Oral cancer affecting the oral cavity represents the most common cancer of the head and neck region. Oral cancer develops in a multistep process in which normal cells gradually accumulate genetic and epigenetic modifications to evolve into a malignant disease. Mortality for oral cancer patients is high and morbidity has a significant long-term impact on the health and wellbeing of affected individuals, typically resulting in facial disfigurement and a loss of the ability to speak, chew, taste, and swallow. The limited scope to which current treatments are able to control oral cancer underlines the need for novel therapeutic strategies. This review highlights the molecular differences between oral cell proliferation, differentiation and terminal differentiation, defines terminal differentiation as an important tumour suppressive mechanism and establishes a rationale for clinical investigation of differentiation-paired therapies that may improve outcomes in oral cancer.The oral epithelium is one of the fastest repairing and continuously renewing tissues. Stem cell activation within the basal layer of the oral epithelium fuels the rapid proliferation of multipotent progenitors. Stem cells first undergo asymmetric cell division that requires tightly controlled and orchestrated differentiation networks to maintain the pool of stem cells while producing progenitors fated for differentiation. Rapidly expanding progenitors subsequently commit to advanced differentiation programs towards terminal differentiation, a process that regulates the structural integrity and homeostasis of the oral epithelium. Therefore, the balance between differentiation and terminal differentiation of stem cells and their progeny ensures progenitors commitment to terminal differentiation and prevents epithelial transformation and oral squamous cell carcinoma (OSCC). A recent comprehensive molecular characterization of OSCC revealed that a disruption of terminal differentiation factors is indeed a common OSCC event and is superior to oncogenic activation. Here, we discuss the role of differentiation and terminal differentiation in maintaining oral epithelial homeostasis and define terminal differentiation as a critical tumour suppressive mechanism. We further highlight factors with crucial terminal differentiation functions and detail the underlying consequences of their loss. Switching on terminal differentiation in differentiated progenitors is likely to represent an extremely promising novel avenue that may improve therapeutic interventions against OSCC. Oral squamous cell carcinoma (OSCC) is the most commonly diagnosed head and neck cancer . OSCC frThe balance between proliferation, differentiation and terminal differentiation is therefore key to maintaining OE homeostasis and securing the physical and physiological functions of the oral barrier ,13. ExpoThe OE undergoes a rapid turnover (estimated 4.5 days) to eliminate cells damaged by constant exposure to environmental risk factors. Stem cells initiate this process through their proliferation and differentiation to repopulate the OE and to maintain its homeostasis . Over thBmi1-expressing OE stem cells were first reported using multi-colour lineage tracing and label retention experiments in the dorsal tongue epithelium [Bmi1-positive stem cells were slow-cycling and distributed at a low density within the basal layer. Their proliferation was shown to follow the invariant asymmetry model, supporting an asymmetrical division of long-lived cells that maintain stemness while producing highly proliferative, transit-amplifying daughter cells that differentiate incrementally to produce the clearly defined OE layers. However, using RNAscope on the dorsal tongue and buccal epithelium, Klein’s group found that all basal cells, including progenitors, express Bmi1, albeit at low levels, contradicting the data suggesting that Bmi1 marked rare, solitary stem cells in the suprabasal layers of the OE [Lrig1 infrequently divide in a symmetrical fashion then become quiescent while Igfbp5+ cells undergo rapid asymmetrical division in the lead-up to differentiation. These studies underscore that our understanding of stem cell niche function within the OE is still confounded by various anatomical locations and technical limitations. Spatial single-cell sequencing will be crucial to identify and characterise specific stem cell populations within various head and neck regions and shed light on the mechanisms governing their maintenance and differentiation.Stem cells are referred to as a quiescent, infrequently dividing cell population with self-renewal properties. The identification and characterization of oral epithelial stem cells have been challenged for decades . The Bmiithelium . The resf the OE . Furtherf the OE . Here, tINK4A may guide replicative senescence, limiting cellular migration and proliferation while retaining normal growth and differentiation characteristics [The OE is equipped with an effective “catastrophe” response to damage induced by a variety of insults, such as wounding, masticatory stresses, chemical exposure and microbial pathogens. A transcriptional analysis of the OE during wound healing identified reduced differentiation and increased proliferation signatures in OE cells recruited to facilitate tissue repair . This reeristics ,22,23,24eristics ,26,27,28Bmi1 expression [Cancer stem cells (CSCs) are believed to act as the drivers of OSCC . These cpression . Bmi1+ cpression . ConsequAs OE progenitor cells commit to differentiation programs and migrate upward, these cells are exposed to a dynamic gradient of Notch/Wnt ligands and growth factors. These gradients contribute profoundly to the strict regulation of basal-suprabasal compartmentalisation .Notch1-driven terminal differentiation in supra-basal layers [TP53 gain-of-function mutation or the expression of HPV oncogenes to induce high-grade carcinomas within the head and neck region [Notch signalling [NOTCH1/2/3 mutations and truncations (~27%) which presumably lead to protein inactivation, disruption of differentiation and OSCC development [NOTCH1 are commonly detected in precancerous lesions, highlighting its protective role against the early onset of OSCC in patients [NOTCH1 mutations are mainly considered drivers of the disease, growing evidence points out to the hyperactivation of NOTCH signalling in a subset of OSCC, proposing an oncogenic potential to wild-type NOTCH1 [Notch signalling is regulated predominantly through cell–cell interactions. Notch ligands are expressed in basal cells while Notch receptors are present on suprabasal spinous cells. The activation of Notch signalling in differentiation-committed cells coincides with their detachment from the basement membrane and the expression of terminal differentiation program genes. Notch regulates cell fate commitment and governs the balance between basal progenitor proliferation and supra-basal differentiated cells within a process known as the basal-to-suprabasal switch . In agrel layers . Loss ofk region . Moreovegnalling . These rgnalling ,42. Receelopment ,44. Morepatients ,40,45. Ce NOTCH1 . NOTCH1-e NOTCH1 ,48. HoweDrosophila through cell fate determination, tissue regeneration and stem cell self-renewal and is mainly regulated through contact inhibition [YAP1 locus and 21.6% with truncated FAT1 [The Hippo pathway controls organ size in hibition . In the hibition . This mehibition . In the hibition . Indeed,hibition . Furtherted FAT1 , an upstted FAT1 ,55. YAP1ted FAT1 .TP63 gene in established SCC tumours leads to rapid tumour shrinkage, revealing a crucial function for TP63 in SCC maintenance [TP63, and these events are associated with poor tumour differentiation and patient prognosis [TP63 belongs to the TP53 family of transcription factors and has two distinct isoforms: TAp63 and ΔNp63. TAp63 possesses a transactivation domain at N-terminal, while ΔNp63 contains a shorter activation domain. Despite the conservation in their structures and transcriptional activities, these isoforms are expressed in different tissues and have distinct roles in embryonic development and epithelial maintenance . In strantenance . Moreoverognosis .During lineage specification, dynamic epigenetic modifications profoundly influence gene expression. The open chromatin conformation in stem cells enables active transcription of genes related to keratinocyte commitment and differentiation. This process is progressively accompanied by increased DNA methylation, the accumulation of various histone markers and chromatin remodelling, resulting in diminished chromatin accessibility and full inactivation of transcription in terminally differentiated cells . These oAnother level of regulation that follows the transcriptional control of differentiation genes depends on the post-transcriptional modifications that also influence the dynamics of protein abundance during differentiation . One of Terminal differentiation programs are fully engaged in granular and cornified layers of the oral epithelium, leading to the establishment of a functional barrier that prevents against environmental insults. This outermost layer of the dorsal tongue epithelium is formed of corneocytes embedded in a lipid matrix that contains small vesicles of cholesterol, phospholipids and ceramides. In addition to protein cross-linking, the correct presence of lipid complexes is essential to maintain barrier function, preventing dehydration and infection . NeverthAbca12 induces a failure of extracellular lipid deposition and premature differentiation, consequently leading to hyperkeratosis and impaired barrier function [ABCA12 regulates vesicular trafficking in terminally differentiated cells and is one of the core components that preserve lipid homeostasis . The losfunction . In humafunction . Interesfunction , furtherFLG in KGs in conjunction with a striking glossy and scurfy epidermal phenotype, water loss and increased susceptibility of ultraviolet B damage [FLG has been recorded in the autosomal semi-dominant disease ichthyosis vulgaris (IV) and in atopic dermatitis (AD), where the presence of loss-of-function mutations in FLG also predisposes to IV and AD as well as additional allergic diseases such as asthma [FLG is one of the most frequently mutated genes (13%) in OSCC [Keratins and filaggrin contribute to 80–90% of the mass of the granular layer in stratified epithelia, where they are tightly cross-linked to establish a physiological epithelial barrier. Notably, filaggrin (filament aggregation protein) serves as an indispensable molecule for the aggregation process of keratin filaments. Filaggrin derives from the proteolytic maturation of profilaggrin (FLG), an S100 fused-type protein of approximately 500 kDa, histidine-rich with tandem repeats of filaggrin stored in the membrane-less protein deposits, known as keratohyalin granules (KGs) . The disB damage . Intrigus asthma . Collect in OSCC ,44, and  in OSCC .HRNR expression is downregulated in the skin of AD patients, and