities that are changing the current landscape in cancer diagnosis, staging, and treatment response. MRI has shown to have higher sensitivity in soft tissue, head and neck pathology, and pelvic disease, as well as, detecting small metastases in the liver and bone compared to CT. Combining MRI with PET allows for detection of metastases that may have been missed with current imaging modalities. In this review, we will examine the clinical utility of FDG PET-MRI in the diagnosis and staging of gastrointestinal cancers with focus on esophageal, stomach, colorectal, and pancreatic cancers. We will also explore its role in treatment response and future directions associated with it. Cancer is a global health issue that affects about 1.7 million patients in United States every year. Current epidemiology suggests that one in two will be affected with this serious life threatening disease once in a life time . MagnetiPositron emission tomography (PET) scans are a noninvasive imaging modality utilizing positron emitting radioisotopes to label molecules and create different images depending on its tissue concentrations. The most common radiotracer used in oncology is F18 fluorodeoxyglucose (FDG) that is a glucose analog with a half-life of 110 min. When these tiny positive electrons encounter a regular negative electron they form a nuclear reaction emitting two photons of high energy at 180°, annihilation rays, that can be detected by the PET crystal detector. FDG is transported via different glucose transporters into the cell then phosphorylated by hexokinase but further glucose metabolism is prevented by the fluorine atom and FDG is trapped inside the cell. Metabolically active cancer cells use more glucose and express higher levels of glucose transporter (GLUT-1) than normal cells, hence, more FDG is expressed in malignancies . In the PET imaging alone has several limitations. There is low spatial resolution and difficulty interpreting abnormalities in the setting of physiological FDG uptake in normal anatomical structures, as well as normal variants. In addition, not only does malignancy show abnormal uptake, but other pathological processes including inflammation and infection can also have prominent FDG uptake . Also thMRI uses magnetic fields with radiofrequency pulses to produce computer images based on stimulating water molecules in the body. MRI is considered the best imaging modality for soft tissue pathology. It is particularly useful in assessing abnormalities in pelvic organs such as the prostate gland and uterus, abdominal organs such as liver, biliary tract, kidneys, spleen, and pancreas. MRI is excellent at musculoskeletal abnormalities making it the standard in evaluating for ligament tears, occult fractures, myopathy, and various forms of arthritis. These strengths in MRI make it ideal for evaluating prostate cancer, gynecological cancers, hepatocellular cancer and liver metastases, renal cell carcinoma, pancreatic adenocarcinoma, soft tissue sarcomas, certain primary bone cancers, multiple myeloma, malignant melanoma, and other malignancies .The introduction of the PET-MRI scanner provided an important diagnostic imaging modality combining the metabolic parameters of PET scanning with the superior soft tissue imaging quality of MR imaging. The first PET-MRI scanners consisted of two separate imaging modalities united by a common gantry or bed so that the patient would not move between the studies. Only one camera was operating at a time, significantly lengthening the study and allowing few patients to be imaged during the day. With the launch of the Biograph mMR, Siemens Imaging allowed a fully integrated hybrid imaging that acquired both the PET and the MRI images simultaneously. Besides reducing the acquisition time in half, the hybrid images lessened misregistration artifact that occurred while moving the patient. This was also an advantage over PET-CT where the CT images were obtained first, followed by PET acquisition that could lead to changes in normal abdominal organs due to bowel movement and bladder filling . AnotherSince PET-MRI is an emerging technology, no large prospective studies validating FDG PET-MRI in oncologic patients are currently available. Initial pilot studies were intended to verify that PET-MRI imaging was equivalent to PET-CT imaging in lesion detection and feasible in clinical situations. These studies were done to justify the substitution of PET-MRI into cancer assessment instead of PET-CT scanning. However, as familiarity with the PET-MRI camera developed, new sequences and new techniques were introduced giving PET-MRI an advantage over PET-CT in many malignancies ,13,14,15Imaging protocols for PET MRI varies in different institutions and standards are controversial. All PET-MRI scanners require a fast view localizer followed by a Dixon AC sequence for PET attenuation correction. We used a Siemens mMR hybrid PET-MRI scanner with 3T magnet. A typical base of skull to mid thigh body protocol requires five separate bed stations or acquisition stations where all MRI sequences must be the same for each bed using body coils. Typically, T1 vibe and T2 haste are the mainstay of acquisition with or without fat suppression . At our After initial diagnosis of esophageal cancer from upper endoscopy with biopsy, the current methods of staging this malignancy involves CT chest and abdomen, endoscopic ultrasonography (EUS), and PET-CT with FDG. EUS is essentially used to determine primary tumor depth and involvement by identifying layers of the esophageal wall. Clinical distinction for T1 and T2-4 diseases is important since neoadjuvant chemoradiotherapy is used in most locally advanced esophageal cancer followed by surgical resection. FDG PET-CT offers an alternative test because it may detect small lymph nodes not detected by size criteria but are metabolically active, but overall, PET-CT and CT are limited in detecting local lymph nodes as well as peritoneal spread of disease. PET-CT is superior at detecting distant metastases in the liver and lungs compared to CT scan alone .The rapid evolving PET-MRI imaging modality with its superior soft tissue resolution and metabolic activity has