The present work presented a very relevant and original assessment associating vitamin D deficiency in children with overactive bladder related urinary incontinence . This toRegarding to Vitamin D, his synthesis depends on adequate sunlight exposure  and also is available from the diet, however, it is biologically inactive. It becomes activated after it undergoes two steps of hydroxylation, in the liver and in the kidneys; Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and has many other biological effects . VitaminVitamin D deficiency is considered as serum vitaamin D levels of <20 ng/ml, insufficiency is considered as levels ranging between 20 and 30 ng/m and normal levels of vitamin D are considered to be >30 ng/ml. Skeletal and smooth muscle growth and function are reported to be affected by vitamin D status . In thisThe present study in its discussion reports that there is an increasing evidence suggesting that vitamin D deficiency or insufficiency is associated with lower urinary tract symptoms . In addiIn the current study, the authors aimed to analyze serum vitamin D levels in children with OAB-related urinary incontinence, to determine their effect on symptoms and quality of life, and to evaluate whether vitamin D supplementation alleviated these symptoms and improved quality of life.In conclusion, the present study showed that vitamin D deficiency was more common in children with OAB-related urinary incontinence than in healthy children, and demonstrated that vitamin D supplementation could reduce urinary symptoms associated with OAB and improve quality of life in treatment-resistant cases. The findings reflect the importance of evaluating vitamin D levels in children with OAB-related urinary incontinence. Although vitamin D deficiency is not routinely evaluated in every patient, they suggest considering it in treatment-resistant cases.These findings are relevant and encouraging as it is not difficult to assess serum vitamin D levels, as supplementation is easy to perform in children, the previous studies cited throughout this commentary and the unpublished results of the present study in children have demonstrated and encouraged that vitamin D supplementation improves quality of life with the improvement of symptoms and that vitamin D supplementation will increase the treatment response in treatment-resistant cases by supporting other treatment modalities.


Detection of cellular changes in tissue biopsies has been the basis for cancer diagnostics. However, tissue biopsies are invasive and limited by inaccuracies due to sampling locations, restricted sampling frequency, and poor representation of tissue heterogeneity. Liquid biopsies are emerging as a complementary approach to traditional tissue biopsies to detect dynamic changes in specific cell populations. Cell-free DNA (cfDNA) fragments released into the circulation from dying cells can be traced back to the tissues and cell types they originated from using DNA methylation, an epigenetic regulatory mechanism that is highly cell-type specific. Decoding changes in the cellular origins of cfDNA over time can reveal altered host tissue homeostasis due to local cancer invasion and metastatic spread to distant organs as well as treatment responses. In addition to host-derived cfDNA, changes in cancer cells can be detected from cell-free, circulating tumor DNA (ctDNA) by monitoring DNA mutations carried by cancer cells. Here, we will discuss computational approaches to identify and validate robust biomarkers of changed tissue homeostasis using cell-free, methylated DNA in the circulation. We highlight studies performing genome-wide profiling of cfDNA methylation and those that combine genetic and epigenetic markers to further identify cell-type specific signatures. Finally, we discuss opportunities and current limitations of these approaches for implementation in clinical oncology. Liquid biopsies are emerging as a minimally invasive approach to complement and potentially advance the traditional standards of care in oncology . Tissue Similar to tissue biopsies, the major purpose of liquid biopsies in oncology is to identify circulating analytes that provide molecular information about the cancer. In this context, there are a multitude of molecules that may be isolated from biological fluids and targeted for analysis. Until recently, the main focus has been on circulating molecules that can be directly tied back to the primary tumor, including circulating tumor cells (CTCs), cell-free tumor DNA (ctDNA), tumor-educated platelets (TEPs), and tumor secreted vesicles  . HoweverThere are still many challenges to overcome before liquid biopsies may be routinely