a single-nucleotide polymorphism of HRNR was identified in people vulnerable to AD [HRNR is also an S100 fused-type protein encoded in the epidermal differentiation complex same as FLG. The precursor of HRNR is approximately 280 kDa with a central tandem peptide repeats domain with calcium-binding sites, located in the periphery of KGs within the upper granular and cornified layers . Similarle to AD . Importale to AD . These oTP53 may render cancer cells resistant to T cell-mediated killing [Most OSCC patients present with advanced-stage disease, and treatment is met with high levels of recurrence and metastasis ,80. More killing . This su killing , and hasThe central concept of targeted therapy typically involves clinical testing to determine features of a patient’s malignant disease that may inform treatment decisions. Why some patients respond well to targeted therapies, and other patients who appear to have the same type of cancer respond poorly or not at all, remains poorly understood. Genomic biomarkers paired with targeted therapies have proven highly efficacious in some cases, such as HER2 amplification and trastuzumab in breast cancer , BRAF muLarge-scale genomic and transcriptomic sequencing of OSCC tumours showed very high (~90%) inactivating mutations in tumour suppressor genes, most of which encoded terminal differentiation factors . TP53 waTP53 with wild-type gene in order to restore p53 functionality, with potential utility as a new treatment approach for head and neck cancers [The lack of effective targeted therapies for heterogeneous OSCC, particularly those with TP53 mutations, has hampered improvements in patient survival, which has remained virtually unchanged for the last 30 years . Nonethe cancers ,111,112. cancers , a treme cancers . Integra cancers . Of thesOSCC genomic alterations are dominated by the loss of terminal differentiation tumour suppressor genes, with 80% of patients harbouring at least one genomic alteration in a targetable gene . This su


ANS function, specifically cardiac vagal tone, was assessed using the Porges-Bohrer method for calculating respiratory sinus arrhythmia (PBRSA). Functional brain networks were generated from resting-state MRI scans obtained following 3-day periods of typical consumption and abstinence. A multi-task mixed-effects regression model determined the influences of HRV and drinking state on functional network connectivity. Results showed differences in the relationship between the strength of network connections and clustering coefficients across drinking states, moderated by PBRSA. Increases in connection strength between highly clustered nodes during abstinence as PBRSA increases demonstrates a greater possible range of topological configurations at high PBRSA values. This novel finding begins to shed light on the complex interactions between typical alcohol abstinence and physiological responses of the central and autonomic nervous system.Alcohol consumption is now common practice worldwide, and functional brain networks are beginning to reveal the complex interactions observed with alcohol consumption and abstinence. The autonomic nervous system (ANS) has a well-documented relationship with alcohol use, and a growing body of research is finding links between the ANS and functional brain networks. This study recruited everyday drinkers in an effort to uncover the relationship between alcohol abstinence, ANS function, and whole brain functional brain networks. Participants ( RSA. This abbreviation is used to distinguish it from the peak-to-trough method for determining RSA, PTRSA, which is common in the literature but is less desirable. Research has consistently shown that higher levels of CVT are associated with psychological resilience, improved physiological recovery following exposure to stressors [Alcohol use is a leading risk factor for declining health and global disease burden , but cestressors , greatertressors , and mostressors RSA metric. Alcohol craving ratings in the everyday drinking population are higher with lower dynamic PBRSA [RSA in conjunction with greater anxiety and stress and overall poor mood in abstinence alcoholic men [Alcohol craving in patients with an alcohol use disorder (AUD) has been associated with high frequency heart rate variability (HF-HRV), another metric used to assess CVT, with acute consumption being related to decreasing HF-HRV ,14,15,16ic PBRSA . Long-teic PBRSA ,19,20. Holic men .RSA in an effort to capture the functional relationship between heart rate, respiration, and brainstem function [RSA as a metric of CVT, since our work is based on PVT. PVT provides an adaptive hierarchical model of autonomic function that parallels phylogeny and maturation. It is this hierarchical model of autonomic regulation that is disrupted by AUD.The relationship between CVT and everyday drinking has been less thoroughly explored, a shortcoming that is the focus of the current study. Specifically, our goal was to examine fundamental neural mechanisms underlying the influence of the autonomic nervous system (ANS) on brain responses to alcohol abstinence in regular drinkers. To do so, ANS activity was assessed using PBfunction ,23. We afunction ,25 have function , who focRSA to brain activity during abstinence was assessed using functional imaging. It is conceptually relevant to consider potential interactions between PBRSA and brain state changes, as PBRSA decreases with increases in threat to the organism. Alcohol craving, especially during abstinence, is highly associated with relapse in individuals recovering from AUD, and has been associated with distinct patterns of brain activity [The majority of existing alcohol-related brain imaging studies have focused on problematic alcohol consumers or those with AUD. The limited number of studies in non-AUD individuals have not explored the effects of a brief period of alcohol abstinence. Given the known rewarding properties of alcohol  and the activity  and connactivity ,32,33. Cactivity . When exactivity . In alcoactivity , rather RSA. Specifically, individuals with higher resting PBRSA would exhibit greater topological changes between the normal and abstained states, consistent with greater cognitive and emotional flexibility associated with higher resting PBRSA.To best capture the mechanistic relationships between the central and peripheral nervous system, this study recruited everyday drinkers without behavioral problems associated with their consumption patterns. This allowed for comparison within individual participants, tracking brain network changes in response to their normal drinking patterns and to a brief period of imposed abstinence. The analyses performed focused primarily on clustering coefficient and global efficiency as network features that capture regional specificity and distributed processing, respectively. We hypothesized that changes in brain network topology between normal drinking and abstained states would be significantly associated with resting PBThe data used in this analysis come from a multi-part study examining neurobiological variables in everyday alcohol consumers. Previous manuscripts published from this same dataset examine patterns of craving and stress across the day and how RSA moderates patterns of craving. The drinking population studied in this protocol consisted of healthy adults whose lifestyle includes routine alcohol consumption above low risk levels  with infThirty-four everyday drinkers were recruited from the community using various advertisement techniques including posted flyers, mailers, and inter/intranet postings. The final sample included 29 participants  after excluding for missing data . Enrollment criteria included adults aged 24–60, alcohol consumption on an average of ≥50% of days, and an average daily consumption of 1–3 drinks/day for females and 2–4 drinks/day for males. Drinking patterns were collected with the Timeline Followback (TLFB), a well-established retrospective measure of alcohol consumption . ExclusiRSA, a phenotypic index of vagal health. As such, PBRSA was calculated from heart rate data collected at baseline, before the study-imposed abstinence period. PBRSA was then analyzed in conjunction with functional MRI data collected following the normal drinking and abstinence experimental periods. An electrocardiogram (ECG) was collected via a Biopac MP150 system during the baseline visit. A three-electrode configuration was used in conjunction with a pulse oximeter. Participants were instructed to refrain from speaking and remain still throughout data collection. Heart rate was recorded for 5 min while participants were seated comfortably. CardioEdit software  was used to visually inspect and edit off-line heart rate data. CardioBatch Plus software  was used to calculate heart rate and PBRSA from the ECG data consistent with procedures developed by Porges [The primary research question raised in this study examined resting levels of PBy Porges . This bay Porges .RSA as a valid index of HRV [RSA using age-specific parameters that are sensitive to the maturational shifts in the frequency of spontaneous breathing. The method, when applied to adults, includes: (1) timing sequential R-R intervals to the nearest millisecond; (2) producing time-based data by resampling the sequential R-R intervals into 500 ms intervals; (3) detrending the time-based series with a 21-point cubic moving polynomial stepped through the data to create a smoothed template, then subtracting the template from the original time-based series to generate a detrended residual series; (4) bandpass filtering the detrended time series to extract the variance in the heart period pattern associated with spontaneous breathing in adults (0.12–0.40 Hz); and (5) transforming the variance estimates with a natural logarithm to normalize the distribution of PBRSA estimates [RSA was quantified during each sequential 30 s epoch and the averages within each condition were used in the data analysis.These methods have been documented to extract a single amplitude of PBx of HRV . CardioBstimates . These ps 0.12–0. Hz; and stimates . This castimates . PBRSA wAt the beginning of each MRI session, participants completed surveys regarding any changes to their typical routine, and probing alcohol craving , stress MRI data was obtained on a 3T Siemens Skyra scanner equipped with a 32-channel head coil, a rear projection screen, and MRI compatible headphones. The imaging protocol consisted of a T1-weighted structural scan followed by a 6 min blood oxygen level dependent (BOLD)-weighted resting state scan. During the resting state scan, participants were instructed to focus on a fixation cross projected on the rear projection screen. High resolution (1 mm isotropic) T1-weighted structural scans were acquired in the sagittal plane using a single-shot 3D MPRAGE GRAPPA2 sequence (repetition time (TR) = 2.3 s, echo time (TE) = 2.99 ms, 192 slices). The resting state BOLD-weighted image sequences were acquired in the transverse