Is spinal manipulative therapy associated with changes in the immune system?In this systematic review of 13 studies comprising 795 participants, no clinical studies investigated the efficacy or effectiveness of spinal manipulative therapy in preventing or improving disease-specific outcomes among patients with infectious disease. Preliminary laboratory experiments indicated that spinal manipulative therapy may, in the short term, be associated with levels of change in immunological biomarkers among asymptomatic participants.These findings suggest that, given the limitations of the evidence, claims that spinal manipulative therapy is associated with changes in the immune system are premature and further clinical studies should be completed. Claims that spinal manipulative therapy (SMT) can improve immune function have increased substantially during the COVID-19 pandemic and may have contributed to the rapid spread of both accurate and inaccurate information .To identify, appraise, and synthesize the scientific literature on the efficacy and effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes in patients with infectious disease and to examine the association between SMT and selected immunological, endocrine, and other physiological biomarkers.A literature search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, the Index to Chiropractic Literature, the Cochrane Central Register of Controlled Trials, and Embase was conducted from inception to April 15, 2020. Randomized clinical trials and cohort studies were included. Eligible studies were critically appraised, and evidence with high and acceptable quality was synthesized using the Synthesis Without Meta-Analysis guideline.A total of 2593 records were retrieved; after exclusions, 50 full-text articles were screened, and 16 articles reporting the findings of 13 studies comprising 795 participants were critically appraised. The literature search found no clinical studies that investigated the efficacy or effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes among patients with infectious disease. Eight articles reporting the results of 6 high- and acceptable-quality RCTs comprising 529 participants investigated the effect of SMT on biomarkers. Spinal manipulative therapy was not associated with changes in lymphocyte levels or physiological markers among patients with low back pain or participants who were asymptomatic compared with sham manipulation, a lecture series, and venipuncture control groups. Spinal manipulative therapy was associated with short-term changes in selected immunological biomarkers among asymptomatic participants compared with sham manipulation, a lecture series, and venipuncture control groups.In this systematic review of 13 studies, no clinical evidence was found to support or refute claims that SMT was efficacious or effective in changing immune system outcomes. Although there were limited preliminary data from basic scientific studies suggesting that SMT may be associated with short-term changes in immunological and endocrine biomarkers, the clinical relevance of these findings is unknown. Given the lack of evidence that SMT is associated with the prevention of infectious diseases or improvements in immune function, further studies should be completed before claims of efficacy or effectiveness are made. This systematic review investigates the association of spinal manipulative therapy with the prevention of infectious disease, improvement of disease-specific outcomes, and changes in immune system function. Therefore, we performed a systematic review of the literature to examine whether SMT was associated with efficacy and effectiveness in (1) preventing the development of infectious disease and (2) improving disease-specific health outcomes among patients with infectious disease. We also aimed to synthesize data from laboratory experiments to investigate the association between SMT and immunological, endocrine, and other physiological biomarkers.State chiropractic licensing boards in the US have provided limited and heterogenous guidance regarding chiropractic practice during the COVID-19 pandemic.15 and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline for systematic reviews.16 Ethics approval was not required, as this study was a systematic review. The review protocol was published in the Open Science Framework Registry on April 21, 202017  and free-text words relevant to our study objectives and design , a biostatistician (S.H.J.), and general scientists . Disagreements regarding study quality were resolved through discussion. We categorized RCTs by study phases, as described by Campbell et al,19 and we synthesized the evidence from high- and acceptable-quality studies based on the Synthesis Without Meta-analysis guideline.20 We restricted the synthesis to studies with high and acceptable quality because those with low and unacceptable quality were more likely to yield biased estimates of effect sizes.25Data including study characteristics, participant demographic characteristics, intervention characteristics, and outcome data were extracted. The lead author (N.C.) critically appraised the internal validity of relevant articles using the Scottish Intercollegiate Guidelines Network criteria for RCTs and cohort studies.69 Of those, 16 articles68 reporting the results of 13 studies comprising 795 participants met the inclusion criteria and were critically appraised.The initial database search retrieved 2593 records. After excluding 598 duplicates, 1995 titles and abstracts were screened . The eli50 was rated as having high-quality evidence, and 7 articles68 were rated as having acceptable-quality evidence. Eight articles were rated as having low-quality43 or unacceptable-quality48 evidence; these articles were excluded from the evidence synthesis because of the high risk of bias. Studies with a high risk of bias had the following methodological limitations: (1) inadequate or unclear randomization (n = 5)48 and (2) inadequate or unclear allocation concealment (n = 3)40 40 . We contiability .68 included in the evidence synthesis, 6 articles68 included SMT that was provided by chiropractors, and 2 articles44 included SMT that was provided by physiotherapists. Three RCTs50 evaluated the association between SMT and levels of immunological biomarkers We did not identify any eligible RCTs or cohort studies that investigated the association between SMT and efficacy, effectiveness, or surveillance in the prevention of infectious disease. We also did not find any eligible RCTs or cohort studies that investigated the association between SMT and efficacy, effectiveness, or surveillance in the improvement of disease-specific outcomes among patients with infectious disease.49 monocytes,49 tumor necrosis factor α,26 interleuken 1β,26 interleuken 2,29 immunoglobulin G,46 and immunoglobulin M46) in asymptomatic participants compared with sham manipulation and a lecture series49 and with venipuncture control groups.46 The duration of these changes and their physiological or clinical significance is unknown. However, SMT was not associated with changes in lymphocyte levels50 among patients with low back pain50 or participants who were asymptomatic46 compared with sham manipulation and a lecture series50 and with sham manipulation and venipuncture control groups , in the immediate term among patients with chronic low back pain27 or participants who were asymptomatic44  studies, including those with a high risk of bias that were not included in the synthesis and therefore could not be used to assess the efficacy and effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes in patients with infectious disease.The findings from this review were based on phase 0 (exploratory) studies that included healthy participants or patients with low back pain but did not include patients with an infectious disease. None of the studies included in the review were phase 2 (biologic activity) studies, which would have established proof of concept that an intervention had any biologic activity. Although some of the studies in the present review appeared to indicate an association between SMT and selected immunological parameters, the clinical implications of SMT for the immune system are unknown.Any intervention must be properly evaluated in clinical trials, including phase 2 (biologic activity) and phase 3 (efficacy or effectiveness) studies, before widespread use. The findings from several phase 0 (exploratory) studies suggested that there was a possible association between SMT and selected biomarkers. However, no clear and consistent associations across studies were identified. Moreover, none of the included studies considered the implications of SMT for immunity but instead explored the association between SMT and selected biomarkers associated with the human inflammatory response. If this area of research is to be prioritized, then the exploratory nature of our findings and the current available evidence-based interventions for the treatment of infectious diseases should be considered, and appropriately designed clinical trials should be conducted. However, given the current lack of clear and consistent data regarding the association between SMT and immune markers, it would be premature to conduct RCTs without high-quality evidence from future phase 0 clinical trials.16 establishment of a protocol before review completion and registration with the Open Science Framework Registry, formulation of a clear research question, use of a robust literature search strategy of 5 databases that was reviewed by 2 librarians, screening of interrater reliability comparison, critical appraisal of eligible studies, and inclusion of a review process that was conducted by senior scientists at each step of the rapid review. We also provided a full electronic search strategy, including limits used, for at least 1 database so that the search can be replicated.This study has several strengths. These strengths include adherence to the PRISMA checklist,70 and the exclusion of articles written in a language other than English would not be likely to produce bias, given that most clinical trials are published in the English-language literature.75 Furthermore, we consulted content experts  regarding their knowledge of other studies in the field to minimize publication bias. Second, screening, critical appraisal, and data extraction were conducted by 1 investigator rather than 2. However, we implemented a structured quality assurance methodology to minimize errors in the screening and selection of articles and data extraction.This study also has limitations. First, we only included studies published in English and in peer-reviewed journals, which has the potential to introduce publication bias; however, most studies are published in English,No clinical evidence from high- or acceptable-quality RCTs was found to support or refute claims that SMT is efficacious or effective in preventing or improving infectious diseases. We found limited exploratory evidence from primarily in vitro studies that SMT may be associated with immediate changes in immunological and endocrine biomarkers among healthy participants or patients with low back pain. However, the clinical relevance of these findings is unknown, particularly among patients with infectious disease. Given the lack of evidence that SMT prevents infectious diseases or improves immune function, further studies are warranted before claims of efficacy or effectiveness can be made.