implemented in the clinic. Signal abundance , sequencing depth, and breadth of genomic regions assayed by sequencing are factors that must be considered to detect signals in the circulation of cancer patients relevant to inform care . StrategDespite its highly fragmented nature, advances in sequencing technologies have made comprehensive profiling of low integrity cfDNA possible. At a fixed target abundance and coverage, detection probabilities can be increased by broader sequencing, increasing the number of potential markers assayed . GenomicComprehensive sequencing approaches have unleashed the potential of liquid biopsies to achieve optimal sensitivity; however, there is still a need to improve the specificity and biological relevance of these assays. With the transition from targeted to comprehensive approaches come decreasing signal-to-noise ratios and new challenges to separate true biological signals from background sources of error . PhysiolDNA methylation functions as an epigenetic regulatory mechanism and involves covalent addition of a methyl-group to the 5-carbon of cytosine (5mc). DNA methylation occurs most commonly in the context of CpG dinucleotides . One of There are many techniques that can be used to study DNA methylation as well as different strategies that can be applied to classify and quantify methylation status . These mBisulfite conversion chemically modifies DNA so that unmethylated cytosines (C) are deaminated to uracil (U) to be later replaced by thymine (T) via PCR, while unmethylated cytosines are protected and remain cytosine (C) . The majWhile bisulfite conversion has long been considered the gold standard of methylation detection, there are major limitations that recent advances in enzymatic approaches show promise in overcoming . For insThe nuances of these different methodologies to detect DNA methylation make choosing the right method and accounting for its limitations essential toward accurate interpretation of results. Methylation detection technologies are rapidly evolving, leading to expanded potential applications. For instance, one such advancement involves the direct detection of methylation without treatment of DNA, possible with nanopore-sequencing from Oxford Nanopore Technologies (ONT) and single molecule real-time (SMRT) sequencing from Pacific Biosciences (PacBio) . AlthougTissue-of-origin (TOO) analysis takes each individual cell-free DNA molecule in the circulation and routes it back to its tissue and cellular origins as a non-invasive monitoring tool for tissue damages . At steaAdvances in liquid biopsy technology have led to the generation of massive amounts of methylation sequencing data that can be difficult to analyze due to the extensive number of possible features in the human methylome. Computational methods, including many machine learning techniques, have been developed to better handle such data by isolating specific signals and discriminative features, thereby reducing the dimensions of the data so that it is easier to interpret . In thisThere are many computational methods that have been successfully applied to facilitate TOO deconvolution of cfDNA . These iDespite demonstrated success applying these computational models to cfDNA methylation deconvolution, these algorithms were originally designed to be learned from very large training datasets . In ordeThere is a need to identify predictive biomarkers for real-time monitoring of therapy-related adverse events relative to therapeutic efficacy. Combining changes to mutant ctDNA with altered proportions of cell-type specific cfDNA can reflect intervention-based changes . TherapyCombining genetic and epigenetic analyses of cell-free DNA has many unique advantages when applied to precision therapeutics in cancer . Liquid Liquid biopsies are rapidly emerging as an alternative and complementary approach to traditional solid tissue biopsies and have high utility for many applications in clinical oncology. Technology advances have made genome-wide profiling of circulating analytes possible and allow for transition from targeted to comprehensive approaches. With transition to “third-generation” liquid biopsies, DNA methylation patterns can be used to leverage signals from both tumor and non-tumor cells to increase signal abundance and discern biological relevance . DespiteMB and AW wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.Georgetown University filed a patent related to some of the approaches described in this manuscript. MB and AW are named as inventors on this application and declare that as a potential conflict of interest. The remaining 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.