plane using an echo-planar imaging sequence .www.fil.ion.ucl.ac.uk/spm/, accessed on 12 October 2018). The functional images were slice time corrected and realigned to the first image of the series. Preprocessing for the structural image consisted of skull removal with the remaining image segmented into grey matter, white matter, and cerebrospinal fluid (CSF) maps using a unified segmentation algorithm [The first 20 s (10 image volumes) were discarded to allow the signal to achieve equilibrium. Initial steps for image processing were performed using SPM12 software  . Motion Full details regarding the methodology used for statistical modeling are included in the RSA as a continuous measure of CVT, and possible confounding variables [p-value <0.05, with p-values adjusted for multiple comparisons using the adaptive False Discovery Rate procedures detailed by Benjamini and Hochberg [A mixed-effects regression was used to assess the relationship between whole brain network connectivity, participants’ drinking state, PBariables ,57,58. THochberg . AnalyseHochberg , Matlab The goal of this analysis was to determine if brain network differences observed across drinking states were driven by HRV. To test this relationship, the model allowed for the comparison of these variables with the strength of network connections, or the similarity of the data recorded from each brain region. More simply, this regression model determined how much each of these variables affected the similarity of data collected from different brain regions, indicating how connected they are as nodes in the whole brain functional network. The variables included average clustering coefficient , average global efficiency , difference in degree (number of connections) between each nodal pair, and overall network modularity (the extent to which the network subdivides into densely interconnected communities that are scarcely connected to the rest of the network)  as well RSA. The results section highlights key findings with the full model results being available in the The mixed-model framework tested the hypothesis that the effects of drinking state on brain network topology are resting levels of PBDescriptive statistics related to participants’ demographic characteristics and variables included in the statistical model are listed in RSA , as shown in RSA values increase. Thus, higher PBRSA values are associated with networks that have the strongest connections between highly clustered nodes during abstinence. At lower PBRSA values, only a small difference was observed in the clustering-strength relationship across drinking states, with weak network connections between highly clustered nodes during abstinence. These differences are meaningful as stronger network connections support synchronization of neural signals across regions, leading to efficient information sharing between clusters. The slope of the regression captures the magnitude of the strength-clustering relationships and is shown for each state at higher and lower PBRSA values in The primary finding from the brain network analysis was a significant interaction between the connection strength, clustering coefficient, drinking state, and PBRSA but this finding only trended toward significance . This statistical trend is presented here because it may be critical for understanding the mechanistic relationships between PBRSA and brain networks. Across all observed PBRSA values, highly globally efficient nodes were more strongly connected during abstinence. The slope of this relationship was steeper at lower PBRSA values, indicating the strength of connections between highly globally efficient nodes increases more rapidly at lower PBRSA values than at higher PBRSA values. This would result in a higher probability of synchronization between highly globally efficient nodes, increasing the distribution of information globally. The slope of these relationships can be observed in A second connection strength relationship was found with global efficiency, drinking state, and PBp < 0.0001). We also observed a significant main effect of PBRSA, indicating that as PBRSA increases network connectivity strength decreases . Additionally, there was an interaction between drinking state and PBRSA that did not reach statistical significance but exhibited a notable positive trend . Clustering coefficients  and global efficiency  were both significant positive predictors of connection strength. Finally, there was an interaction of PBRSA with clustering  but not with global efficiency.RSA measured at rest. These results showed increasing connection strength between highly clustered nodes during abstinence as PBRSA increases, and these network changes suggest a greater range of possible topological configurations at high PBRSA values. A thorough understanding of the biological effects underlying alcohol abstinence will help lay a foundation of alcohol research focused on development of clinical treatment and prevention strategies related to alcohol consumption.This study examined how HRV relates to brain network topology changes between periods of normal drinking and alcohol abstinence in everyday drinkers. The main study hypothesis was supported by the results found in this study: differences in the relationship between the strength of network connections and clustering coefficients across drinking states was mediated by PBRSA values increased. Among those with higher PBRSA values following abstinence, we found strong connections between highly clustered nodes and weaker connections between globally efficient nodes. However, during normal drinking, we would expect weaker connections between highly clustered nodes. At lower PBRSA values, the edges connecting highly globally efficient nodes would be expected to be weaker during abstinence. When considering combined effects, the clustering and global efficiency findings suggest that as PBRSA values increase, the network takes on a more lattice-like structure during abstinence, and a more small-world topology during normal drinking [RSA values. These findings have substantial implications for the exchange of information across the whole brain.To fully understand the implications of these findings, we must remember what the statistical network model is evaluating. In a traditional functional brain network built with Pearson’s correlations, as a network feature such as clustering coefficient or global efficiency between two nodes increases, the strength of the edge connecting those nodes should also increase . The strdrinking , with a As biomedical sciences take a broader approach to examining alcohol disorders, treatment, and prevention, there is a growing relevance of novel translational biomarkers. HRV has potential as a translational biomarker, in relation to alcohol consumption, and more broadly with emotional or cognitive deficits, as dysfunction in HRV is observed in many psychiatric disorders ,69,70. LRSA dependent network changes. Finally, because this study was specifically interested in a resting PBRSA phenotype and therefore used a baseline measure to associate with brain network topology, our study is not able to assess the effects of abstinence on PBRSA. However, this is an important question that warrants further study in the future.This study is not without weaknesses that should be recognized. While the interaction involving clustering was highly significant, the interaction with global efficiency did not reach statistical significance. Nevertheless, the global efficiency findings fit conceptually with the clustering findings, and future work is needed to replicate these findings in order to determine the implications of the global efficiency finding. The relatively small sample size in the current study could have contributed to the lack of significance. It should also be noted that the small sample size may limit the generalizability of the findings. However, robust significant effects were found despite the small sample size. Another potential limitation was the timing of MRI scanning: all fMRI data used in this protocol was collected between 8 am and 12 pm on the fourth day of each normal drinking/abstinence week. Previous analyses in this population have shown limited craving for alcohol, even during abstinence, until late afternoon ,29, meanRSA.Regular alcohol consumption is common practice in our world today. The largest study of alcohol use to-date found that at least 60% of the US population consumes 1–3 alcoholic beverages per day [


Surgical management of patients with abdominal aortic diseases associated with distal narrowing is a challenging situation.To evaluate outcomes of unibody bifurcated endovascular stent graft repair.This is a retrospective, observational, multi-institutional database study of a cohort of consecutive cases, approved by the local Ethics Committee. Records were reviewed of patients diagnosed from 2010 to 2020 with “shaggy” aorta, saccular aneurysm, penetrating aortic ulcer, and isolated aortic dissection located in the infrarenal abdominal aorta. All patients were treated with a unibody bifurcated stent graft. Main outcomes were technical success, procedure complications, long-term patency, and mortality in the follow-up period up to 5 years. Data on demographics, comorbidities, surgical management, and outcomes were analyzed.Twenty-three patients were treated with unibody bifurcated stent graft repair, including 7 cases of “shaggy” aorta, 3 isolated dissections of the abdominal aorta, 4 penetrating aortic ulcers, and 9 saccular aneurysms. Immediate technical success was achieved in 100% of cases. At follow-up, all stent grafts remained patent and there were no limb occlusions. The patients were symptom-free and reported no complications related to the procedure. There were 5 deaths during the follow-up period (median= 4 years), but none were related to the procedure and there were no aorta-related deaths.The present study shows that unibody bifurcated stent grafting is safe and effective in this group of patients with narrow distal abdominal aorta and complex aortic pathology. The results were similar for both infrarenal aortic aneurysms and aorto-iliac atherosclerotic disease. A narrow aortic bifurcation was defined by outer-to-outer aortic diameter <18 mm measured in any location within the distal 5 cm above the aortic bifurcation.This is a retrospective, observational, multi-institutional (2 independent centers) study of a cohort of consecutive cases with “narrow distal abdominal aortic diseases” (NDAAD) treated with an endovascular technique using the EndologixThe study was approved by the Ethics Committee (decision number 3.493.497). The early postoperative period was defined as the 30 days after the operation. Mortality and morbidity were investigated, including arterial or stent graft stenosis, kinking, or occlusion.Consecutive patients with NDAAD treated with unibody bifurcated stent graft in the period between 2010-2020 were included. Exclusion criteria were treatment