potential in initial staging of esophageal cancer. With the improvement of MRI cameras, protocols, and techniques that resulted in high quality imaging, staging of esophageal cancer has significantly improved. Diffusion weighted imaging with the conjunction of high resolution T2 weighted MRI images, the extent of tumor wall invasion as well as local and distant metastases have improved. Other sequences like STIR and TSE have also improved diagnostic accuracy. MRI contrast agents may even detect small lesions which are difficult to see ,18. VariUse of MRI in treatment response in esophageal cancer is currently evolving. Ayoyagi et al. have shown that high ADC values were associated with better response to chemoradiotherapy in esophageal cancer patients and higher survival rates . This arThe preoperative staging of stomach cancer has been traditionally performed with endoscopic ultrasonography and contrast enhanced CT. EUS has been valuable in assessing tumor wall invasion and in the detection of lymph node involvement. EUS has the ability to evaluate the tumor in close proximity viewing all five layers of the wall with the ability of performing biopsy for lymph node involvement. One weakness of EUS is lack of metastatic assessment in more advanced cancer .CT has the ability to assess for locoregional involvement, as well as, distant metastases. It has limitations in T staging but can provide anatomic information of metastatic lymph nodes based on size and morphology criteria. The addition of PET imaging can detect normal size lymph nodes with cancer involvement. PET is more suitable in detecting distant metastatic disease, especially hepatic metastases ,23. In rLocalized gastric cancer is treated with either pre-operative systemic chemotherapy followed by surgical resection or surgical resection followed by adjuvant chemotherapy. Since there is a very small percentage who will have complete pathologic response to systemic chemotherapy alone, there is less enthusiasm in assessing treatment response in gastric cancer. Data is emerging on the use of PET-MRI in the treatment response to chemotherapy and pilot study of 11 patients showed a synergetic advantage of FDG PET-MRI in advanced gastric cancer with good correlation to chemotherapy response ,26,27.The initial evaluation of colon cancer often involves colonoscopy with biopsy and contrast enhanced CT for assessment of liver lesions. Contrast enhanced CT has an acceptable detection of liver metastases but may miss detection in up to 7% of the patients and may overestimate liver involvement of others. Extrahepatic abdominal metastases are commonly missed by CT and has difficulty in differentiating post-surgical changes from recurrence. PET-CT has been shown to be slightly more sensitive than CT in liver metastases and better at detecting extrahepatic abdominal metastases. However, due to the variable uptake in hepatic lesions, PET-CT may miss small lesions .Unenhanced standard MRI sequences including T1 and T2 weighted images can accurately characterize and detect most focal liver lesions and can differentiate between solid and non-solid lesions as shown in The risk of lymph node involvement increases with depth of tumor wall invasion ranging from 15% to 65%. Traditional mesenteric lymph node metastases are based on nodal size and shape with 5 mm being the optimal size. Both CT and MRI have detection capabilities for nodal metastases. However, reactive lymph nodes are common and can confuse interpretation of metastatic spread . FDG PETFDG PET-MRI may have a special role in staging and restaging of rectal cancer. At our institution, in addition to full body PET-MRI scanning, we obtain dedicated pelvic MRI sequences with intravenous contrast after the body images on all rectal cancer patients. During the dedicated pelvic MRI sequences, we continuously acquire the PET signal which leads to a high resolution image of the pelvis. This leads to a high sensitivity in detecting small pelvic lymph nodes. MRI does not have a high degree of accuracy in distinguishing T1 from T2 tumors, but T3 tumors that extend beyond the muscularis propria can be easily detected. In addition, MRI correctly characterizes T4 tumors that spread into visceral peritoneum, adjacent organs, or the levator musculature. MRI has limited sensitivity and specificity in determining pelvic lymph node spread based on changes in size, morphology, or enhancement. The addition of PET imaging showing abnormal metabolic activity in regional lymph nodes adds to a more accurate assessment . These aPancreatic cancer is diagnosed using multiple modalities including abdominal ultrasound, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, CT, MRI, and PET/CT. For staging purposes, current recommendations include cross-sectional imaging such as contrast enhanced CT or MRI. PET-CT imaging has played an important role in characterizing pancreatic lesions and its metastatic spread. Most malignant tumors of the pancreas are active on FDG PET imaging and PET-CT has much higher sensitivity and specificity than contrast enhanced CT  as illusNagamachi et al. examined 119 patients with pancreatic lesions and compared PET-MRI to PET-CT images. PET-MRI demonstrated higher accuracy of 96% vs. 86% in the assessment of pancreatic tumors in comparison to PET-CT . PET-MRIWith the recent introduction of an integrated PET-MRI, this novel imaging modality is available for the detection, staging, and evaluation of gastrointestinal cancers. PET-MRI has a significant reduction in radiation exposure compared to PET-CT which may benefit younger patients or patients that require frequent repeat PET imaging. MRI offers superior soft tissue resolution compared to CT in rectal and pancreatic cancer. As novel hybrid imaging technology improves, PET-MRI has great potential in the assessment of esophageal cancer, colorectal cancer, stomach cancer, and pancreatic cancer in terms of primary lesion evaluation, nodal involvement, and liver metastases with a high degree of diagnostic accuracy and specificity. Larger clinical validation studies are needed to make PET-MRI an integral part of gastrointestinal cancer patient management in the near future.