The speed and directionality of the ribosome movements during mRNA translation are determined by the mRNA sequence and structure and by various decoding factors. However, the molecular mechanisms of this remarkable movement during protein synthesis, or its relevance in brain disorders, remain unknown. Recent studies have indicated that defects in protein synthesis occur in various neurodegenerative diseases, but the mechanistic details are unclear. This is a major problem because identifying the factors that determine protein synthesis defects may offer new avenues for developing therapeutic remedies for currently incurable diseases like neurodegenerative disorders. Based on our recent study (Eshraghi  Figure 1) that has a role in neuronal survival, vesicular trafficking, and transcription, as well as in immune cell functions. However, the mechanism by which poly-Q expanded mutant HTT (mHTT) promotes toxicity remains enigmatic, and its complexity has precluded the development of effective HD drugs. This situation is further complicated by the fact that mHTT is ubiquitously expressed and yet it promotes massive neuronal degeneration in the striatum that then produces peripheral defects, such as skeletal muscle atrophy.The symptoms of HD, a neurodegenerative disorder, are severe disruption of cognitive and motor functions, including changes in posture and gait. HTT, the gene responsible for HD, is CAG (codes for glutamine (Q)) expanded and encodes a 350-kd protein  and mHTT can bind to ribosomes and slow down ribosome movement; however, mHTT binds much stronger. We used a combination of biochemical and sequencing methods to show that wtHTT inhibits ribosomal movements and that this function is further enhanced by mHTT. The end result is that mHTT causes ribosomal jamming and a consequent decrease in protein synthesis (C).A new mechanism of HTT action in regulating ribosome movement is revealed in our recent report by Eshraghi A role for mHTT in protein synthesis has been recognized for some time, but the molecular mechanisms of how mHTT blocks protein synthesis are still unclear. Our ribosome-sequencing (Ribo-Seq) data suggest that translating ribosomes are differentially accumulated on several hundred mRNAs in HD cells. The Ribo-Seq approach provides a “snapshot” of all the ribosomes active in a cell at a specific time point, so it preserves the ribosome location during translation and documents the ribosome position in the 5' to 3' direction on mRNA. We found an interesting accumulation of ribosomes at the 5' position on the mRNAs of HD cells that expressed both copies (homozygous) of mHTT, but a 3' accumulation of ribosomes on mRNAs of HD cells expressing one copy (heterozygous) of mHTT. No evidence presently indicates a particular “signature” of mRNAs whose ribosome occupancy is altered in HD; however, this differential ribosome occupancy indicates that the amount of mHTT will determine the ribosome distribution across the various mRNA types. This most likely reflects differential ribosome binding of wtHTT versus mHTT.B). HTT may also control ribosomal translocation by differential binding to the 5' and 3' ends of mRNAs and to other non-ribosomal proteins such as signal recognition particle (SRP) involved in translation elongation. Thus, the main role of HTT throughout the elongation process may be to act as a scaffold that facilitates ribosomal movement, thereby functioning as a “molecular brake” . Impeded elongation may also promote the formation of a stalled initiation complex downstream comprising ribonucleoprotein components known as stress granules (SGs). Thus, HTT, which interacts with caprin1, a SG marker, may be recruited to SGs to diminish protein synthesis also by blocking the initiation of translation.Any mechanism proposed to explain how HTT promotes this ribosome stalling must take into account the complexity of mRNA translation and the various intracellular locations where translation occurs. Approximately half of the mRNAs that encode cytosolic proteins and almost all mRNAs encoding secretory and membrane proteins are bound to the endoplasmic reticulum (ER). Thus, the ER is now emerging as a major site for the translation of mRNAs that encode both cytosolic and targeted proteins. HTT may bind to 40S and 60S ribosomal subunits in the cytosol or in the ER and then regulate ribosome translocation on specific mRNAs in a compartment-dependent manner  suggests that both the full-length and fragmented forms may have inhibitory effects by serving as scaffolds for interacting with ribosomes. The HTT region involved in the regulation of ribosome movements is presently unidentified. HTT domain analysis reveals an unusual occurrence of 28–36 Huntington/Elongation/A subunit/Target-of-rapamycin (HEAT) repeats with a conserved amino acid sequence that is often found in protein synthesis assemblies, such as eIF4G, that bind to particular RNA- and protein-binding motifs. We predict that many of these HEAT repeat sites in HTT may be regulating ribosome movements; however, further structural analysis is necessary to identify the locations of specific ribosomal proteins and the positions of defined segments of rRNA, mRNA, or protein ligands associated with HTT. Therefore, structural determination studies  will substantially improve our understanding of how HTT modulates ribosome movements.Many aspects of these processes are unknown. The existence of HTT fragments . This effect is so distinctive that almost no alterations in ribosome occupancy were detected in nuclear-encoded OXPHOS mRNA in HD cells. Perhaps the most challenging question is the nature of the mechanisms used by mHTT for selective regulation of ribosome