with other devices or typical atherosclerotic aortic diseases (occlusive or stenotic disease not characterized as “shaggy aorta”) or NDAAD located in segments of the aorta other than the infrarenal segment. There were no cases with contraindications to use of a unibody stent graft design.R software was used for measuring and planning the procedures. All patients were screened for cardiac risk and those with extensive coronary disease were treated by cardiologists or cardiovascular surgeons before the operation. Nephrology was consulted during the course of treatment of those patients in whom pre-existing renal insufficiency was identified. Spinal anesthesia was performed in 66%, considering surgical risk stratification. Common femoral access was generally obtained by percutaneous puncture under ultrasound guidance (n=15) using the Preclose technique,R AFX stent grafts  were implanted using the standard technique described in the manufacturer’s instructions for use, under fluoroscopic guidance with fixed angiographic equipment.Computed tomography angiography (CTA) was selected as the standard imaging modality for diagnostic confirmation and therapeutic planning in all cases, complemented by digital angiography when necessary. Terareconidance n= using thR Proglide (Abbot Vascular) devices were used for closure of femoral puncture accesses.The bifurcated unimodular main body stent graft was introduced via the femoral artery through a 17F sheath and the pre-loaded contralateral leg was captured via the contralateral femoral access with a 9F introducer. The main body measurements and the lengths and diameters of their respective proximal extension devices were chosen according to the measurements of the aorta and the common iliac arteries. In most cases, the main body of the device alone was sufficient for complete NDAAD treatment. Proximal extension devices were required in just five cases to accomplish complete treatment of their main respective diseases. PercloseCompletion angiography with digital subtraction showed good flow through the graft and iliac-femoral arteries. All patients were maintained post-operatively on an antiplatelet regimen of aspirin (100 mg) only, for life.The primary outcomes were immediate technical success, procedure complications, patency rates, and short (30 days) and long-term mortality. Secondary outcomes included demographic data, risk factors for atherosclerosis , surgical risk factors, cardiac risk, renal function, and presence of clinical symptoms related to the respective conditions. In addition, survival free of symptoms  and complications related to the procedure  were assessed.The statistical analysis consisted of descriptive statistics with calculation of proportions. Sample selection was by convenience, attempting to include all cases with the same profile of diagnosis and treatment. The Kaplan Meier survival curve was plotted considering a follow-up period of 5 years and median of 4 years .From 2010 to 2020, 23 consecutive NDAAD patients underwent treatment. Demographic data for these patients are shown in Except for one case of traumatic abdominal aortic dissection that required urgent treatment, all patients were evaluated pre-operatively considering cardiac risk, renal function, current medication, introduction or maintenance of antiplatelet therapy, and preparation for surgical procedures. One patient had renal insufficiency (Stage II) and one patient had renal failure (Stage III). All other patients had normal renal function.R AFX stent graft (17F) main body were obtained by femoral exposure in 7 cases and by percutaneous access in 16 cases. Percutaneous access was obtained by femoral artery puncture under vascular ultrasound guidance using the Preclose technique,,R). One patient developed a small pseudoaneurysm as a complication of percutaneous femoral access for main body device implantation (17F), which was successfully treated with ultrasound-guided compression.The femoral access sites for the EndologixThe following cases are examples of each type of aortic disease.Seven cases of “shaggy Aorta” were treated. Surgical intervention was performed due to symptoms of severe claudication (Rutherford 3), associated with aortoiliac occlusive disease in 4 patients, while 3 patients had symptoms due to distal embolization . Although the indications for surgery of abdominal aorta PAU are not well established, symptomatic disease is the main indication for surgery due to elevated risk of rupture (20-50%).There were 3 cases of isolated abdominal aorta dissection. Indications for surgery were as follows: one patient already had aneurysmal degeneration, another patient with risk factors for atherosclerosis had spontaneous dissection , and a third patient presented with dissection caused by an abdominal trauma against a concrete structure after a fall from a height of 3 meters, with severe abdominal pain unamenable to analgesic medications (intractable pain) and underwent urgent surgery. Angio-CT and intraoperative angiography provided all information needed for treatment and IVUS was not needed. All patients remain in clinical follow-up with no symptoms or complications .Blood loss was negligible in all procedures and no transfusions were needed. All patients spent at least 12 hours in the intensive care unit (ICU) and no patients in this cohort remained in the ICU longer than 24 hours. Renal function was maintained at baseline pre-operative values. The mean length of hospital stay was 3.6 days.Post-procedure follow-up clinical assessments were performed at 3 months, 6 months, 1 year, and annually thereafter. Successful treatment of a narrow distal aortic bifurcation with standard endovascular devices can be challenging We report our experience with treating this anatomy with a unibody design. In general, the demographic profile was: predominantly older, male, hypertensive, and dyslipidemic patients, compatible with a pattern of atherosclerosis, aneurysm, and arterial dissection risk factors. About 40% were diabetic and around 1/3 of the patients were smokers and had coronary disease, which are also risk factors for peripheral atherosclerosis.Cases of diffuse atherosclerotic aortic disease (“shaggy aorta”) associated with lower limb ischemia (symptomatic PAD) or distal embolization of atheromatous plaque fragments (blue toe syndrome) should be treated surgically.,-,,PAU in the abdominal aorta occurs in only 17% of cases-For isolated acute abdominal aorta dissections with refractory abdominal pain and limb ischemia or for chronic aneurysm degeneration, endovascular treatment is associated with lower mortality rates and perioperative complications. This treatment avoids both aortic clamping and sutures in the highly friable aortic wall.Saccular aneurysm of the abdominal aorta is associated with higher risk of rupture compared to the typical fusiform configuration; extreme thinning and weakening of the aortic wall is associated with asymmetric dilation or focal protuberance.,Narrow diameter at the aortic bifurcation has been recognized as a risk factor for stent graft limb collapse and occlusion and arterial disruption.The diameters of most other bifurcated devices when fully expanded range from 20 to 26 mm, which may cause collapse of the contralateral gate and prevent successful catheterization with the standard technique.R stent grafts is its profile , allowing percutaneous treatment using the PrecloseR technique. However, the device requires common iliac arteries with more than 30 mm length, and appropriate aortic and iliac artery diameters and length, due to the limited range of diameters and lengths available.The authors considered the AFX device safer and effective to treat this particular group of NDAAD due to its unibody bifurcated stent graft configuration, with pre-loaded contralateral leg, no need of an appropriate minimum diameter in the distal aorta for opening and catheterization of the contralateral leg, and anatomical fixation enabling a safe “paving and cracking” maneuver without additional procedures, if necessary. These characteristics of the AFX device could avoid critical maneuvers which are frequently needed in standard bi-modular or tri-modular stent grafts, and may decrease the morbidity of the procedure. Another advantage of the AFX - EndologixR endograft in these cases and provoked changes to its design.In cases of abdominal aortic aneurysms, especially with exaggerated angles and/or short necks, an increased frequency of proximal extension disconnection from the main body has been described, which has limited the indications for the AFXR stent grafts in other “off label” uses in occlusive aortic diseases showed a primary patency rate of 78.8% at 36 months (n = 91 cases), with an assisted patency rate of 97.4% over the same period.Long-term studies with the AFX - EndologixDue to the low frequency of NDAAD, limitations of this study were the small and heterogenous sample , the fact that this is a retrospective review, and absence of a control group. Since NDAAD are mostly infrequent conditions, a possible selection bias may occur due to the insufficient sample size. Nevertheless, our patients were consecutive, presented similar risks, and a single type of stent graft was used.,Most previous studies of use of unibody stent grafts were anecdotal case reports or series of a few cases of atherosclerotic disease treatment.R unibody bifurcated stent graft in this group of NDAAD suggesting that it was an effective technique with patency rates similar to those of endovascular treatments of abdominal aortic aneurysms and aorto-iliac atherosclerotic disease,,The present series showed potential appropriate applications and favorable results of AFX-Endologix