Despite the substantial role played by the hypothalamus in the regulation of energy balance and glucose homeostasis, the exact mechanisms and neuronal circuits underlying this regulation remain poorly understood. In the last 15 years, investigations using transgenic models, optogenetic, and chemogenetic approaches have revealed that SF1 neurons in the ventromedial hypothalamus are a specific lead in the brain’s ability to sense glucose levels and conduct insulin and leptin signaling in energy expenditure and glucose homeostasis, with minor feeding control. Deletion of hormonal receptors, nutritional sensors, or synaptic receptors in SF1 neurons triggers metabolic alterations mostly appreciated under high-fat feeding, indicating that SF1 neurons are particularly important for metabolic adaptation in the early stages of obesity. Although these studies have provided exciting insight into the implications of hypothalamic SF1 neurons on whole-body energy homeostasis, new questions have arisen from these results. Particularly, the existence of neuronal sub-populations of SF1 neurons and the intricate neurocircuitry linking these neurons with other nuclei and with the periphery. In this review, we address the most relevant studies carried out in SF1 neurons to date, to provide a global view of the central role played by these neurons in the pathogenesis of obesity and diabetes. Obesity is a multifactorial chronic disease associated with a higher risk of developing cardiovascular diseases, diabetes, cancer, and, more recently, COVID-19 infection. According to the World Health Organization (WHO), in 2016, worldwide obesity had nearly tripled since 1975, with 39% of adults and 18% of children and adolescents overweight or obese [The regulation of peripheral metabolism and glucose homeostasis not only resides in the tissue’s autonomous responses to nutrients and hormonal signals but also in some brain regions, particularly the hypothalamus. The hypothalamus integrates multiple metabolic inputs from peripheral organs with afferent stimuli coming from other brain regions and coordinates a diversity of efferent responses to control food intake, fat metabolism, hormone secretion, body temperature, locomotion, and behavior in order to maintain energy balance and blood glucose levels. Within the hypothalamus, the ventromedial nucleus (VMH) located above the arcuate nucleus (ARC) and the median eminence, was identified in the mid-1900s as the satiety center because its injury produced hyperphagia, insulin resistance, and body weight gain ,4. At thThe majority of VMH cells, especially in the dorsomedial and central regions of VMH  , expressIn an attempt to clarify the contribution of this specific population of neurons to hypothalamic regulation of obesity and diabetes, in the last 15 years, several transgenic models have been developed by deleting specific targets in SF1 neurons related to energy balance and glucose homeostasis. In 2013, a profound review article was published by Choi and colleagues  summarizDespite these studies contributing to understanding the mechanisms by which SF1 neurons regulate energy homeostasis, new questions arose from these results. An important issue to clarify is the heterogeneity of SF1 neurons in terms of glucose, leptin, and insulin sensing or non-sensing neurons, indicating the operation complexity of SF1 neurons and the intricate mechanisms of afferent and efferent neurocircuitry involved in the control of energy balance. In this review, we address the most relevant studies carried out on SF1 neurons to date, from transgenic mice to neurocircuitry studies, in order to discuss the most relevant findings of these investigations and provide an exhaustive overview of the role played by SF1 neurons in the hypothalamic regulation of energy expenditure and glucose homeostasis, and the potential mechanisms involved.In order to selectively manipulate the SF1 neuronal activity in a physiological context, optogenetic and chemogenetic approaches have emerged ,22. ThesMice engineered to activate SF1 neurons by optogenetics were designed through the injection of adeno-associated virus (AAV) particles expressing a Cre-dependent channelrhodopsin (ChRs) into the VMH of SF1-Cre mice to produce SF1-ChRs animals ,24. The One of the first results obtained from this model revealed that SF1 neurons are closely associated with defensive reactions. David J. Anderson and colleagues in 2015, demonstrated that the optogenetic stimulation of SF1 neurons applying a frequency of 20 Hz induced freezing or activity burst, while no response on feeding behavior or energy balance was reported . HoweverTT mice displayed reduced energy expenditure and increased body weight [The chemogenetic modulation of SF1 neurons under potentially more physiological firing patterns has been performed using hM3Dq and hM4Di designer receptors exclusively activated by designer drugs (DREADDs). The expression of DREADDs specifically in SF1 neurons allows to excite or inhibit them in response to clozapine (CNO) or JHU37160 dihydrochloride (J60) which is an in vivo DREADD agonist with high affinity and potency for hM3Dq and hM4Di receptors ,28. In ay weight .Besides their implication in energy balance, the use of optogenetics has highlighted the role of SF1 neurons in the hypothalamic control of systemic glucose levels. For a long time, it was known that VMH triggered the counterregulatory response (CRR) induced by hypoglycemia ,31 but iTaken all together, these genetic approaches have revealed the specific involvement of SF1 neurons in many aspects of metabolic regulation due to their direct or indirect role in the maintenance of the energy balance and glucose levels, confirming the classification of VMH as a primary satiety center ,35.Sf1 regulatory elements [floxed strains. In the following sub-sections, we discuss different studies of SF1-CRE transgenic mice organized by the type of molecular target under investigation  in SF1 neurons have been thoroughly investigated. The first and most representative study was performed by Bradford Lowell and colleagues, in which genetic deletion of LEPR selectively from hypothalamic SF1 neurons triggered an increase in body weight gain without changes in food intake, leaving these mice unable to adapt to HFD or to activate energy expenditure . To rein neurons  was deveondition . The impondition . Gsα couondition .The protein-tyrosine phosphatase 1B (PTP1B) is another negative regulator of leptin signaling in SF1 neurons . Its actLepR-deficient mice. They concluded that LEPR signaling in the VMH is not sufficient to protect against obesity in this null mouse [A more recent study tried to rescue native LEPR in SF1 neurons in ll mouse . This fiSocs3 in SF1 neurons, where leptin signaling is over-activated, Ren Zhang and colleagues observed improved glucose homeostasis, showing protection against hyperglycemia and hyperinsulinemia caused by HFD feeding [According to glucose metabolism, leptin has been long related to glucose homeostasis improving insulin sensitivity, since intra-VMH injection of leptin increases glucose uptake in peripheral tissues  and norm feeding . These sAnother key hormone implicated in the balancing of energy metabolism is insulin. It is known that insulin acutely suppresses food intake and decreases fat mass in both rodents and humans ,46 Figu. Mice laLeptin depolarizes or hyperpolarizes SF1 neurons, depending on the subpopulation, while insulin only hyperpolarizes them, as both actions are in a downstream PI3K-dependent manner ,47,48,49Other hormones studied in SF1 neurons are estrogens. Female mice lacking the estrogenic receptor α (ERα) in SF1 neurons were obese due to a reduced energy expenditure . AblatioGrowth hormone (GH) also plays a role in glucose metabolism via SF1 neurons. GH is secreted in a metabolic stress situation such as hypoglycemia. Deletion of its receptor in SF1 neurons resulted in an impaired capacity for recovery from hypoglycemia . These mAltogether, these findings identify SF1 neurons (the predominant VMH population) as a key player in the regulation of energy expenditure and glucose homeostasis, being particularly important in the adaptive response to HFD feeding. Most of the mutant mice with deletion of several hormone receptors and associated proteins in SF1 neurons have no changes or mild metabolic alterations under chow diet, but they show substantial metabolic variations under HFD exposure. The action of hormones and related proteins in SF1 neurons is also involved in the CRR to hypoglycemia to maintain glucose balance between the brain and the periphery. Future studies are needed to describe the specific molecular mechanisms and subsets of SF1 neurons underlying the effects of hormones in glucose homeostasis and energy expenditure.The regulation of energy homeostasis is importantly regulated by proteins acting as nutrient and energy sensors, such as AMPK and SIRT1, which restore energy balance during metabolic challenges both at the cellular and physiological levels . A link AMPK is a highly conserved master regulator of metabolism, which is activated under low energy conditions, increasing energy production and reducing energy waste. Current evidence demonstrates the critical role of hypothalamic AMPK in the regulation of food intake and energy expenditure, as well as glucose and lipid homeostasis at the whole-body level ,65,66,671 null mouse by Cre-Lox recombination. Ablation of AMPKα1 in these neurons led to feeding-independent weight loss associated with an increase in energy expenditure [1flox/flox mice displayed BAT activation, which was confirmed by increased BAT temperature and UCP1 protein expression, elevated sympathetic activity, and higher 18F-FDG uptake in brown fat [1flox/flox mice fed with a long-term HFD had a feeding-independent decrease in body weight and adiposity, associated with increased energy expenditure and VO2, higher BAT thermogenesis activation, and browning of subcutaneous WAT. These findings point to AMPKα1, but not AMPKα2, in SF1 neurons as the main catalytic AMPK subunit in the VMH that regulate thermogenic control, particularly under HFD exposure.The identification of SF1 neurons as the main neuronal AMPK-expressing population in VMH to be targeted in obesity was demonstrated by several studies of Miguel Lopez lab. They generated an SF1 specific AMPKαenditure . In accorown fat . SF1-Cre1 attenuation in SF1 neurons [Other studies demonstrating that the stimulatory effect of thyroid hormones in BAT thermogenesis , WAT bro neurons  strongly neurons . These s1 deletion in SF1 neurons against HFD-induced obesity was mainly associated with increased energy expenditure, slight alterations in glucose balance (decreased glycemia and improved glucose tolerance without changes in insulin sensitivity and insulin levels) found in mutant mice fed with an HFD, could be involved [Txn2 , providing protection against ROS produced during hypoglycemia. Conversely, under hyperglycemia, a reduction in ROS production is mediated by