occupancy of mitochondrially encoded mRNA, as this translation takes place inside the mitochondrion . The implied involvement of mHTT in OXPHOS ribosome occupancy is conceptually problematic because, unlike the case for cytoplasmic mRNAs, no clear evidence indicates a localization of mHTT inside the mitochondrial matrix. One tantalizing possibility is that association of mHTT with the mitochondrial membrane can elicit signals that trigger ribosome occupancy in the matrix, so that mHTT also regulates mitochondrial protein synthesis via trans-mitochondrial signaling across the membrane .Our Ribo-Seq data has revealed a central perturbance of ribosome occupancy of mitochondrially encoded mitochondrial OXSPHOS mRNA in HD cells  that are translationally dysregulated and potentially contribute to HD.These new findings provide examples of how mHTT may affect HD progression by impeding ribosomal movements. This then disrupts systematic decoding of mRNA and generates mismatches, misfolded proteins, and aberrant translational products. Rigorous mechanistic studies could therefore reveal new insights into the roles of ribosome stalling and mRNA translational dysregulation in the neuronal vulnerability seen in neurodegenerative disorders.


There is growing international interest in adopting a risk-based approach to breast cancer screening, where an individual’s risk would inform screening practices. It has been suggested that primary care will contribute to the delivery of this service by conducting risk assessment and providing primary prevention advice. The aim of our review was to understand what primary care providers think and feel about performing these tasks by examining their attitudes and typical activity in clinical practice (routine behaviours). The results suggest that primary care providers mainly assess breast cancer risk by collecting family history information but feel less comfortable advising on risk-reducing medications. Primary care will need to proactively assess breast cancer risk for women to get the most benefit from risk-based screening and prevention. To promote risk assessment and prevention activities, improved education/training and changes to resources  will be necessary.Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July–August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education. Population based screening programmes aim to detect asymptomatic cancers at an earlier stage to reduce mortality rates and the need for aggressive treatments associated with long term morbidities . A substAdopting an alternative risk-based approach to breast cancer screening has the potential to improve the benefit to harm ratio . The devA key benefit of risk estimation is the ability to identify women at increased risk, affording them the opportunity to benefit from preventative strategies. There are two strategies that have proven benefit in reducing breast cancer risk. The use of selective oestrogen receptor modulators and aromatase inhibitors, commonly referred to as chemoprevention or risk-reducing medication, have been shown to reduce breast cancer incidence ,15. FurtAs the first point of healthcare contact for the general population, primary care has been repeatedly identified as the most opportune setting to conduct breast cancer risk assessment ,19. SecoAs the likely roles of primary care in delivering risk-based screening and prevention will be risk assessment and provision of primary prevention advice including prescription of risk-reducing medication, it is important to assess acceptability of these activities. Acceptability is increasingly being recognised as an important component of the feasibility of complex interventions in guidance documents such as the Medical Research Council (MRC) framework .A previous review identified a considerable evidence base related to the acceptability of primary care involvement in risk-based screening and prevention . This reThe present systematic review aimed to provide a robust and in-depth examination of acceptability beyond identification of barriers and facilitators. It achieves this by employing the theoretical framework of acceptability which recognises the value of participant-reported evaluations of acceptability in addition to behavioural assessments . Howeverratings of acceptability  by primary care providers with respect to (1) breast cancer risk assessment and (2) primary prevention advicethe performance of routine behaviours by primary care providers regarding (1) breast cancer risk assessment and (2) primary prevention advicesources of variation in acceptability and behavioursSpecific objectives were to summarise the evidence base on:The protocol of this systematic review was pre-registered in PROSPERO (CRD42020197676) and follows the reporting guidelines detailed in the PRISMA statement . The proThe following electronic databases were searched: MEDLINE, EMBASE, CINAHL Plus, PsycINFO (each up to 10 July 2020) and ProQuest Dissertations & Theses Global (up to 26 August 2020). Databases were searched from 1989 as the first breast cancer risk model incorporating multiple breast cancer risk factors was published in this year . Search Healthcare professionals who provided primary care services. To account for variation in professional roles between healthcare structures in different countries, samples reported as being primary care providers were regarded as such. In ambiguous cases, authors were contacted to clarify whether their samples provided primary care services in line with the World Health Organisation’s definition .Studies conducted with both primary and secondary care providers were only included if it was possible to separately identify those findings relevant to primary care providers.Data had to be reported about risk assessment and/or providing primary prevention advice in the context of breast cancer. Studies focusing on cancer risk or primary prevention whereby data specific to breast cancer could not be extracted were excluded.