Biofilm is a community of bacteria embedded in an extracellular matrix, which can colonize different human cells and tissues and subvert the host immune reactions by preventing immune detection and polarizing the immune reactions towards an anti-inflammatory state, promoting the persistence of biofilm-embedded bacteria in the host.It is now well established that the function of immune cells is ultimately mediated by cellular metabolism. The immune cells are stimulated to regulate their immune functions upon sensing danger signals. Recent studies have determined that immune cells often display distinct metabolic alterations that impair their immune responses when triggered. Such metabolic reprogramming and its physiological implications are well established in cancer situations. In bacterial infections, immuno-metabolic evaluations have primarily focused on macrophages and neutrophils in the planktonic growth mode.Based on differences in inflammatory reactions of macrophages and neutrophils in planktonic- versus biofilm-associated bacterial infections, studies must also consider the metabolic functions of immune cells against biofilm infections. The profound characterization of the metabolic and immune cell reactions could offer exciting novel targets for antibiofilm therapy. Biofilm has been characterized as an accumulation of microorganisms embedded in extracellular polymeric substances (EPS) and attached to biotic or abiotic surfaces , Enterobacteriaceae carrying the genotoxic polyketide synthase (pks), as well as Fusobacterium nucleatum , showing intestinal inflammation also impacts host susceptibility  and prominent periodontal pathogen  to promote co-aggregation, and separate OMVs only have been showed to exert an equivalent capacity to co-aggregate other bacteria examined to the complete bacterial culture  and the pathogenic  periodontal bacteria, which are able of creating biofilms, are identified in the intestinal biofilms  persist in this environment with its urease activity compensating gastric acid, whereas biofilm development may be further necessary for its persistent colonization  or histology), and that coccoid forms have been certainly more commonly observed in gastric mucosa of gastric cancer cases than in that of peptic ulcer subjects  seroprevalence, probably because of honey's antimicrobial activities and yogurt's probiotic and prebiotic actions , an alpha--fucosyltransferase, an outer membrane protein (OMP) (encoded by homD), and a cytotoxin-associated gene (Cag) pathogenicity island (PAI), were similarly correlated with biofilm development in Mammalian cells depend on basic metabolic processes for energy generation, macromolecule biosynthetic pathways precursors, and redox control power reduction  and anabolic reactions to produce biomolecules  and M2  modes for macrophages, which promoted the idea of immunological polarization. These states characterize macrophage proinflammatory vs anti-inflammatory properties, respectively   cells, inhibits the effector action of CTLs and performs essential physiological functions in preventing autoimmune disorder, and intensifies immunity from infections Zou , 2020. TIn chronic biofilm-associated device infections, internalized bacteria and cells in biofilms could adopt a phenotype of small colony variant (SCV), which is known for a slow rate of growth and reduced levels of secretion of toxic factors, which enable the internalized bacterial cells to survive for long periods osis of PMN cells, it was also shown that S. aureus secretes enzymes that produce deoxyadenosine from NET degradation, which then stimulates the caspase 3 (Cas 3) mediated death of immune cells  patients produced the alginate polysaccharide as the main EPS component, whereas non-mucoid strains did not , C–X–C Motif Chemokine Ligand 2 (CXCL2), and C–C Motif Chemokine Ligand 2 (CCL2) formation that limited macrophage invasion into the biofilm. Also, there was a skewing of the immune cells away from a bactericidal phenotype, as determined by a decrease in the formation of inducible nitric oxide synthase (iNOS) concomitant with robust ARG-1 induction  are the predominant species that cause this infection  was significantly reduced in MyD88 knockout animals. Tissue staining for biofilm by the immunofluorescence technique showed an increased fibrosis in these mice, coinciding with increased recruitment of M2 macrophages. According to previous works on TLR2, TLR9, and IL-1β knockout mice, the report of Market al.  is a costly problem for the health care system, and strains of rket al.  suggestsMDSC is a subset of immature granulocytes and monocytes that are intermediates of common myeloid differentiation and development . This reduces leukocyte pro-inflammatory function, which is one mechanism that accounts for biofilm persistence. This is similar to tumor cells generating lactate in the tumor microenvironment, promoting the development of MDSCs and immunosuppression. A study conducted by Husain et al. , DCs, and T cells and their altered functions during tumor progression are dipticated in Figs. Immune cells such as stimulated cytotoxic T cells experience complete metabolic changes to conduct effector roles, such as destroying tumor cells and secreting cytokines Table  Singer . AerobicUnder normoglycemic circumstances, T cells upregulate the main glucose converter Glucose transport protein type 1 (GLUT1), accompanied by enhanced glucose absorption and glycolysis following antigenic stimulation  in hypoxia environments  was found following contact of P. aeruginosa with immune cells such as neutrophils  and high rate of kynurenine (ΔkynU) co-cultures showed that kynurenine enhances the survival of this bacterium.Currently, it has been found that P. aeruginosa to circumvent the immune reaction by scavenging ROS formation by neutrophils. Overall, these results prove the influence of kynurenine produced by bacteria on neutrophils' killing activity via ROS scavenging.Interestingly, an increase in the rate of kynurenine hampers the production of ROS by stimulated neutrophils. Genestet et al. , via a RS. aureus are polarized to an M2 phenotype. The adoptive transfer of the M1 phenotype results in attenuated biofilm burden, proposing the critical activity of macrophage inflammatory responses during biofilm infection of S. aureus . Besides, activated macrophages effectively diminished the S. aureus burdens in established biofilm (degradative effect)  macrophages via in vitro macrophage differentiation and exposure schemes (CD14+ magnetic-activated cell sorting), 1D 1H NMR metabolomics, as well as metabolic profiling analysis. In their study, M0 macrophages were differentiated from primary monocytes via macrophage colony-stimulating factor (M-CSF) before activation with planktonic and biofilm P. aeruginosa  citramalyl-CoA lyase, and itaconate coenzyme A (CoA) transferase , and metabolic therapy approaches can offer a promising field of research into the treatment and control of infectious diseases (Shen et al. Biofilm plays a crucial role in the prognosis and progression of various bacterial infections that are often associated with chronic states and cause long-term problems for patients. Mechanisms of stability and resistance of biofilm bacteria present unique and evolving challenges to patients and physicians. For this reason, biofilm research is receiving more attention. Interestingly, biofilm infections have been shown to modify the host's peripheral environment. Most importantly, it has been shown that biofilm infections can change the inflammatory immune reactions, as evidenced by macrophage polarization and recruitment of MDSCs, to anti-inflammatory modes. Overall, these findings show that biofilm infections can change immune cells' metabolism, affecting the development and activation of immune reactions Table . Innovat


This cohort study evaluates whether rates of treatment or follow-up office or emergency visits associated with telemedicine visits differ from those associated with in-person visits in a large integrated health system. In patient-scheduled primary care video or telephone visits with existing physicians, do rates of treatment or follow-up office or emergency visits differ from rates of in-person visits?In this cohort study of 1 131 722 patients, adjusted rates of prescribing and nonmedication orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher rates of follow-up office visits after telemedicine visits but no significant difference in rates of 7-day emergency visits or hospitalizations.The findings suggest that video or telephone visits may offer a convenient way to address some primary care needs within ongoing patient-physician relationships, without substantially higher rates of follow-up office visits or health events . Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization  within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.This study included 1 131 722 patients  with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6%  of video visits, 34.7%  of telephone visits, and 51.9%  of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2%  of video visits, 27.3%  of telephone visits, and 59.3%  of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4%  of video visits, 26.0%  of telephone visits, and 24.5%  of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events . Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs. Still, it is unclear whether telemedicine visits adequately address the patient’s clinical concern, are more likely to require subsequent follow-up outpatient care, or are more likely to be followed by a serious health event that requires an emergency department visit or hospital stay.The COVID-19 pandemic unexpectedly shifted the US health care system toward a large volume of telemedicine care. Longer-term telemedicine use in primary care, however, may not be driven primarily by social distancing efforts but instead may focus on ways that telemedicine can offer a convenient option for expanding access to health care.4 In contrast, little evidence exists about these care processes in telemedicine visits between patients and their own primary care physicians.5In addition, prior evidence from direct-to-consumer telemedicine, which is often not integrated with the patient’s regular physician or full electronic health record, suggests potential over-prescribing and differences in physician orders and follow-up visits when primary care is delivered through telemedicine compared with through a typical office visit.In a setting with prepandemic patient-scheduled video and telephone telemedicine with patients’ own primary care physicians, we compared telemedicine visits and in-person office visits with regard to care processes and postvisit health care utilization. We hypothesized that serious outcomes would be rare after telemedicine visits but that some patients would require additional follow-up visits.STROBE) reporting guideline.In this cohort study, we examined primary care visits in a large integrated health care delivery system with more than 4 million members, Kaiser Permanente Northern California, which uses a comprehensive outpatient-inpatient electronic health record  and patient portal. The institutional review board of the Kaiser Foundation Research Institute approved the study protocol and materials and waived the requirement for written informed consent for participants because the study used deidentified data. This study followed Strengthening the Reporting of Observational Studies in Epidemiology  or other primary care clinicians the patient had visited recently. The scheduling availability and clinicians available were comparable across visit types, with appointment availability generally within 3 days (often available the same day). Further details about video visits used in this setting, patient characteristics associated with use, and patient experiences have been described in prior publications.As in an office visit, clinicians conducting telemedicine visits had full access to the patient’s EHR history and documented telemedicine visits directly within the EHR. Patients could receive a call for a telephone visit at any phone number and could access video visits from home or elsewhere in their daily lives directly through any internet-connected and