Drosophila melanogaster. ten Bosch et al. showed that the heptamer consensus sequence CAGGTAG  is overrepresented in regulatory regions of the earliest expressed zygotic genes [zelda  as the TAGteam binding factor was a breakthrough in MZT research [PLOS Genetics showed that Zld binds to over 1,000 cis-regulatory regions during D. melanogaster early embryogenesis [Dorsal and bicoid), resembling the role of pioneer vertebrate TFs  [zld was shown to be important for the establishment of topologically associating domains (TADs) during zygotic genome activation [During metazoan early embryonic development, maternal mRNAs are gradually eliminated and replaced by zygotic ones during the maternal-to-zygotic transition (MZT), a stage where the zygotic genome takes control of developmental processes . In 2006research . In 2011ogenesis , 5. Zld d Gata4) . Recentltivation .Drosophila [PLOS Genetics showed that Zld is conserved throughout Pancrustacea and comprises other widely conserved regions, including an acidic patch—which could be involved in the recruitment of chromatin remodeling proteins—and two N-terminal ZnFs, ZnF-Novel and ZnF1 [zld is found as a single-copy gene in all insect genomes sequenced to date, indicating that it is sensitive to increased gene dosage [Although many important roles of Zld in transcriptional regulation have been elucidated over the past 10 years, the biochemical and structural features that make Zld a master TF remain largely unknown. Previous biochemical and cell culture analysis revealed a low complexity region, corresponding to the transactivation domain, and four C-terminal ZnFs that are required for DNA binding and transcriptional activation in osophila . Recentland ZnF1 . Interesand ZnF1 . In addie dosage .PLOS Genetics, Hamm and collaborators [D. melanogaster Zld conserved domains in vivo and in vitro. An elegant Cas9 engineering system was used to generate flies with point mutations in ZnF1, in the acidic patch, or in the ZnF2 JAZ-finger. This approach has the advantage of generating mutations in the native locus, avoiding issues with position effects of transgenic insertions. While mutations in the ZnF1 or in the acidic patch did not affect viability, mutations in the ZnF2 JAZ-finger domain led to a maternal-effect lethal phenotype. Hamm et al. also conducted a transcriptome analysis of the mutated zld ZnF2 JAZ-finger (zldZnF2). They showed that the ZnF2 JAZ-finger acts as a maternal repressive domain during fly embryogenesis in vivo, being particularly involved in the transcriptional regulation of zygotic zld targets and maternal mRNA clearance. Collectively, Hamm et al. [In December 2017’s issue of borators  report tm et al.  show forD. melanogaster (as hypothesized by the authors) or; 3) these domains are not essential in flies kept under standard laboratory conditions.The work by Hamm et al. also poses intriguing questions. The observation that point mutations in the acidic patch and ZnF1 did not alter fly viability suggests at least three scenarios: 1) the amino acid changes did not impair the activity of the domains; 2) these domains are dispensable for Zld-mediated transcriptional activation in zld expression has been reported to be critical for correct activation of target genes in time and space [zld lines display altered gradients of key TFs  by live imaging. Further, analysis of TAD boundaries by Hi-C in zldZnF2 mutants could provide new hints of Zld's function in the establishment of chromatin architectures [We believe that the former two possibilities are unlikely because Zld is a master TF, and the most important (and conserved) residues of the acidic patch and ZnF1 were precisely mutated. The latter hypothesis seems more appealing, as these domains have been conserved for over 300 million years in various insect lineages . Detailend space , 13, it tectures .zldZnF2 male and female adults displayed small eyes [zld also performs post-embryonic roles, as previously reported in beetles [zld expression in eye and wing imaginal discs [zld in such processes are yet to be elucidated. Recently, zld was also described as an important factor for neuronal progenitor formation in flies, and its inhibition by the tumor suppressor TRIM-NHL protein Brain tumor (Brat) appears to be essential to avoid neuronal tumor progression [zld gene regulatory networks are similar among these developmental processes will be of great value.Another interesting finding from Hamm et al. was that a subset of homozygous all eyes , strongl beetles . Importaal discs , 14. Progression . Hence, zld in early transcriptional reprogramming and unlock further secrets about evolution of this master TF throughout the Pancrustacea.Finally, Hamm et al. open new perspectives in the elucidation of Zld functions. Comparative functional studies in other insect species may provide a unique opportunity to address the roles of