UCP2 in GE SF1 neurons [Although the protection of AMPKαinvolved . The modinvolved . The aut neurons . These fIn addition to AMPK, the metabolic sensor of nicotinamide adenine dinucleotide-dependent deacetylase SIRT1, which is highly expressed in the VMH, has shown to contribute to both control of energy balance and clock function from SF1 neurons ,71,72. SAs observed with AMPK, the anatomical location of SIRT1 in the hypothalamus is relevant for the protection against diet-induced obesity: although SIRT in POMC neurons is required for normal BAT-like remodeling in the perigonadal fat depot , SIRT1 iIn addition, to protect against dietary obesity, SIRT1 in SF1 neurons is relevant for homeostatic responses that can protect against dietary diabetes, since mice overexpressing SIRT1 exclusively in SF1 neurons were protected from developing diet-induced insulin resistance in skeletal muscle and hyperglycemia, whereas mice lacking SIRT1 in the same neurons were more prone to develop insulin resistance in skeletal muscle after HFD . It is iIn addition to these investigations, SIRT1 also contributes to the synchronization of the circadian clock in the brain, by nutritional inputs, which is crucial to maintaining cellular and body homeostasis . Mice wiOverall, specific targeting of metabolic sensors such as AMPK and SIRT1 in SF1 neurons of the VMH would be enough to modulate body weight gain and energy expenditure, in a feeding-independent manner, but associated with synchronization of the central clock with the periphery. This is a challenging approach but with significant translational relevance in obesity management.The expression and activity of synaptic receptors and glutamatergic neurotransmission in SF1 neurons of the VMH have been identified to contribute to energy balance dysregulation in obesity and diabetes.flox/flox mice did not become obese when exposed to a chow diet and had mild obesity when fed with an HFD [Since neurons in the VMH are largely glutamatergic, the importance of glutamate neurotransmission versus other neurotransmitters and neuropeptides in mediating the functions of these nuclei seem to be higher, not only in energy homeostasis but also in sexual and defensive behaviors ,33. The The relevant role of glutamatergic neurotransmission in SF1 neurons to regulate energy homeostasis was also recently established by the development of mice lacking the metabotropic glutamate receptor mGluR5 in these neurons . The mosOther receptors involved in neuronal activity have shown their contribution to the regulation of obesity and diabetes by SF1 neurons in the VMH. Among them, the calcium channel subunit α2δ-1 has a non-canonical role in SF1 neurons to control glucose and lipid homeostasis . This neThe endocannabinoid receptor CB1 located in SF1 neurons of the VMH has been also involved in glutamatergic output regulating feeding and in the control of metabolic flexibility in response to dietary changes. Hypothalamic slice preparations exposed to a CB1 receptor-specific agonist, displayed inhibition of the electrical activity of SF1 neurons . In lineAltogether, although these studies provide substantial evidence of the role of glutamatergic neurotransmission and neuronal receptors in SF1 neurons to control glucose homeostasis and metabolic adaptation to dietary challenges, they raise important questions that still need to be clarified such as (i) the identification of the exact afferent and efferent components of the neurocircuitry linking SF1 neurons with other brain areas and the periphery , (ii) the evaluation of sex-dependent function, (iii) the exploration of SF1 neuronal subpopulations in response to different stimuli .Atg7 deletion in POMC neurons implied an obesogenic phenotype, especially when feeding an HFD [Atg7 in SF1 VMH neurons of mice [Atg7 in this neuronal population has no effect on body weight, food intake, or energy expenditure. However, when fasted overnight, mice lacking Atg7 displayed reduced O2 consumption, CO2 and heat production, and reduced food intake after refeeding. Atg7 deletion in SF1 neurons only implied moderate changes in fed plasma insulin levels and insulin resistance, without changes in glycemia and glucose tolerance.Autophagy plays a critical role in several physiological processes such as metabolic regulations. Deletion of essential autophagy genes, such as the autophagy-related gene (Atg) 7 in peripheral tissues drives significant changes in body weight and glucose balance ,80. Moreg an HFD ,82, wherg an HFD . A more  of mice . The autAtg7 deficient mice in SF1 VMH neurons [This study demonstrates autophagy activation in the VMH, in addition to other regions such as the ARC, in response to fasting. This was supported not only by increased expression of autophagy-related proteins in the area but also by a 2- to 3-fold increase in the density of cFos-immunoreactive cells in the VMH, ARC, and DMH of control mice in response to fasting, an induction that was abrogated in these three regions in  neurons . Then, t neurons .Atg7 in SF1 neurons showed a reduced number of mitochondria-autophagosome contacts with alterations in mitochondria morphology and respiration, indicating abnormal mitophagy [Atg7 in glucose metabolism.Loss of autophagy in SF1 VMH neurons also caused alterations in mitochondrial function and morphology, which was associated with inadequate metabolic response to fasting . During itophagy . Since Uitophagy ,86, the itophagy . In agreitophagy . Howeveritophagy , could eSF−1 was caused by a marked decrease in energy expenditure, hyperphagia (only under HFD feeding), blunted BAT function, insulin resistance, and glucose intolerance. In addition, deletion of primary cilia in SF1 neurons led to an impairment in bone homeostasis. The downregulation of the sympathetic activity in IFT88-KOSF−1 mice was linked to the reduction of the metabolic rate and increase in bone density, as this effect considered was independent of the obese phenotype [Very recently, the SF1 neurons’ primary cilia, a solitary antenna-like extension of the plasma membrane, was demonstrated as an important organelle for the regulation of energy homeostasis . In thishenotype . Considehenotype .It is known that the VMH is sexually dimorphic, showing females higher ERα concentration than males . AdditioEstrogens could affect and change some intracellular signaling cascades leading to these differences observed between males and females, as female mice have greater expression of ERα. This would explain why the presence or absence of different patterns of receptors impacts the estrogenic effect on SF1 neurons, as some of the sex-specific signaling cascades are being altered. Other sex-specific effects related to SF1 neurons can be found in their synapses with POMC neurons, as estradiol attenuated the retrograde endocannabinoid signaling from POMC to SF1 neurons, increasing the glutamatergic inputs to POMC . This stThen, estrogen signaling in SF1 neurons is a must for metabolic health in female mice. Despite the fact that many studies presented in this review were performed only in male mice, these last results obtained in both sexes reinforce the idea of SF1 neurons having a sex-specific effect on energy balance and glucose metabolism.TauGFPSf-1 and Sf1:CreZ/EG mice models were originally designed to trace the major VMH axonal projections during embryonic and postnatal stages [Remarkable progress in the neuroanatomy of VMH projections has been obtained from novel biological tools. Some notions on how the VMH connects with other brain centers come from stereotaxic injection with anterograde axonal tracers in adult rats ,91. WhilSf-1 regulatory elements. In the second model, the SF1 Cre mouse was crossed with a Z/EG reporter mouse, resulting in constitutive expression of eGFP (enhanced GFP) after Cre-mediated recombination [The first of these models is a knock-in line that contains the wheat germ agglutinin (WGA) and Tau-green fluorescent protein (TauGFP) under the control of bination . The anabination .+ fibers within the ARC. Thus, additional studies using synaptophysin or rabies virus would be helpful to explore the specific network between SF1 and hypothalamic nuclei involved in energy balance. Recently, Yunglei Yang and colleagues have optogenetically identified the downstream target underlying the SF1 suppression of food intake  ,92. Howed intake . The autSF1→aBNST is the most relevant circuit involved in controlling glycemia since the photostimulation of this circuit triggered an increase of the blood glucose levels [Downstream projections of SF1 neurons regulating glycemia were identified through the same novel strategy derived from optogenetics. The researchers administrated fluorescently tagged ChRs into the VMH of SF1-Cre mice to visualize the projection fields using histological imaging to detect the EYFP reporter in axonal projections . Once ide levels  . These controversies could be associated with the existence of several sub-populations of SF1 neurons that respond differently to insulin, leptin, and glucose. For instance, whereas some SF1 neurons seem to be specialized in the regulation of blood glucose levels, some others are responsible for insulin sensitivity in the periphery.When investigating the hypothalamic regulation of obesity and diabetes, in addition to the identification of SF1 sub-populations, it is important to explore the coordination of SF1 neurons with other neurons outside the VMH to trigger metabolic functions. For instance, HFD-induced hyperinsulinemia drives SF1 neurons hyperpolarization, leading in turn to functional changes in the synaptic output onto POMC neurons, causing obesity and glucose intolerance. This evidence suggests that the nucleus-specific responses upon HFD feeding can cooperate to cause obesity and diabetes, and disruption of this cooperation could act as a link between both diseases.Despite the advances in the neurocircuitry connecting SF1 VMH neurons with other brain areas, the exact efferent circuits leading to changes in peripheral tissues need further investigation. How mice lacking a protein only in SF1 neurons present a strong phenotype in the periphery in terms of glucose homeostasis and energy expenditure under nutritional challenges? Are these circuits restricted to SNS and PSNS? A new point of view also emerges from these studies: a disruption in a specific type of neurons in the hypothalamus could trigger the pathogenesis of type 2 diabetes and obesity. How this neuronal dysfunction drives peripheral insulin resistance, adiposity, and thermogenesis alteration remains unclear. Reconsidering the pathogenesis of obesity and type 2 diabetes and now including the essential role of SF1 neurons, new strategies to treat these diseases could emerge. Targeting this specific population of neurons in the VMH, and even another cooperating population outside the VMH at the same time could modulate specific metabolic functions, a challenging approach but with significant translational impacts in the management of obesity and diabetes.