video-enabled computer or mobile device.6 We also identified subsets of visits with diagnoses of upper respiratory tract infection (URI) and skin conditions, 2 commonly reported categories of telemedicine chief complaints and diagnoses.We studied all completed primary care appointments booked via the patient portal from January 2016 to May 2018. We included only index visits without any other clinical visits within the previous 7 days to define a relatively distinct patient-initiated care-seeking episode. We also excluded visits for routine physical, which were not eligible for telemedicine.9For each visit, we identified any prescribing or other orders  associated with the visit, including the subset of prescriptions specifically for antibiotics. To characterize short-term follow-up health care utilization, we extracted all office-visits, emergency department visits, and hospitalizations within 7 days after the index primary care visit. We examined each outcome in the full sample of all patient visits, and in the subset of visits with diagnoses of URI and skin conditions because these were common visit reasons with prior telemedicine evidence.6 We used the EHR to identify patient sociodemographic characteristics , patient’s residential address to define patient neighborhood socioeconomic status (2010 US census measures at the census block group level), and neighborhood residential high-speed internet access level . We included patients’ mobile portal use in the prior 365 days as a measure of mobile device access and video visit use in the prior 365 days as a measure of video visit experience. We extracted the patient’s insurance benefit cost-sharing for office visits. We also extracted the estimated drive time from the patient’s residence to the nearest health system medical facility and the type of parking offered at that facility (free parking lot or structure vs paid parking structure). We used automated data to identify whether the index visit was scheduled by a family care partner with permissions to act for the patient through the patient portal and whether the appointment was scheduled with the patient’s own personal primary care clinician.When comparing outcomes associated with index visit type, we accounted for a broad set of visit covariates using several types of patient characteristics previously shown to be associated with visit-type choice, including patient sociodemographic characteristics, and other measures of accessibility and affordability grouped into technology access, in-person visit barriers, and patient-clinician affiliation.International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code grouping of primary diagnosis); whether the patient had preexisting chronic conditions ; and medical center. We examined each outcome using a separate logistic regression model because standard composite measures of study outcomes were not readily available and each outcome represents a clinically distinct action and outcome. Standard errors were adjusted for repeated visits by patients. For easier interpretation, we calculated an adjusted rate for each outcome from the multivariable logistic regression model as if every visit in the entire cohort was an in-person visit, as if every visit in the entire cohort was a video visit, and as if every visit in the entire cohort was a telephone visit. We repeated the analyses for the 2 subsets of visits with diagnoses of URI and skin conditions .We used a multivariable logistic regression model to examine the association between index visit type  and outcomes, including any prescribing, antibiotic prescribing, and orders during the visit; any in-person visit, emergency department visit. and hospitalization within 7 days after the index visit. The model was adjusted for patient age, sex, and race and ethnicity; neighborhood socioeconomic status; preferred language for health care; out-of-pocket cost-sharing for office visits; drive time to clinic; facility parking garage and fee; neighborhood internet access level; mobile portal use in prior 365 days; video visits in prior 365 days; whether the appointment was booked by a care partner on behalf of the patient; whether the clinician was the patient’s own personal primary care clinician; patient medical problem , 1 870 552 (86%) were scheduled as office visits and 307 888 (14%) as telemedicine visits, with 20 115 (7%) of the telemedicine visits by video. Overall, 13.5% of visits were for patients younger than 18 years and 22.2% were among patients 65 years or older; 54.9% were for female patients, 59.8% were for White patients, and 95.1% were for English-speaking individuals .6After adjustment , the ratAfter adjustment, 24.5%  of office visits, 25.4%  of video visits, and 26.0%  of telephone visits were followed by an in-person office visit in the subsequent 7 days . AdjusteIn a large, integrated health care setting newly offering patient-scheduled primary care telemedicine visits, adjusted rates of prescribing and ordering were statistically significantly lower for telemedicine visits compared with in-person office visits. This was consistent for all visits and for the subset of visits with diagnoses of URI or skin conditions. Return office visit utilization was slightly higher after video and telephone visits than after an in-person primary care visit. Rates of emergency visits and hospitalizations were low and comparable between in-person and video or telephone primary care visits.10 In contrast to prior findings from direct-to-consumer telehealth physicians that may not be linked with a patient’s history or ongoing clinician relationships, we found lower rates of antibiotic prescribing via clinically integrated telemedicine visits compared with in-person clinic visits.3 Our findings of low but differentially higher in-person follow-up visits after telemedicine are consistent with prior findings in direct-to-consumer telemedicine settings.4 Still, even in cases in which a telemedicine visit does not serve as a stand-alone visit, there may be additional potential visits in telemedicine in offering initial clinical and site-of-care guidance.We examined the integration of patient-initiated telemedicine visits with ongoing clinical care and patient-clinician relationships in a nonpandemic study period. Although the landscape of telemedicine payment barriers has improved particularly during the COVID-19 pandemic, this study offers an opportunity to examine a study setting with patient-scheduled telemedicine fully integrated into clinical care delivery and into the EHR, with consistent clinicians and availability between visit types. This type of integration between physicians conducting in-person and telemedicine visits and settings is increasingly common under pandemic telemedicine expansions.8 We have previously published associations between patient sociodemographic and technology access characteristics and visit type choice.6 In addition, patients may also choose telemedicine if they do not expect that their condition will require in-person examination or services. Despite increasing use and availability of video technology, telephone-based virtual care is often still the dominant type of telemedicine used by patients and physicians, including during the COVID-19 pandemic.3 Furthermore, given the potential digital divide in technology access to support video telemedicine visits, our findings of general comparability in adverse health events between telephone and video-based telemedicine visits in primary care suggest that phone visits may continue to offer a simple health care access option without raising safety concerns.6Even as pandemic concerns subside over time and telemedicine use rates continue to evolve, our findings suggest that telemedicine can be used to safely address some concerns when offered in the context of integrated in-person health care services. Aside from social-distancing aspects of telemedicine, patients will likely continue to choose virtual care for convenient health care access, potentially when facing barriers to in-person health care services, such as travel, mobility, taking time off from work, or caregiving responsibilities.This study has limitations. In this observational study, although our analyses adjusted for a wide range of patient and clinical covariates, we could not rule out unmeasured confounding, especially because the visit type in our study was self-selected by patients. Also, in examining patients self-scheduled visits via the portal, these findings may not represent visits booked by clinic staff at the request of a physician. More research is needed to fully characterize the full range of telemedicine visits used by patients and physicians. Our study outcomes were constructed such that the orders we identified in a given visit  or visits in a given follow-up period  may not have been directly related to the index visit. Because the subgroup analyses were limited to 2 specific common clinical subsets (skin and URI concerns), further research is also needed to characterize the use and outcomes associated with the wide range of specific clinical concerns and pathways addressed in primary care. In using a relatively short number of days to define a distinct care-seeking episode, we were not able account for patients’ longer-term history with a condition or the condition’s severity or its effect on the current visit type or outcome. This study did not aim to directly assess clinical appropriateness of a given visit type or health care utilization choice; further research is needed to closely examine this question.Also, the generalizability of our study is limited to the care delivery and nonpandemic setting of the data. Further research in the use of telemedicine during the COVID-19 pandemic is needed, particularly as the balance between telemedicine and in-person services and between telephone and video visits continues to evolve. Similarly visit types may vary between health care systems and geographic areas and may also vary over time.In contrast to direct-to-consumer telemedicine, in this cohort study of patients using telemedicine to visit their own primary care physicians, we did not find evidence of overordering or overprescribing. Future study is needed to further examine the quality and safety of telemedicine within ongoing patient-physician relationships. Patient-scheduled video or telephone visits with their own primary care physicians were associated with a modestly higher rate of follow-up outpatient office visits than were initial in-person visits. This might be expected owing to the lower barrier to entry for telemedicine and to some level of anticipated need for follow-up. There were, however, no statistically significant differences in the rate of emergency department visits or hospitalization after telemedicine. Video or telephone visits may be a convenient and safe way for patients to address some primary care needs without generating a substantial number of follow-up office visits or experiencing health events.