(a)Acceptability defined as anticipated or experiential cognitive and emotional responses. Studies had to report one or more of the following outcomes using quantitative methodologies: attitudes, opinions , beliefs, feelings , barriers or facilitators.(b)Routine behaviours defined as typical or regular activity in clinical practice. Frequency of behaviours reported in a specific timeframe were not eligible for inclusion. Hypothetical clinical scenarios/vignettes or reflections on previous clinical cases were ineligible as these methods ascertain the action taken in a specific situation which may not be indicative of routine behaviours.Either or both of the following:Studies: Full empirical articles of any quantitative design published in the English language. Grey literature including PhD theses, dissertations and unpublished research were eligible for inclusion. Additionally, baseline surveys of intervention studies designed to improve breast cancer risk assessment behaviours or provision of primary prevention advice were included.Studies were included in the review if they met the following criteria:The search results were downloaded into Endnote and duplicates were removed. The library was then uploaded to Rayyan  to complFollowing full text review, detailed information on study characteristics , sample characteristics  and outcome data relevant to the objectives were extracted by the first author for all eligible articles. A second reviewer (RH) verified the data extraction by independently extracting primary outcome data for 50% (15/29) of eligible articles.The Mixed Methods Appraisal Tool (MMAT) was deemed most suitable for quality assessment due to its demonstrated reliability and inclusion of quality criteria specifically designed to appraise quantitative descriptive study designs such as surveys . CriteriIn line with MMAT recommendation, two authors (SB and DF) discussed which quality indicators were most important to consider for each criterion listed and following this a coding scheme was devised and agreed upon. All studies were appraised using the criteria for quantitative descriptive designs to assess the quality of the survey design and outcome measures which were of most interest to the review. A 50% rate of response was a priori regarded as satisfactory for avoidance of nonresponse bias, in line with response rates observed in previously published provider surveys . Two autA meta-analysis was deemed inappropriate as studies varied widely in outcomes, measurement scales and study populations. Instead, a narrative synthesis was conducted with findings tabulated . The outTo aid interpretation and allow meaningful patterns to be identified, outcomes were categorised into broader themes depending on content see . InitialThe searches identified 6750 articles, of which 3164 remained after duplicates were removed . A totalPrimary care providers’ perceptions of responsibility with respect to tasks implicated in breast cancer risk assessment and primary prevention were examined in several studies. Taking a family history was overwhelmingly perceived as a primary care responsibility  and reassuring low-risk patients (46.0–67.7%) . Very loThe discussion and collection of breast cancer family history was reported to be a common task . Rates wProfessional specialty and training level were found to be associated with reported behaviours. A higher proportion of providers specialising in obstetrics and gynaecology reported using risk assessment tools in comparison to family and internal medicine providers ,45. AddiOverall, there was higher endorsement of barriers for primary prevention than risk assessment. The most prevalent barriers for providing primary prevention advice were concern and discomfort prescribing risk-reducing medication and insufficient education/training, in line with barriers to risk assessment . FurtherPrimary care providers endorsed all facilitators to a relatively high degree  . Only onOverall, study quality was poor . A detaiThe results from this systematic review indicate that primary care providers typically take a reactive role in breast cancer risk assessment that is predominantly focused on collection of family history and provision of support following identification of increased risk. Reported use of multi-factorial risk assessment tools was low. Primary care providers reported higher discomfort and lower confidence with respect to prescribing risk-reducing medications when compared to risk assessment. However, few providers reported beliefs suggestive of doubts about the evidence base underpinning risk-reducing medications. Insufficient education/training and perceived discomfort were amongst the most commonly endorsed barriers reported for both activities. The strongest facilitators for offering risk-reducing medication related to availability of provisions such as clear guidelines and tools to facilitate identification of suitable patients. Professional background, training and country were identified as sources of variation in acceptability and behaviours. The methodological quality of included studies was generally poor and common limitations were high nonresponse rates and use of non-standardised outcome measures.Previous systematic reviews have consistently identified primary care providers’ lack of knowledge about breast cancer risk assessment and management as a significant barrier to