Analyzing different tumor regions by next generation sequencing allows the assessment of intratumor genetic heterogeneity (ITGH), a phenomenon that has been studied widely in some tumor types but has been less well explored in endometrial carcinoma (EC). In this study, we sought to characterize the spatial and temporal heterogeneity of 9 different ECs using whole-exome sequencing, and by performing targeted sequencing validation of the 42 primary tumor regions and 30 metastatic samples analyzed. In addition, copy number alterations of serous carcinomas were assessed by comparative genomic hybridization arrays. From the somatic mutations, identified by whole-exome sequencing, 532 were validated by targeted sequencing. Based on these data, the phylogenetic tree reconstructed for each case allowed us to establish the tumors’ evolution and correlate this to tumor progression, prognosis, and the presence of recurrent disease. Moreover, we studied the genetic landscape of an ambiguous EC and the molecular profile obtained was used to guide the selection of a potential personalized therapy for this patient, which was subsequently validated by preclinical testing in patient-derived xenograft models. Overall, our study reveals the impact of analyzing different tumor regions to decipher the ITGH in ECs, which could help make the best treatment decision. Endometrial cancer (EC) is the most common gynecological cancer in developed countries, and it accounts for nearly 5% of cancer cases and more than 2% of cancer-associated deaths in women worldwide . EC has Intratumor genetic heterogeneity (ITGH) has emerged based on the analyses of different areas of the primary tumor and metastatic lesions from the same patient using whole-exome sequencing (WES) and targeted massively parallel sequencing –12. In tTo get deeper insights into the behavior of ECs and to be able to adapt the clinical management of EC patients accordingly, it is imperative to decode the genomic evolution of these tumors. Thus, we sought here to define the spatial and, in some cases, temporal heterogeneity of ECs, their clonal composition, and the clonal shifts between primary and metastatic disease. Spatially distinct samples of primary tumors and metastatic lesions from five patients with metastatic endometrioid EC , three patients with metastatic serous EC (SECs), and one patient with high-grade AEC, were subjected to WES, targeted massively parallel sequencing, and a subset to array comparative genomic hybridization (aCGH) to decipher their genomic landscape. These data were employed to reconstruct the spatial and temporal, when was possible, evolution of the tumors within each patient. Several phylogenetic patterns were identified in these tumors, independent of their classic histological or molecular classification, including similar patterns in cases with ovarian metastasis or recurrent disease. Despite the abundant spatial ITGH within the primary ECs, the majority of anatomically distinct EC metastatic lesions from a given patient displayed genomic homogeneity. In addition, we defined the molecular evolution in an AEC tumor. Interestingly, our analyses on AEC identified new potential targetable biomarkers that were validated by treating a patient-derived xenograft (PDX) with specific therapies. Overall, our results could help to prompt new paths for the personalized treatment of EC patients and potentially for a rare subtype of these cancers like AEC.POLE sequencing results (Table POLE hotspot mutation (data not shown), that 3/5 EECs lacked MLH1 and PMS2 expression and were classified as MSI molecular subtype, that 2/5 EECs were classified as CN-low, and that all 3 SECs showed aberrant p53 expression and were classified as CN-high (serous-like) , 3 serous ECs SEC1-3) and 1 AEC. Immunohistochemistry (IHC) analysis of the DNA mismatch repair (MMR) proteins and p53  and histological type  revealed significantly different overall survival rates . Interestingly, the case of AEC and serous tumors were associated with the poorest survival. Even though, these results should be confirmed in a larger cohort, our analysis supported previous studies that showed an association of endometrioid cases with low-intermediate-risk and serous-like groups with the worst outcomes [Although small sample size, comparison based on TCGA classification (including CN-low P < 0.001) genetic variants  than samples from ECs of CN-low , and CN-high subtypes  and the AEC case , PTEN , and as expected, TP53 and PPP2R1A were mutated in the SECs  were analyzed by WES to a 52× median depth (range = 30–70×), recording the somatic variants identified in each sample , which shared more than 40% of the somatic variants detected  samples (20 from metastasis and 21 from primary tumor)  of the genetic alterations selected for validation were found in all the samples analyzed by WES . Thus, it can be hypothesized that metastatic lesions were dormant whereas the primary tumor continued to evolve, or a possible clonal selection after primary tumor treatment occurred, in accordance with the phylogenetic tree , defined by aCGH analysis, was found in the SECs Fig. . While 2TP53 tumor suppressor gene and/or stabilization of the p53 protein are the most frequent alterations in SECs [TP53 mutation  amplification was validated in SEC1 at the protein level, in which HER2 membranous expression by IHC (2+) was seen in the primary tumor region, being even more intense in both the metastatic sections analyzed  and was associated with loss-of-heterozygosity (LOH).Finally, we focused on the genomic profile of the AEC characterized by a solid arrangement and lack of any kind of differentiation , or features of undifferentiated carcinoma Fig. . The WESThe proportion of somatic mutations shared between the two primary and the metastatic areas was high, with more than 63% of the genetic alterations being present in all the samples analyzed Fig. . The phyLike the other ECs, targeted sequencing was used to validate the AEC genetic variants found in the WES study, validating 86 of 215 variants tested (40%) by Ampliseq sequencing ; the deepest part of the tumor at the myometrial invasion front (AEC_PDX2); the right lymphatic node metastasis (AEC_PDX3); the left lymphatic node metastasis (AEC_PDX4); and the tumor infiltrating the cervix (AEC_PDX5). After tumor growth, the PDXs were resected and analyzed with a panel of biomarkers previously used to differentiate between high-grade endometrioid and serous carcinoma . As prevATM gene associated with LOH  ribose polymerase (PARP) inhibitors  Supplem and drugutations –46. Thusutations , 48, in ITGH is a consequence of deficient DNA replication that has been described since the early days of cancer research –51. GeneNumerous studies have shed light on the extent of tumor diversity in distinct solid tumor types, such as pancreatic , 54, lunHere, different degrees of ITGH were found between the multiple EC molecular subgroups, the highest number of mutations identified for the MSI subgroup, coupled with the highest level of ITGH. This ITGH was less pronounced for the CN-high/SEC subgroup (30% common SNVs) followed by the AEC patient (40% common SNV), being the lowest levels of ITGH found in the CN-low ECs, where more than 60% of the variants were shared among all the regions. Furthermore, the majority of variants detected were associated with a clonal status in each sample, suggesting that most of the cancer cells carried the majority of variants detected in this specific region when a single sample was considered. This could be misunderstood as the absence of heterogeneity, however, clonal mutations in one region of the tumor could be completely absent in another tumor region, as reported previously for renal , lung 7 or ovariThe low sequencing depth of the WES and the low tumor proportion sampled represent the most important limitations in our study. WES studies provide the mutational landscape of the EC samples, the evolution of the regions analyzed and identify the molecular subtypes. Although our WES study provided evidence of the presence of ITGH in EC patients, there was more limited detection of low-frequency mutations which often include private mutations that represent the majority of the ITGH within a cancer . To addrIt is interesting to compare the metastatic timeline of EC to different organs based on the phylogenetic trees. Peritoneal and lymph node metastasis are expected to occur late in the process of tumor dissemination, as observed in the trees for EEC3, EEC4 and EEC5. However, the timeline for ovarian metastasis is probably more variable, in particular for EEC. There is a subset of patients with EEC and ovarian metastasis that have a very good prognosis. In fact, historically patients in this type of tumors were interpreted as having two independent primary tumors due to their indolent behavior –76. HoweConversely, EEC3 and EEC4 patients had more variants in their metastatic lesions, lymph nodes and omentum than in the primary tumor regions. In both cases, metastases were detected as a recurrent disease after 3 years of primary tumor treatment. These results may indicate that recurrent metastatic samples acquire additional mutations during or after tumor treatment, which favored their growth even after years of disease remission. In these cases, metastasis would slowly acquire a more complex genetic phenotype, which could lead to an aggressive behavior during their development.ERBB2 amplification was detected in the CGH study for SEC1, SEC2 (both the primary tumor and metastasis) and SEC3 (only in metastasis), while the IHC analysis of different tumor regions reflects the ITGH in the patient and could reveal new targets for available treatments.Despite the low levels of ITGH observed in SECs, both in the WES and targeted sequencing studies, CGH studies highlighted ITGH at the SCNA level among different tumor regions from the same patient for the most important genes affected by SCNA in EC . In thisRegarding the mutational profile of AEC, we determined and confirmed the absence of the most frequent molecular alterations in EC by two different approaches. AEC analysis revealed a mutational landscape not closely related to either high-grade ECs or SECs. AEC is an uncommon type of cancer, previously reported in the literature –7 and diATM gene, as validated by massive parallel targeted sequencing. This gene is involved in DNA repair and commonly found mutated in cancers associated with poor outcomes and resistance to chemotherapy [ATM and TP53 loss of function mutations are mutually exclusive [TP53 mutations, yet it harbored bi-allelic ATM inactivation. To further investigate the biology of this AEC, five PDXs were set up from the superficial and deepest primary tumor areas, as well as from metastatic foci. Targeted massive parallel sequencing revealed that most of the mutations previously detected in the patient (81%) were also found in all the PDXs analyzed, including that found in the ATM gene. This did not