Nampt, resulting in a 72% reduction in myocardial NAD after two-weeks. RESULTS/ANTICIPATED RESULTS: Echocardiography revealed that Nampt cKO mice displayed a significant reduction in left ventricular (LV) contractility as well as cardiac hypertrophy. Despite the further loss of NAD, the majority of animals survived to 8 weeks of age before experiencing sudden deaths resulting in significant mortality over the next several weeks. Remarkably, we observed only a slight increase in acetylation of mitochondrial proteins, and cardiac mitochondria isolated from Nampt-null mice even at 8 weeks displayed a normal or higher oxygen consumption rate. We found that mitochondrial NAD levels were preferentially maintained and depleted at a slower rate compared to those in bulk tissue. DISCUSSION/SIGNIFICANCE OF IMPACT: While mild depletion of cardiac NAD has been reported in heart failure, our data indicate that the heart can adapt to much more severe loss of NAD prior to the loss of viability.OBJECTIVES/GOALS: Nicotinamide adenine dinucleotide (NAD) plays essential roles in energy metabolism and cell signaling pathways. NAD functions as a coenzyme by accepting electrons during glycolysis and the TCA cycle and subsequently donates them to complex I of the electron transport chain providing the driving force for ATP production. NAD also acts as a co-substrate for several classes of enzymes, including sirtuin deacetylases. Both NAD and the enzyme that is rate limiting for synthesis, Nicotinamide phosphoribosyltransferase (Nampt), are depleted in the failing heart, concurrent with hyperacetylation and mitochondrial dysfunction. Moreover, treatment with NAD precursors reduced cardiac injury in several heart failure models. However, NAD precursors may have systemic effects, and it remains unproven whether depletion of myocardial NAD is causative or merely correlative for the onset and progression of heart failure. METHODS/STUDY POPULATION: To test this, we generated a cardiac-specific tamoxifen-inducible (αMHC-MerCreMer) model for deletion of Nampt (Nampt cKO) in cardiomyocytes. Adult mice were administered tamoxifen for 5 days leading to deletion of


The liver has remarkable capability to regenerate, employing mechanism to ensure the stable liver-to-bodyweight ratio for body homeostasis. The source of this regenerative capacity has received great attention over the past decade yet still remained controversial currently. Deciphering the sources for hepatocytes provides the basis for understanding tissue regeneration and repair, and also illustrates new potential therapeutic targets for treating liver diseases. In this review, we describe recent advances in genetic lineage tracing studies over liver stem cells, hepatocyte proliferation, and cell lineage conversions or cellular reprogramming. This review will also evaluate the technical strengths and limitations of methods used for studies on hepatocyte generation and cell fate plasticity in liver homeostasis, repair and regeneration. The liver is our body’s largest solid organ, and its multifaceted functions are essential for life. Key liver functions include bile production for fat metabolism, blood filtering, execution of immunological functions, supporting blood clots, absorption and metabolism of bilirubin, storing vitamins and minerals, and synthesis of many hormones. The basic structure is a hexagonal liver lobule, by which central veins are positioned in the center of a hepatic lobule, and portal triads  are on the border of the liver lobule. Within the lobule, the primary cell types are parenchymal cells (hepatocytes and bile duct cells), and non-parenchymal cells . The microenvironment including nutrients, oxygen, and secreted factors from surrounding non-parenchymal cells varies in different positions of the lobule, resulting in the heterogeneity of hepatocytes  can contribute to liver regeneration by converting to hepatocytes  are the main components of the epithelium in the liver. In the embryonic liver, hepatoblasts, considered as liver stem cells, are bi-potential and give rise to hepatocytes and bile duct epithelial cells -induced tumor models, these Lgr5+ cells can contribute to hepatocellular carcinoma. This latest study challenges the view that Lgr5+ cells act as in vivo facultative liver stem cells. It also implies that cell plasticity uncovered by the organoid culture or transplantation of cultured cells may not necessarily reflect the in vivo cell fate under physiological conditions.Lgr5s Barker . However+ cells using Sox9-IRES-CreER;Rosa26-LacZ mice and found that 99.4% of LacZ+ cells were detected in bile duct cells 1 day after tamoxifen injection, while LacZ+ hepatocytes gradually increased over time e.g. 10 and 30 days. They suggested that Sox9+ progenitor cells contribute to hepatocytes, which is accelerated by liver injury . Indeed, several groups detected a subpopulation of periportal hepatocytes expressing Sox9 -box 9 (Sox9) is a member of the box transcription factor family and plays a critical role in embryonic development, tissue homeostasis, and regeneration of multiple tissues and organs Akiyama . RecentlKrt19-CreER mice to label cholangiocytes and found they do not contribute to hepatocytes. Similarly, by labeling almost all hepatocytes using AAV8-TBG-Cre virus, they found no significant dilution, indicating new hepatocytes are mainly derived from preexisting hepatocytes  deficient mice and found bone marrow cells contributed to hepatocytes significantly through cell fusion and rescued liver function  revealed that Mfsd2a+ hepatocytes decreased during liver homeostasis , occurs in periportal region  was scatted throughout the liver lobule. Lineage tracing of Terthigh hepatocytes demonstrated that Terthigh hepatocytes comprised 3% of the liver area and could expand to about 30% of the liver area after 1 year’s tracing during liver homeostasis. The expansion of Terthigh hepatocytes was accelerated in liver injury. Also, ablation of Terthigh hepatocytes in DDC-induced injury resulted in more serious liver fibrosis and collagen deposition, indicating that Terthigh hepatocytes were essential to liver regeneration  mice in which ER is flanked by two rox sites. By crossing with R26-DreER mice, Dre-rox recombination would remove ER after tamoxifen treatment, which converts Ki67-CrexER into Ki67-Cre genotype to continuously record cell proliferation thereafter in DreER-expressing cells , which enables continuous recording of in vivo cell proliferation (He et al. Collectively, the above lineage tracing studies using different lineage tracing strategy provide different conclusions about the origin of hepatocytes renewal. A possible interpretation for the inconsistency in results between the groups is the discrepancy in the strategies for constructing CreER mouse lines. Another possible explanation is the limitation of technology used by different groups. These groups only focused on the expansion of a subset of hepatocytes, which lacks direct comparisons of different hepatocytes subpopulations’ expansion side by side.The mechanisms regulating liver zonation and hepatocyte function remain largely unknown. Wnt signaling has been reported as a major regulator of liver zonation (Burke et al. Wnt2 and Wnt9b for pericentral hepatocytes proliferation in homeostasis (Wang et al. It’s well known that hepatocyte renewal occurs through replication of preexisting hepatocytes (Malato et al. The liver can adopt different strategies for repair and regeneration according to the extent of the injury. Hepatocyte proliferation is the dominant cellular mechanism for liver regeneration in the majority of injuries. In conditions where hepatocyte proliferation is impaired, bile duct epithelial cells can transform into hepatocytes and contribute to liver regeneration. For hepatocyte proliferation, there are many different models supported by different genetic tracing tools. The latest reports support that zone 2 hepatocytes mainly contribute to the source of new hepatocytes. Nevertheless, there are still many questions on the proliferation potential of zone 2 hepatocytes, e.g., the underlying molecular mechanisms that provide zone 2 hepatocytes with higher proliferation potential, and the crosstalk of hepatocytes with the surrounding environment for regulation of cell proliferation. Currently, it’s unclear which non-parenchymal cells maintain the potential niche for zone 2 hepatocyte proliferation. In addition, the mechanisms controlling bile duct epithelial cell to hepatocyte conversion remains largely unknown. Do bile duct epithelial cells first transform into a liver progenitor cell status and then differentiate into hepatocytes? What are the surrounding cell types that provide critical microenvironmental cues to promote cell conversion? Further studies focusing on these unsolved, yet important and intriguing questions would provide new insights for the treatment of liver diseases, and would also uncover new therapeutic targets for the treatment of liver diseases.