engagement ,24,25,62Prior to this review, widespread reticence by primary care providers to discuss and prescribe risk-reducing medications has been recognised ,63,64,65This review has been the first to investigate sources of variation in acceptability and behaviours. Examination of routine behaviours illustrated that primary care providers infrequently report using multi-factorial risk assessments such as the Gail or Tyrer–Cuzick models ,8. NonetProfessional background was also associated with outcomes. Providers specialising in women’s health issues reported feeling more comfortable with respect to both risk assessment and primary prevention as evidenced by greater reported use of quantitative risk assessments and fewer negative views about the risks of risk-reducing medications. These perceptions are likely to be the result of specialised knowledge acquired through additional training. For instance, an understanding of the diagnosis and clinical management of hereditary breast and ovarian cancer syndrome is considered essential for obstetrician/gynaecologists . TherefoThe present review has identified methodological biases present in the primary studies. Firstly, high rates of nonresponse were observed in a significant proportion of the studies. Primary care providers who respond to surveys might have more positive views of breast cancer risk assessment and primary prevention than non-responders which may lead to overestimations of acceptability. Furthermore, there was a reliance on convenience sampling procedures in many studies. Outcomes were not assessed using standardised measures with demonstrated reliability and validity. In addition, older studies included in the review may be a poor reflection of current clinical practice given the significant advances made in breast cancer risk assessment and management in recent years. Primary prevention outcomes tended to be assessed in more recent studies which is in line with risk-reducing medications being a relatively new option in comparison to risk assessment. Nonetheless, findings were largely consistent across studies suggesting that methodological limitations with sampling and publication date did not unduly affect the overall conclusions.Substantial heterogeneity across included studies was evident and therefore a meta-analysis was not possible. To allow meaningful patterns to be identified via narrative synthesis, the research team decided how outcomes were categorised and to some extent this process was subjective. Nevertheless, analytical processes were reviewed in reflective team meetings to achieve consensus and ensure a rigorous and robust synthesis.Additionally, a wide range of values were observed for some outcomes indicating uncertainty about the average values presented. This is likely to be the result of heterogeneous outcome measurements, as well as differences in samples included. Consequently, caution is warranted when drawing conclusions about the precision of estimating strength of outcomes.Finally, and perhaps surprisingly, the review did not identify any studies investigating primary care providers’ perceptions of discussing health-related behaviours within the context of breast cancer risk reduction. There is, however, an evidence base focusing on cancer risk more generally. Inclusion of this literature may have provided a more comprehensive understanding of primary care’s perceived role in primary prevention than was possible in this review.The present review suggests that provision of education/training will be necessary but not sufficient to facilitate primary care involvement in breast cancer risk assessment and primary prevention. The findings on facilitators and routine behaviour indicate that adapting infrastructure and providing prompts to utilise available resources are essential to increase the likelihood of primary care providers routinely conducting both activities. For instance, the integration of risk assessment and management tools into practice software or access to web-based applications would facilitate the desired behaviours, as has been demonstrated for cardiovascular risk assessment and management . SeveralNursing staff were underrepresented in the included studies. Decision makers have suggested that nurses could assume increased duties in risk assessment and management to support implementation of risk-based screening and prevention . In relaAdditionally, there is a clear need for more research using populations outside the US to understand the feasibility of primary care assessing and managing breast cancer risk in different healthcare contexts. Future primary studies would benefit from assessing similar outcomes across studies using measures with demonstrated reliability and validity. Wider and more representative sampling frames should be used to obtain better coverage of the target population. Furthermore, recruitment strategies that build personal connections with potential participants such as using physician recruiters ought to be considered to reduce nonresponse rates .Within the context of implementing risk-based breast cancer screening and prevention, the findings of this review suggest that primary care providers are more likely to accept an increased role in breast cancer risk assessment compared to advising on risk-reducing medications. Adaptations to infrastructure will be necessary to promote enactment of breast cancer risk assessment and management behaviours in addition to provision of education. To fully realise the benefits of risk-based breast cancer screening and prevention, guidelines will need to be reviewed to ensure promotion of a proactive approach to breast cancer risk assessment in primary care.