occur with most of the variants that were heterogeneously identified in the patient, which were not observed in the PDX models. Moreover, a personalized treatment for the AEC patient was explored, being PARP inhibitor considered a new potential therapeutic approach in this specific tumor context. The PARP inhibitor Olaparib has a good response rate in patients with ATM mutations [ATM mutations could benefit from therapy with Olaparib.Despite the decreased ITGH observed in our WES studies, this was stronger when additional tumor regions were studied by targeted sequencing, highlighting the need for including different tumor sections to better characterize the tumor at the molecular level. Remarkably, our results confirm that UAs could recapitulate the ITGH in EC in a best way than traditional biopsies . Furtherotherapy . Consistxclusive , this hiutations –46 and iTaken together, although our study presents some constraints in the number of analyzed patients by subtype to extract outright conclusions and more samples should be studied to resolve these limitation, a mean of 9 sample regions per tumor have been analyzed which should be considered an important number to infer the ITGH. Furthermore, this study emphasizes the significance of analyzing the maximum number of samples to better understand the tumor evolution, especially when the genetic heterogeneity found between multiple samples of the primary tumor is considered Fig. . NeverthA series of 9 metastatic EC cases for which multiple fresh-frozen tumor zones were available were collected from the Arnau de Vilanova University Hospital (Lleida), the MD Anderson Cancer Center (Madrid), the Vall d’Hebron University Hospital (Barcelona) and the Bellvitge University Hospital (Barcelona), with the support of the MD Anderson Foundation Biobank , the Xarxa Catalana de Bancs de Tumors and Plataforma de Biobancos ISCIII 364/2014). In addition, a uterine aspirate (UA), a minimally invasive sample of the endometrium collected for diagnostic purposes, was obtained from the AEC patient and used in the validation study  methodology and TumorTracer Server have been detailed in Supplementary Material and MethodsWES was performed in collaboration with Sistemas Genómicos, S.L.  and the MSKCC Integrated Genomics Operation . Fresh-frozen regions were analyzed by WES using the SureSelectXT Human All Exon + UTR (71 Mb) v5 enrichment kit  and paired-end sequencing was performed in an Illumina HiSeq 2500 sequencer . A median depth of coverage was achieved of 51x (range = 32–74×) for tumor samples and 52× (range = 45–60×) for normal samples. A total of 40 frozen tissue samples analyzed by WES were subjected to Ampliseq targeted re-sequencing to validate the variants selected. The Targeted resequencing analysis has been included in The bioinformatics analyses were performed as described previously , 93. BriMaximum parsimony phylogenetic trees were generated using CCF values from the WES analysis and the data on the presence/absence of somatic mutations in the validation of each tumor region, as described previously . Brieflyhttp://ctdbase.org/) and STITCH  and all the procedures involving animals were performed according to protocols approved by the Animal Experimentation Ethics Committee at the Vall d’Hebron University Hospital (CEEA 16/16). Details are specified in U test. Patient subgroups were compared with an unpaired Student’s t-test (comparisons between two groups) or with one-way ANOVA and Tukey’s multiple comparison tests (comparisons between more than two groups). Statistical analyses were performed using the SPSS Statistics 17.0 software package . For SCNA comparison between WES and aCGH, “in house” python scripts were used. The concordance between both analyses was described with the kappa value using R [https://CRAN.R-project.org/package=survival).The data was compared between the TCGA dataset, and the patient series included in this project using the Mann–Whitney  using R . OS was Supplementary InformationSupplementary Figures 1-6Supplementary Table S1Supplementary Table S2Supplementary Table S3Supplementary Table S4Supplementary Table S5Supplementary Table S6Supplementary Table S7


The fibroblast growth factor 2 (FGF2) is a member of the FGF family which is involved in key biological processes including development, cellular proliferation, wound healing, and angiogenesis. Although the utility of the FGF family as therapeutic agents has attracted attention, and FGF2 has been studied in several clinical contexts, there remains an incomplete understanding of the molecular and clinical function of FGF2 in the auditory system. In this review, we highlight the role of FGF2 in inner ear development and hearing protection and present relevant clinical studies for tympanic membrane (TM) repair. We conclude by discussing the future implications of FGF2 as a potential therapeutic agent. Fibroblast growth factors (FGFs) comprise a large family of proteins which are involved in several biological functions including embryonic development, cell growth and differentiation, angiogenesis, and wound healing  primarily through the RAS-mitogen activated protein kinase (MAPK) pathway to regulate cellular function in the skin, blood vessels, tendons, ligaments, bone, and teeth  reconstruction.FGF2 has been proposed to fulfill many functions during vertebrate auditory development. The expression of FGF2 has been detected through messenger RNA (mRNA) and protein levels in the cochlea and vestibule throughout the life span of animal models . The preFGF2 mRNA expression showed large increases of ~103 fold, and this expression was relatively evenly distributed throughout the mouse cochlea  except in the cartilage where it was low in the postnatal day (P)-0 mouse cochlea -10.5 stage (when the otocyst is closed as a sac) of inner ear development in the otocyst epithelium and neuroepithelium -11 (40–45 h). Expression was increased during the formation of the otic vesicle at HH15  plasmid had a protective and rescue effect (15 and 6 mean dB improvement respectively when compared to control) following noise-induced trauma in guinea pigs  layer of tissue which separates the external and middle ear. In the normal hearing process, the TM receives sound vibrations and transmits them to the auditory ossicles. The TM also serves as a barrier protecting the middle ear space from water, bacteria, or other foreign substances. Rupture of the TM can occur due to middle ear infections, barotrauma, loud sound exposure, or severe head trauma. While most TM perforations heal spontaneously within a few weeks, failure of healing can result in chronic perforation which can lead to hearing loss, infections, middle ear cholesteatoma, and other complications. Delayed healing may also necessitate surgical intervention for closure of the rupture. In recent years, alternative treatments for the repair of TM perforations have been explored including topically applied growth factors such as FGF2.The precise mechanisms by which FGF2 functions in human TM repair remains unclear, however, studies performed in animal models have provided insight into its potential roles. TM healing proceeds through three stages: inflammatory, proliferative, and remodeling . Many of these studies reported improved closure rates  are the most common tumors of the cerebellopontine angle, and often present with sensorineural hearing loss  the role of FGF2 as a preventive and curative agent in auditory damage; (4) regenerative function of FGF2 in TM; and (5) FGF2 activity in tumors related to hearing loss. These studies highlight the potential of FGF2 based therapies for hearing disorders. However, there are many unanswered questions prior to verifying FGF2 as a useful therapeutic for hearing loss. Therefore, future studies need to be conducted to fill these gaps in knowledge which are outlined below.Knowledge of the role of FGF2 in auditory development and interest in its potential as a therapeutic agent has advanced considerably in the past decades. In this review, we comprehensively summarized: (1) the expression pattern and activity of FGF2 during inner ear development and maintenance in vertebrate models; (2) the effect of FGF2 on proliferation and differentiation of inner ear cells in vitro and in vivo experiments of induced auditory trauma with mammalian animal models . For studies that used noise-induced trauma, parameters such as the intensity (115–172 dB) and duration of exposure (4–5 h) varied significantly. Therefore, direct comparison even in these studies with the same mechanism of auditory trauma was challenging as more than one parameter was different. Two studies used the same noise parameters and differed only in route of FGF2 delivery  and large (greater than 1/4 of TM) perforations . Repair of the TM is expected to improve the air conduction threshold, and thereby close the air-bone gap. Nearly all the clinical studies of FGF2 for TM repair reported improvements in PTA air conduction and air-bone gap in patients who achieved TM closure. Two studies, however, also reported improvements in bone conduction thresholds, which they attributed to improved sound transmission due to TM repair (Lou et al., Hearing loss is the most common sensory deficit worldwide, and the burden of disability is projected to increase in the coming years (Sheffield and Smith, MJ and VS wrote the manuscript. KB prepared all the tables. VS prepared the figure. KS conceived, designed, and supervised the manuscript writing and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Maternal diabetes is a prevalent pathology that increases the risk of cardiovascular diseases in the offspring, the heart being one of the main target organs affected from the fetal stage until the adult life. Metabolic, pro-oxidant, and proinflammatory alterations in the fetal heart constitute the first steps in the adverse fetal programming of cardiovascular disease in the context of maternal diabetes. This review discusses both human and experimental studies addressing putative mechanisms involved in this fetal programming of heart damage in maternal diabetes. These include cardiac epigenetic changes, alterations in cardiac carbohydrate and lipid metabolism, damaging effects caused by a pro-oxidant and proinflammatory environment, alterations in the cardiac extracellular matrix remodeling, and specific signaling pathways. Putative actions to prevent cardiovascular impairments in the offspring of mothers with diabetes are also discussed. The concept of developmental programming was first introduced more than 20 years ago by Dr. David Barker, who investigated the association between low birth weight and increased risk of coronary disease in adult life  or have its onset during pregnancy . All types of diabetes have been shown to induce an adverse fetal programming . Epidemiin utero have significantly higher systolic and mean arterial blood pressures , panthothenate kinase , SCAN domain-containing protein 1 , and GJA4  were associated with