Neuromodulation by acetylcholine plays a vital role in shaping the physiology and functions of cerebral cortex. Cholinergic neuromodulation influences brain-state transitions, controls the gating of cortical sensory stimulus responses, and has been shown to influence the generation and maintenance of persistent activity in prefrontal cortex. Here we review our current understanding of the role of muscarinic cholinergic receptors in primate prefrontal cortex during its engagement in the performance of working memory tasks. We summarize the localization of muscarinic receptors in prefrontal cortex, review the effects of muscarinic neuromodulation on arousal, working memory and cognitive control tasks, and describe the effects of muscarinic M1 receptor stimulation and blockade on the generation and maintenance of persistent activity of prefrontal neurons encoding working memory representations. Recent studies describing the pharmacological effects of M1 receptors on prefrontal persistent activity demonstrate the heterogeneity of muscarinic actions and delineate unexpected modulatory effects discovered in primate prefrontal cortex when compared with studies in rodents. Understanding the underlying mechanisms by which muscarinic receptors regulate prefrontal cognitive control circuitry will inform the search of muscarinic-based therapeutic targets in the treatment of neuropsychiatric disorders. The ability to maintain and manipulate information about the sensory world, motor actions, and previously learned experience is central to cognition and flexible behavior. Persistent, short-term elevated activity in cortical circuits has been proposed to All major ascending neuromodulatory systems innervate the cerebral cortex, including the PFC and influence the dynamics of persistent activity and cortical WM circuitry . The modAcetylcholine mediates its neuromodulatory influence via the ionotropic nicotinic and metabotropic G-protein coupled muscarinic receptor families . SubtypeAmong several cholinergic nuclei in the brainstem and basal forebrain, the nucleus basalis of Meynert is the principal source of ACh in the primate cerebral cortex . Additioq-coupled M1, M3, and M5 receptors and Gi/o-coupled M2, and M4 receptor families (The prominent nicotinic receptor subtypes expressed in macaque cortex, including PFC, are α4β2 and α7 receptors . The musfamilies . Of thesfamilies , primatefamilies  and humafamilies . M3 recefamilies . HoweverIn rodents, cortical M1 receptors are predominantly expressed postsynaptically  and are M1 receptor expression in monkey cortex was examined with immunohistochemistry and mRNA expression in a series of studies by Mrzljak and colleagues , 1998. IHowever, other elegant work from the Barbas group demonstrated hodological specificity in M2R expression in dorsolateral PFC . The choIn vivo, the dynamics of ascending neuromodulatory arousal systems engender these transitions (The ascending reticular activating system, including the cholinergic and noradrenergic systems, regulate the sleep-arousal cycle and transitions between the different brain states . During nsitions .q coupled muscarinic receptors were essential in regulating this epoch of the sleep rhythm (The ascending brainstem and basal forebrain cholinergic systems causally contribute to regulating these physiological transitions accompanying brain state transitions . A briefp rhythm .in vivo can be measured by amperometric methods (There are tonic and phasic components to the activity of cholinergic neurons and ACh fluctuations  methods , 2007. A methods .To summarize, the cholinergic system is essential in the regulation of states of cortical arousal, and neuromodulation by muscarinic receptors, particularly of the M1R family, are essential in the generation of desynchronized states during REM sleep and awake behavior. Some of the physiological mechanisms that elicit the transitions to wake-like desynchronized cortical activity may also be involved in the neuromodulation of persistent activity in awake cortical circuits engaged in active behavior.A substantial body of work has examined the role of the cholinergic system in cognitive performance in rodents, monkeys, and humans . Early cHowever, other reports have addressed the role of cholinergic innervation locally in the PFC in WM and other PFC-dependent cognitive tasks. Baxter’s group reported an intriguing finding: cholinergic deafferentation, by injection of an immunotoxin based on saporin in the PFC of rhesus monkeys, resulted in a specific and selective deficit in spatial delayed response, but not in other demanding tasks that engaged attention but did not require WM, such as strategy implementation, object-in-place scene learning, or reward-based decision-making as assessed by reinforcer devaluation . Other eThere have been fewer studies describing the neurophysiological effects of muscarinic modulation in primates. Muscarinic blockade disrupts attentional modulation of cortical activity in primary visual cortex but nicotinic blockade, while reducing V1 excitability, did not affect attentional modulation . HerreroAnother study examined the effects of systemic injections of scopolamine on the activity of macaque PFC neurons  engaged in vivo studies are on the order of ∼100 nA and are not expected to elicit extraneous electrophysiological effects on the recorded neurons. Moreover, usually, the quantities of drugs ejected are not enough to elicit behavioral effects. The results of Recently, stimulation of nicotinic α4β2 receptors was also examined in monkey PFC during spatial delayed response task performance . The autThus, the findings regarding muscarinic blockade of neuronal selectivity for the peripheral visual stimulus and perisaccadic selectivity in 2+ plateau potentials. Thus, ACh, through muscarinic mechanisms, could facilitate persistent activity in cortical neurons through cell-autonomous intrinsic mechanisms that, in concert with stimulus evoked responses, could engender WM representations. However, traditionally, WM persistent activity is thought to be a network phenomenon, generated by slow reverberatory synaptic activity in a network of neurons (in vivo in primate PFC was not clear.Since muscarinic antagonism engendered such pronounced suppression of the activity of PFC neurons during WM, it would be expected that muscarinic and cholinergic agonists may enhance persistent activity and WM representations. There is some evidence that muscarinic stimulation can sustain persistent activity through intrinsic mechanisms . Rat ent neurons . WhetherTo clarify whether carbachol could induce or augment persistent activity in PFC during WM task performance, our group conducted experiments where we microiontophoretically applied carbachol on PFC neurons in rhesus monkeys performing the rule-memory guided pro- and antisaccade task . SurprisGiven the pervasiveness of scopolamine-induced suppression of PFC neurons described above , and thain vivo and restored reversal learning in a transgenic model of Alzheimer’s disease (q signaling (q signaling and the inositol phosphate pathway (As discussed previously, M1Rs are the dominant muscarinic receptor subtype expressed in PFC. Since they are localized postsynaptically at asymmetric synapses on dendritic spines of pyramidal neurons, M1R constitutes an attractive candidate for mediating the general suppression of PFC by muscarinic blockade. M1R stimulation inhibits the M-current and can thereby increase cortical neuronal excitability . M1Rs an disease . A selec disease . M1R kno disease . An M1R  disease . M1R als disease . KCNQ ch disease , and inh disease . The M-cignaling . Since M pathway , it may 2+ mobilization from intracellular stores through the IP3 receptor and this release of Ca2+ can transiently hyperpolarize neocortical neurons through the activation of calcium-activated SK potassium channels (On the other hand, M1R could have inhibitory influences by direct activation of parvalbumin-positive interneurons . In rheschannels . The trachannels . One conchannels . Among tchannels  but are channels . Recentlchannels . These cRecently, our group has tested the effects of M1Rs on persistent WM activity for rules in monkey PFC . MicroioIn summary, these results indicated that M1R blockade could not account for the pervasive neuronal suppression and general disruption of task selectivity that was observed with general muscarinic blockade with scopolamine . FurtherAnother recent study examined M1R modulation of PFC WM activity during oculomotor delayed response performance in aged monkeys . This stThe effects of different muscarinic actions on neuronal physiology in the PFC from the studies discussed above have been summarized in 2+ mobilization due to M1R stimulation, as discussed elsewhere in this review (q protein-coupled receptors have found that stimulating these receptors has inhibitory effects on PFC neurons in primates and in some rodent studies. a1 adrenergic receptor stimulation suppresses delay period activity in a spatial delayed response task (q metabotropic glutamate receptor 1 was shown to increase inhibitory transmission in rat medial PFC, impairing decision-making (Several mechanisms may account for the suppression due to M1R overstimulation. One possibility is that M1R excitation of interneurons at high doses of stimulation leads to a suppression of PFC neurons. However, this is unlikely, as noted above because s review . It is nnse task  and Gq mn-making .i/o-coupled receptors, and previous microiontophoretic studies in monkey PFC have shown that stimulation of the dopamine D2 receptor, which is also coupled to Gi/o, can augment the activity of specific classes of PFC neurons during WM tasks (WM tasks . Thus, iWM tasks , post-syThese results with M1R compounds in monkey PFC are of particular interest, because M1R-selective agents are being actively investigated for cognitive enhancement and amelioration of cognitive deficits in neuropsychiatric disorders . M1R basIn this review, we have discussed the neuromodulatory influence of the corticopetal cholinergic system through muscarinic receptors on primate PFC WM circuits that manifest persistent memory-related activity. The anatomical localization of these receptors shows exquisite specificity and correspondence with network connections within the PFC. Cortical muscarinic receptors play a pivotal role in arousal and brain state transitions, and their activation is necessary for the proper functioning of recurrent circuits in the PFC that generate persistent activity in WM tasks. Recent work shows that their role in primate PFC may be quite different from what would be expected from prior studies in other model systems like rodents and moreover, diverges from their role in sensory cortical areas. Further elucidation of muscarinic neuromodulation of PFC cognitive circuitry promises to be a rewarding endeavor for translational research and the development of new targets for the treatment of neuropsychiatric and neurological disorders.SV and SE wrote and edited the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.