Non-mammalian vertebrates can restore their auditory and vestibular hair cells naturally by triggering the regeneration of adjacent supporting cells. The transcription factor ATOH1 is a key regulator of hair cell development and regeneration in the inner ear. Following the death of hair cells, supporting cells upregulate ATOH1 and give rise to new hair cells. However, in the mature mammalian cochlea, such natural regeneration of hair cells is largely absent. Transcription factor reprogramming has been used in many tissues to convert one cell type into another, with the long-term hope of achieving tissue regeneration. Reprogramming transcription factors work by altering the transcriptomic and epigenetic landscapes in a target cell, resulting in a fate change to the desired cell type. Several studies have shown that ATOH1 is capable of reprogramming cochlear non-sensory tissue into cells resembling hair cells in young animals. However, the reprogramming ability of ATOH1 is lost with age, implying that the potency of individual hair cell-specific transcription factors may be reduced or lost over time by mechanisms that are still not clear. To circumvent this, combinations of key hair cell transcription factors have been used to promote hair cell regeneration in older animals. In this review, we summarize recent findings that have identified and studied these reprogramming factor combinations for hair cell regeneration. Finally, we discuss the important questions that emerge from these findings, particularly the feasibility of therapeutic strategies using reprogramming factors to restore human hearing in the future. Hearing loss is a globally prevalent disorder characterized by one or a combination of loss of inner ear hair cells, malfunction, or degeneration of components critical to hearing such as the stria vascularis, or loss of spiral ganglion neurons or their synaptic connections with hair cells. In practice, assistive devices such as hearing aids, cochlear implants, and auditory brainstem implants are the only current options available to help manage hearing loss, but these cannot fully restore hearing. Regeneration of inner ear hair cells by supporting cells or other non-sensory cells has been an attractive possibility for hearing restoration since its discovery as a naturally occurring phenomenon in non-mammalian vertebrates —was demonstrated to reprogram mouse embryonic and adult fibroblasts into a “pre-differentiated” or pluripotent stem cell state , FSK , CHIR , 616452 (a TGF-beta receptor inhibitor), Tranyl (a histone demethylation inhibitor), DZNep  and TTNPB  could replace all four transcription factors to successfully reprogram mouse somatic cells into pluripotent stem cells  from human dermal fibroblast cells  that are sufficient for a self-sustaining pluripotency state, along with the upregulation of telomerase. Exogenous expression of the OKS factors alone was found to enable multiple somatic cell types to reprogram to an iPSC fate   which catalyze the addition of a methyl group to the cytosine residue at specific DNA loci  were identified to be essential during embryonic beta-cell development  transdifferentiated cardiac and dermal fibroblasts into induced cardiomyocytes  are expressed in abundance during embryonic ages and co-operate during the formation of photoreceptors and retinal neurons in the mammalian eye , silent chromatin to induce transcription of genes . A specific example is that in macrophages obtained from reprogrammed fibroblasts, there is residual fibroblast gene expression, instability, and de-differentiation once the reprogramming factor expression ceases  cells are columnar cells lying adjacent to the inner hair cell layer of the organ of Corti. They are a transient population of cells occurring in neonatal animals and undergo thyroid hormone-dependent remodeling between 1 and 2 weeks of age . ATOH1 independently recognizes and binds to specific E-box motifs in the promoter and enhancer regions of its targets  in response to ectopic expression of Atoh1  is a downstream target of ATOH1 and is induced after the onset of a et al. , 2012]. Gfi1 null mice, outer hair cells followed by inner hair cells undergo apoptosis that is complete by 2 weeks of age, although vestibular hair cells survive, albeit in an abnormal condition  in adult mice showed that adenoviral delivery of ATOH1 and GFI1 together post hair cell ablation in the organ of Corti led to the transdifferentiation of supporting cells to give rise to hair cells at a significantly higher efficiency than ATOH1 alone  is a zinc-finger transcription factor expressed in hair cells and cochlear neurons during development  is a LIM domain transcription factor and like ATOH1, ISL1 behaves in a context-dependent manner in neuronal and non-neuronal tissue types  have been successful in reducing hearing loss in mice (Gao et al., The application of reprogramming factors as a therapeutic strategy for hair cell regeneration requires optimal gene delivery Gene delivery through viral methods includes the use of adenovirus, adeno-associated-virus, lentivirus, and exosome-associated adenoviruses. Studies in animal models have shown that adeno-associated viruses are effective in targeting hair cells for hearing loss gene therapy (Landegger et al., Both authors wrote and edited the manuscript. AI prepared the figures. 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.