cardiovascular risk  are an excellent model for the study of vascular endothelium properties and the main biological pathways involved in endothelium function.Studies in primary culture of HUVECs and human placental microvascular endothelial cells from GDM pregnancies have shown the dysregulation of adenosine metabolism , 2015. Aenhancer of zester homolog 2 – β (EZH2β) related to an increase in the expression of miR-101, a microRNA that targets EZH2β (EZH2β is part of a multisubunit complex that initiates and maintains the trimethylation of histone H3 on lysine 27 (H3K27me3), an epigenetic mark associated with heterochromatin formation and gene silencing , which, at the appropriate dose, acts by selectively destroying pancreatic cells, leading to insulin deficiency and hyperglycemia in different animals .Regarding the mechanisms underlying the programming of cardiovascular diseases, studies in animal models can be divided into those focused on (1) epigenetic mechanisms, (2) altered pathways of cellular metabolism, (3) alterations induced by a pro-oxidant/proinflammatory environment, and (4) alterations in extracellular matrix remodeling and intercellular communication.Animal studies focused on epigenetic mechanisms may improve our understanding of how epigenetic gene transcriptional regulation responds to an altered gestational milieu to influence the developmental origin of health and disease.heat shock protein 1a1 (Hspa1a) and Hspa1b, showed enriched H3K4me3 peaks , a class III histone deacetylase . This alironment . Sirt1 fironment . One of ironment . FoxO1 dironment .Another putative epigenetic mechanism involved in the programming of cardiovascular diseases involves biogenesis of miRNAs which can be delivered by exosomes. Exosomes are nanovesicles that contain intact and functional mRNAs, miRNAs and proteins, which function as pivotal mediators of cell-cell communication among neighboring or distant cells and play a key role in multiple physiological or pathological processes .in vitro studies have shown that endothelial cells absorb placental-derived exosomes through endocytosis , which in turn downregulates PI3K/AKT pathway activation that lead to increased glycogen synthase kinase 3 β (GSK3β) and peroxisome proliferator-activated receptor gamma coactivator alpha , a cellular sensor for energy metabolism and nutrient availability that controls cellular growth and metabolism. mTOR forms two different complexes (mTORC1 and mTORC2), which differ in downstream signaling pathways and function . ActivatIn the offspring heart of an obesity model with hyperglycemia and hyperinsulinemia, Zhang et al. found that the mTORC1 signaling pathway was increased. These authors also found that a maternal treatment with the antioxidant N-acetyl-cysteine during pregnancy normalized the altered mTOR signaling in the offspring heart .Regarding lipid metabolism, in maternal diabetes, insulin concentration, and/or signaling deficiency may lead to an excess of metabolic substrates and impairments in maternal lipid metabolism. In addition, diabetes in pregnancy frequently induces dyslipemia in the mother . We haveLactiplantibacillus plantarum improved the lipid profile and insulin resistance and restored the dysbiotic gut microbiota in dams, reducing blood pressure and recovering the vascular function in the adult offspring -dependent pathways have also been found to be sex-dependent . In expeIn an animal model of diabetes induced by STZ administration during pregnancy, results showed diastolic dysfunction in the offspring at the neonatal stage  and impaAlterations in mitochondrial function lead to an increase in reactive oxygen species and thus to an increase in oxidative stress , which iIn cardiac tissues, a major source of reactive oxygen species under both physiological and pathological conditions is NADPH oxidases NOX; . In a stIn another study in a model of mild diabetes obtained by STZ administration, the offspring’s heart at neonatal stage showed an increase in nitrated proteins, which evidences protein damage by peroxynitrites , potent Lipids can also be the target of reactive oxygen species. In an experimental model of STZ-induced diabetes, sex-dependent differences were found related to lipoperoxidation, as only neonatal hearts of male offspring showed an increase in thiobarbituric acid reactive substances (TBARS), which are formed as a byproduct of lipid peroxidation . At the Regarding maternal treatments that have an impact in modulating the pro-oxidant intrauterine environment, at our lab, we observed that a maternal treatment with an olive oil-supplemented diet administered during pregnancy was able to prevent the increased pro-oxidant markers as well as apoptosis in the heart of 21-day-old offspring of diabetic rats . At our The cardiac extracellular matrix (ECM) is a complex and dynamic structure that forms a three-dimensional network in the cardiac interstitium. It provides structural support for several distinct cell types, contains growth factors and cellular adhesion proteins, and integrates extracellular signals and cellular responses . In cardThe balance between ECM synthesis and degradation is of crucial relevance in maintaining cardiac structural integrity. In this context, it is important to mention the role of matrix metalloproteinases (MMPs), which are proteolytic enzymes able to degrade ECM components. Expression and/or activity of MMPs are upregulated by the pro-oxidant/proinflammatory environment. In particular, MMP-9 expression has been found increased in hearts of neonates from diabetic rats . InteresMmp-2 and Ctgf, and in collagen deposition and fibrosis .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Impaired energy homeostasis and aberrant translational control have independently been implicated in the pathogenesis of neurodegenerative diseases. AMP kinase (AMPK), regulated by the ratio of cellular AMP and ATP, is a major gatekeeper for cellular energy homeostasis. Abnormal regulation of AMPK has been reported in several neurodegenerative diseases, including Alzheimer’s disease (AD) and amyotrophic lateral sclerosis (ALS). Most importantly, AMPK activation is known to suppress the translational machinery by inhibiting the mechanistic target of rapamycin complex 1 (mTORC1), activating translational regulators, and phosphorylating nuclear transporter factors. In this review, we describe recent findings on the emerging role of protein translation impairment caused by energy dysregulation in neurodegenerative diseases. Despite the tremendous effort that has been devoted to the investigation of neurodegenerative diseases in the past decades, effective treatments remain limited. Among the common features of most degenerative diseases, impaired energy homeostasis due to mitochondrial defects and reduced protein translation efficiency are commonly reported. Ample evidence has shown that boosting bioenergetics in neurons may provide beneficial effects in various experimental models of neurodegenerative diseases, suggesting the importance of energy deficiency in diseased brains. Because the AMP-activated protein kinase (AMPK) is a key sensor of cellular energy status and an upstream regulator of multiple cellular machineries, its functions during energy stresses have been well investigated. Conversely, the protein translation process is highly energy- dependent and tightly regulated by hundreds of proteins at multiple steps under various pathophysiological conditions. In particular, gradual loss of protein translation efficiency along the progression of neurodegenerative diseases has been reported. This mini- review summarizes the current understanding of the role of energetic stress-mediated translational dysfunction in neurodegenerative diseases. Our focus is on the molecules and/or pathways in protein translation that are disturbed by energy deficiency and aberrant AMPK activation in neurodegenerative diseases, with a specific focus on Alzheimer’s disease (AD) and amyotrophic lateral sclerosis (ALS).Eukaryotic protein translation is tightly controlled by hundreds of proteins at four steps  needed for protein translation from mRNA are known to be regulated by posttranslational modifications such as protein phosphorylation. Likewise, phosphorylation of the ribosomal protein S6 (rpS6), a component of the 40S ribosomal subunit, was reported many years ago  signaling pathway is a key pathway that integrates multiple signals for cell growth and differentiation and controls protein translation  containing a wide variety of translationally stalled mRNAs and mRNA-binding proteins (RBPs) in the cytoplasm to suppress protein translation -mediated manner  and to alter their cellular distributions  in motor neurons. TDP-43 has diverse functions, including RNA splicing, mRNA transport, protein translation, and storage of specific mRNAs in SGs  translation has attracted much attention. The RAN translation of C9-G4C2 repeats results in poly(PA), poly(PR), poly(GA), poly(GP), and poly(GR) dipeptides. Translational initiation factors (such as eIF4B and eIF4H) are important for the RAN translation of poly-GR production  transgenic mice and ALS patients. In a Drosophila ALS model and human iPSC-derived motor neurons, C9 arginine-rich dipeptide repeats disrupted ribosomal biogenesis by interacting with ribosomal proteins such as rpS23, rpS30, rpL5, and rpL36 . Under oxidative stress, SFPQ is recruited to SGs and colocalizes with Tau. Such dysfunction of SFPQ is associated with rapidly progressive AD patients  in many experimental models of neurodegenerative diseases. AMPK is considered a master regulator of energy homeostasis and its activation has been reported in various stages of neurodegenerative diseases. To date, many direct or indirect activators of AMPK have been developed, and some are currently being evaluated for their contribution to human diseases and disorders (mostly metabolic diseases, inflammation-associated diseases, and cancers; Steinberg and Carling, Y-JL and YC both wrote parts of the mini review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This review highlights a commonality of implementation barriers across geographically dispersed GeneXpert interventions for TB testing. This indicates the importance of using implementation frameworks to report findings that can improve public health outcomes across low- and middle-income countries. In low- and middle-income countries (LMICs) that have a higher burden of TB, the necessity for improved and rapid diagnostic testing, such as Xpert MTB/RIF that detects both TB and rifampicin resistance, has been limited by resource-related implementation challenges.Identifying and responding to the implementation-related barriers and enablers in Xpert testing programs across LMICs can help improve public health outcomes, which in this review were negatively impacted by barriers that were identified.We found that across the studies included in the review, an integrated and coordinated approach was required for implementing Xpert TB models of care into different health settings, but in LMICs, this approach can be associated with a lack of integration and coordination.When deciding on a particular implementation approach, the existing context of a health setting and the expertise and needs of key stakeholders  should be considered.Reporting of Xpert programs against an implementation science framework can increase learning across geographically diverse settings and thereby support improvement in program design. Current evidence indicates that the impact of GeneXpert for diagnosing TB in low- and middle-income countries (LMICs) has not demonstrated equivalent outcomes when compared to Xpert evaluations in upper-middle-income countries. Challenges associated with implementation are possible contributing factors preventing this innovative diagnostic technology from achieving more significant public health outcomes. This review aimed to assess the use of implementation science frameworks when reporting the enablers and barriers for the implementation of GeneXpert for diagnosing TB in LMICs.We conducted a qualitative systematic review of the peer-reviewed literature using PubMed, Medline, and Scopus. Eligible articles were those published between January 2010 and March 2020 that identified enablers and barriers to GeneXpert implementation, as well as the implementation approach delivered in an LMIC.Eleven studies were included in the review. Implementation barriers were found to be relatively consistent across studies and included patient-level factors, human resources, material resources, service implementation, service coordination, and technical operations. Few studies (n=5) identified enabling factors in the implementation of Xpert for TB testing. Identified enablers included strategies such as active case finding, expanding diagnostic algorithms, and daily transport of samples. The public health impact of Xpert TB testing interventions was commonly influenced by implementation barriers (n=4). Of the 11 studies, only 3 reported against an implementation framework.This review identified a commonality in implementation barriers and enablers that influenced the overall public health impact of GeneXpert. With greater transparency of these barriers and enablers, program planners can promote a more collaborative approach and adapt interventions. It is recommended that program planners use implementation science frameworks when conducting research and publishing. This will build an evidence base focused on implementation and thereby support programs to address implementation barriers and include enabling factors in program design. The specific objectives were to (1) identify approaches to implementing Xpert in LMICs, (2) determine the barriers and enablers across the identified Xpert testing programs, and (3) assess the use of implementation science frameworks in Xpert programs in LMICs.This qualitative systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, which ensures transparency in the formulation of findings.,The PICOS  was used to frame the research question. The population was limited to LMICs as defined by the World Bank classification of low-income economies or lower-middle-income economies.As the Xpert was recommended for use by the WHO in 2010, articles were limited to those published from January 1, 2011, to March 31, 2020. Included studies were peer-reviewed and published in English where the full-text article was available. Articles were excluded if they were not single country reviews and if they did not specify the implementation approach as well as identifying barriers and/or enablers to the implementation approach. Further to this, articles focused on the implementation of Xpert for TB in closed population settings, such as prisons or pediatric clinics, multicountry reviews, and interventions occurring under a research trial were also excluded.To identify relevant literature, PubMed, Medline, and Scopus databases were searched over 3 weeks beginning April 4, 2020. Search terms included the keywords “implementation,” “GeneXpert OR Xpert” and “Tuberculosis OR TB.” The preliminary search was performed in PubMed.In total 2,296 articles were initially identified. Articles were extracted to EndNote X9.3.2 and 116 duplicates were removed. All articles identified underwent a review to assess relevance against the eligibility criteria. This review process occurred in stages, which initially involved screening the article titles . Then, the abstracts of the remaining 151 articles were assessed to identify those suitable for full-text review. In completing this process, a further 133 articles were excluded. This resulted in 18 articles undergoing an eligibility assessment involving a full-text review. A total of 7 articles were excluded as they did not address the barriers and/or enablers in the implementation of the intervention. A second full-text review process was then completed involving all 3 authors, who assessed the remaining articles against the eligibility criteria and mutually agreed on the final selection of studies for the data extraction process. A total of 11 articles were included in the review .Data were independently extracted from selected articles and transferred into an Excel spreadsheet to maintain consistency. Before the data extraction process, variables for extraction were agreed upon among all authors. The final variables included author, year, country of implementation, implementation approach , health setting, testing algorithm, public health impact, as well as the identified barriers and enablers to implementation and use of an implementation framework. The hub-and spoke-model was characterized by a centrally located laboratory performing the TB testing using the Xpert machine and returning the results to the community health clinic that initially collected the sputum sample. The point-of-care model involved the installation of the Xpert machine at health centers where sputum samples were collected and tested.The final 11 articles were published between 2015 and 2020, with Xpert implementation occurring in Asia (n=5) and Africa (n=6). More details on the characteristics of the 11 studies are summarized in ,––,Among the studies included in this review, the hub-and-spoke implementation approach for Xpert was used more often (n=6),,,,,,,,,,,–,For the hub-and-spoke models (n=6), the Xpert machine was installed at a combination of high level facilities such as regional (n=2), district (n=3) and urban (n=1) public hospitals (n=4),,,,–,,,,,,,,,,The testing algorithm that determined eligibility for an Xpert test varied across all interventions. Although the majority used Xpert as an initial diagnostic for their targeted population (n=6),,,,,,,,,,,,,,,Seven of the 11 studies outlined some form of public health impact achieved by the implementation of Xpert.The barriers were allocated into the following 6 categories: patient-level factors, human resources, material resources, service implementation, service coordination, and technical operations . Of the –,–,,,,,The greatest number of barriers were categorized as service implementation factors (n=7). However, the most cited barrier was a service coordination factor (n=8) involving the lack of communication/referral pathways between staff in laboratories and health centers.The greatest number of barriers were categorized as service implementation factors; however, the most cited barrier was a service coordination factor.,,–Overall, the hub-and-spoke model generated the most commonly occurring barriers. Of the studies that implemented this approach, Cowan et al.,,,,,,Five studiesOf the enablers identified, the single factor highlighted by more than 1 study was the addition of human resources to support the implementation of a new program.,,Of the studies included in this review, only 3 reported being guided by a structured reporting framework,,,,,This review aimed to assess the use of implementation science frameworks when reporting approaches to implementing Xpert in LMICs and determining the barriers and enablers across the identified Xpert testing programs. The review found 7 of the 11 identified studies outlined some form of public health impact achieved by Xpert, which included treatment success (n=3),In this review, we found an integrated and coordinated approach was required when implementing Xpert models of care into a health setting.Recommendations to enhance integration and coordination included supporting continuous quality improvement of systems, as well as procuring and maintaining appropriate equipment, strengthening supply chains, having reliable specimen referral networks, suitable laboratory information systems, and proper laboratory training for staff.–,–,–,,,,,,–Across all the identified studies, 2 main barriers to the identification of active TB cases were identified, the underutilization of Xpert and the inadequate identification of eligible patients. These barriers frequently resulted from a lack of communication/referral pathways between health centers and laboratories (n=8)Two main barriers to the identification of active TB cases were identified, the underutilization of Xpert and the inadequate identification of eligible patients.,,,,,–,,,,As the Xpert allows for the timely turnaround of test results, a secondary public health impact of Xpert is the immediate initiation of treatment to prevent onward transmission.,,,,,,,,In this review, only 5 studies specifically identified enablers for the implementation of Xpert for TB testing in LMICs.Sharing of knowledge via standardized reporting provides valuable information that supports the ongoing integration of Xpert for TB testing in LMICs.,,Implementation frameworks such as the Standards for Reporting Implementation Studies (StARI) and the Consolidated Framework for Implementation Research (CFIR) were developed with the knowledge that effective interventions are often found to be ineffective when implemented in a real-world context.,,This review had several limitations. We searched 3 databases and restricted our search to English language publications. Further, of the studies included in this review, only 3 reported being guided by a structured reporting frameworkWith a higher burden of TB in LMICs, implementation research can advance understanding of implementation barriers and enablers. This study demonstrates the commonality of these barriers across geographically dispersed Xpert interventions in LMICs. With greater transparency of these barriers and enablers, program planners can promote a more collaborative approach and adapt interventions to reduce the impact of implementation barriers. To build the evidence base and in turn improve the implementation and effectiveness of Xpert, it is recommended that programs use implementation science frameworks when conducting research and disseminating findings. Wider use of these frameworks will provide valuable insight and support the ongoing improvement of TB programs in LMICs.


HAM gene family and stem cell homeostasis in land plants.Land plants develop highly diversified shoot architectures, all of which are derived from the pluripotent stem cells in shoot apical meristems (SAMs). As sustainable resources for continuous organ formation in the aboveground tissues, SAMs play an important role in determining plant yield and biomass production. In this review, we summarize recent advances in understanding one group of key regulators – the HAIRY MERISTEM (HAM) family GRAS domain proteins – in shoot meristems. We highlight the functions of HAM family members in dictating shoot stem cell initiation and proliferation, the signaling cascade that shapes HAM expression domains in shoot meristems, and the conservation and diversification of HAM family members in land plants. We also discuss future directions that potentially lead to a more comprehensive view of the  Land plants develop diversified shoot architectures, which are determined and sustained by pluripotent stem cells in shoot apical meristems (SAMs). In seed plants, the multicellular SAMs are organized into distinct cell layers and zones . In the HAIRY MERISTEM (HAM) gene was firstly identified and characterized in Petunia, and it was named after the phenotype of its loss-of-function mutant, the ectopic formation of differentiated hairs (trichomes) at the surface of shoot apices  are expressed in Arabidopsis shoot meristems, root meristems, and vascular tissues  triple loss-of-function mutant or the ham1ham2 (ham12) double mutant showed delayed inflorescence initiation, early termination of shoot meristems, disorganized meristem structure and morphology, and reduced axillary shoot branches  play both overlapping and distinct roles in control of Arabidopsis SAMs. The single loss-of-function mutant of each Type II member does not result in any obvious defects in Arabidopsis shoot meristem development . By contbranches , demonstl niches . HAM3, tl niches .WUS transcripts are restricted into the organizing center (OC) in deep cell layers  and the secreted peptide CLAVATA3 (CLV3) form a negative feedback loop to keep a constant population of stem cells in SAMs . The WUSl layers  and WUS pression . On the em cells . The abiHAM1 and HAM2 are co-expressed with WUS in the L3 layer. HAM1/2 act as WUS transcriptional cofactors to regulate the downstream targets and drive proliferation of shoot stem cells  – function as the negative regulator of Type II HAM members . miR171 nscripts . Consist3 mutant .MIR171 family genes  are identified in Arabidopsis, all producing miR171 precursors and contributing to the total level of mature miR171 (MIR171/170 genes are directly activated by the homeodomain transcription factor ARABIDOPSIS THALIANA MERISTEM LAYER 1 (ATML1) and its close homolog PROTODERMAL FACTOR 2 (PDF2) in the L1 layer  as mentioned above, in flowering plants  shows the shoot meristem defect , one Type II HAM from a monocot (rice), and two Type II HAM members from eudicots (soybean and pepper), are able to replace the role of Arabidopsis Type II HAM members in Arabidopsis shoot meristems  patens, SmHAM from the lycophyte Selaginella moellendorffii, CrHAM from the fern Ceratopteris richardii, and LkHAM from the gymnosperm Larix kaempferi) are expressed under the control of the Arabidopsis HAM2 promoter, they replace the function of Type II members  in regulating the CLV3 expression domain, maintaining established SAMs, and promoting the initiation of new stem cell niches in Arabidopsis ham123 mutants  patens  patens . Overexpte stage . Taken tesources , establiesources  and quanesources  in seed-HAM members and the majority of Type II HAM members in flowering plants  in tomato (Solanum lycopersicum) and four HAM homologs in rice (Oryza sativa) are also specifically targeted and cleaved by miR171  is highly conserved within the coding sequences of the non-flowering g plants . The negy miR171 . Overexpelopment .PpHAM, SmHAM, CrHAM, and LkHAM) and several Type II HAM members from flowering plants  are expressed under the control of Arabidopsis HAM2 promoter, these HAM reporters showed the concentration gradient from low to high along the apical-basal axis of Arabidopsis SAMs  maintain the conserved miR171 binding site, and many others from a considerable number of flowering plants lost the conservation of the miR171 binding site. For example, HAM4 (the Arabidopsis Type I HAM) contains six nucleotides different from the conserved miR171 binding sequence and is unlikely targeted by miR171 , and the Purdue Center for Plant Biology Graduate Student Fellowship and Ross-Lynn Graduate Research Scholarship (to YG).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pulmonary neuroendocrine tumors (pNET) represent a particular type of malignant lung cancers and can be divided into well-differentiated low-grade NET and poorly-differentiated high-grade NET. Typical and atypical carcinoids belong to the first group while large cell neuroendocrine carcinomas (LCNEC) and small-cell lung cancers (SCLC) belong to the second one. The aim of this mini-review is to focus on the role of surgical therapy for high grade neuroendocrine tumors. SCLC has the worst prognosis among all lung cancer neoplasms: in fact, the two-year survival rate is about 5% and median survival usually ranges between 15 and 20 months. The surgical treatment of SCLC has thus infrequently been judged as a valuable aspect of the therapeutic approach, the gold standard treatment being a combination of platinum-based chemotherapy and radiotherapy. As LCNEC are rare, there is a lack of extensive literature and randomized clinical trials, therefore the curative approach is still controversial. Current treatment guidelines suggest treating LCNEC by surgical resection in non-metastatic stages and recommend adjuvant chemotherapy according to SCLC protocol. Upfront surgery is suggested in early stages (from I to IIB), a multimodality approach is recommended in locally advanced stages (III) while surgery is not recommended in stage IV LCNEC. The rate of surgical resection is quite low, particularly for SCLC, ranging from 1 to 6% in limited diseases; lobectomy with radical lymphadenectomy is considered the gold standard surgical procedure in the case of limited disease SCLC and resectable LCNEC; pneumonectomy, although reported as an effective tool, should be avoided in the light of local and distant recurrence rates. Pulmonary neuroendocrine tumors (pNET) represent a particular type of malignant lung cancers and can be divided into well-differentiated low-grade NET and poorly-differentiated high-grade NET. Typical and atypical carcinoids belong to the first group while large cell neuroendocrine carcinomas (LCNEC) and small-cell lung cancers (SCLC) belong to the second one .High grade neuroendocrine tumors present significantly higher mitotic rates when compared to low-grade neuroendocrine tumors; moreover, increased necrosis is commonly observed as well as their combination with other types of lung cancer like adenocarcinomas or squamous cell carcinomas .The vast majority of high-grade neuroendocrine tumor patients are older and heavy smokers, with an early tendency to metastasize and a globally poor long-term prognosis with 5-year survival rates ranging from 15 to 57% –5.SCLC account for 15–20% of all pulmonary tumors; among them, only 10 – 20% of cases are early-stage tumors amenable to curative local treatments; on the contrary, the vast majority of patients present huge and centrally-located lesions – very often causing superior vena cava compression and/or infiltration - and early dissemination, chemotherapy thus being the most effective fist-line treatment , 7. AbouLCNEC account for <1% of all lung cancers and 40% of affected patients are diagnosed in metastatic stage . HistoloSmall cell lung cancer (SCLC) has the worst prognosis among all lung cancer neoplasms: in fact, the two-year survival rate is about 5% and median survival usually ranges between fifteen and 20 months . It is cTwo randomized controlled trials performed in the 70's and 90's evaluated the contribution of surgical resection to the therapeutic pathway of limited disease-small cell lung cancer: although some important limitations of both studies emerged, none of them was able to find any survival benefit of neoplasm resection , 11. In Locally advanced SCLC (stage IIIa) should not be considered for surgery as suggested in almost no guidelines –29; noneIn our personal retrospective experience, we observed 65 patients suffering from SCLC and surgically treated with curative intent. Our results disclosed a median overall survival of 36 months and postoperative 1, 5 and 10-year overall survival rates of 73.6, 42, and 25.6%. In particular, patients receiving surgical radical resection and presenting a pathological stage I had a 5-year overall survival of 76.6%; on the contrary, patients undergoing induction treatments or adjuvant radiotherapy had a worse prognosis probably due to a more advanced stage with lymph node involvement. In fact, lymph node involvement together with volume and site of the tumor were significantly related to overall survival, pT4 or pN2 patients presenting 1-year overall survival rates of 50 and 57.1% respectively; none of them was alive at 5 years .The role that surgery may play for treating limited-stage SCLC remains unclear due to controversial literature results and the absence of recent randomized clinical trials.Considering how easily SCLC tends to metastasize and its high chemo-sensitivity, many recent guidelines suggest a non-surgical approach to limited disease-SCLC, recommending platinum-based chemotherapy and mediastinal radiotherapy, or chemotherapy alone with prophylactic cranial irradiation for more advanced diseases , 32.Recent larger retrospective series have shown possible advantages offered by the resection of limited-stage SCLC. Encouraging 5-years overall survival rates of 48, 39, and 15% for operated patients in stage I, II and III respectively have been shown by The International Association for the Study of Lung Cancer (IASLC) Lung Cancer Staging Project in a group of 349 patients .SimilarlThe role of surgery in early stage SCLC might be not only limited to an improvement of overall survival but also to an appropriate histo-pathological diagnosis, thus supporting SCLC histology which could be misdiagnosed in the case of mixed forms, some NSCLC or rare tumors, thus adapting the treatment plan to the new acquired histology and helping the formulation of a different prognosis , 36.To date, there is no evidence supporting surgical indication in stage II and stage IIIA SCLC. NCCN guidelines, in fact, do not recommend resecting advanced tumors as they do not benefit from surgery , althougThe surgical approach to limited disease-SCLC should be standard lobectomy with lymphadenectomy which provides the best overall survival, in particular when compared to lesser resection such as wedge resection ; on the A more effective role of surgery has been observed within a multimodality approach including chemotherapy and/or radiotherapy in patients presenting a resectable disease . The NCCWorth of being reported is a combined form of SCLC and NSCLC which is relatively rare and it is defined as SCLC combined with any elements of non-small cell lung cancer . IncidenIt has been widely demonstrated that is quite difficult to obtain a precise diagnosis before surgery in the case of LCNEC; in the vast majority of cases, in fact, a definitive pathological confirmation is acquired by analyzing resected specimens –48. As LLCNEC shows a significantly worse prognosis when compared to other large cell non-neuroendocrine lung cancers , 51. A sAlthough the lack of randomized controlled trials and the retrospective nature of published studies do not allow definitive conclusions about the role of induction therapy or adjuvant treatments, it is quite well known that LCNEC is most often responsive to platinum-based neoadjuvant treatments . In factCurrent NCCN treatment guidelines suggest treating LCNEC by surgical resection in non-metastatic stages and recommend adjuvant chemotherapy according to SCLC protocol . UpfrontSCLC and LCNEC are high-grade neuroendocrine neoplasms; they grow faster than other NSCLC and show a more aggressive behavior and worse prognosis. While SCLC usually present as centrally-located bulky lesions, LCNEC are more frequently diagnosed as peripheral neoplasms. They are typically detected in heavy smoker older patients in stage IV at first diagnosis in 60–80% of cases in SCLC and 40% of cases in LCNEC. The rate of surgical resection is quite low, particularly for SCLC, ranging from 1 to 6% in limited diseases; lobectomy with radical lymphadenectomy is considered the gold standard surgical procedure in the case of limited disease SCLC and resectable LCNEC; pneumonectomy, although reported as an effective tool, should be avoided in the light of local and distant recurrence rates. The surgical route should always be evaluated within a multimodality approach including chemotherapy and radiotherapy in almost every stage.FP, CB, MC, and LS took part in all the aspects of the paper, idealization, writing, and revision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.