Shin et al.). However, biological effects of LDR are not fully understood and could not be concluded as harmful to human since there are some uncertainties in the risk assessment. A great number of works demonstrated that radiation could induce epigenetic effects  RNAs) which can change gene expression without altering DNA sequences. Since epigenetic effects are susceptible to environmental changes, they are thus considered to be a possible mechanism to explain the long-term effects after radiation exposure .Since the discovery of X-ray in 1895, ionizing radiation has been well known to be one of genotoxic stresses which, by direct deposition of energy and by indirect action of reactive oxygen species, can induce a wide spectrum of DNA alterations including structural changes of DNA molecules, sequence mutation, and consequently chromosomal aberrations . Dependiexposure . Understexposure . The fluexposure . RadiatiYushkova). It can ultimately influence the inheritance of radiation-induced instability, interplaying among the transposon and crucial DNA repair genes after chronic radiation exposure , can explain the radiation sensitivity in a manner that depends on the exposed doses-, sex-, tissue-specificity . Differeexposure . Finallyexposure .Soumboundou et al.). It should be taken in great consideration when adequate biological dosimetry and radiation therapy is required in cancer patients. Many studies reported that people in high level background radiation area above 10 mSv/year showed no health risks for cancers or life-shortening, compared to the residents in other areas .Considering environmental factors such as the ethnicity and natural background level in the radiation mechanism of biological effects can also reduce the uncertainties in the risk assessment on long-term exposure to LDR. Ethnicity in different living environments can determine different cytogenetic responses against radiation-induced genotoxic stress at the level of human populations (er areas . FurtherThe articles of this research topic provide valuable information on the genetic and epigenetic modification responding to radiation exposure in bacteria, and eukaryotic organisms including humans. These findings will contribute to more comprehensive understanding for cellular response to radiation and shed light on the future studies of health risk assessment for radiation exposure.


Autophagy or auto-phagocytosis is self-phagocytosis of tissues and cellular materials i.e., “self-maintenance.” While phagocytosis normally refers to the innate immune process of white blood cells engulfing foreign bodies such as infectious materials, autophagy is a regulatory phenomenon of dysfunctional cellular components being removed  being a factor that can exacerbate lipid peroxidation  to increase autophagy in diabetes. Also, oxidative damage panel screening will show cardiovascular effect such as increased blood viscosity (Nwose, Perhaps, it is pertinent to emphasize that although assessment of EOS and its role in autophagy would be a potential therapeutic screening method, what needs to be addressed is “y Nwose, . Thus, bThis perspective recommendation advances the knowledge that oxidative stress induces autophagy (Hariharan et al., Current considerations of autophagy acknowledge oxidative stress in the cause-and-effect physiology as well as therapeutic modes of action. However, monitoring by laboratory methods is yet to integrate the available and validated oxidative stress parameters. What this opinion paper brings to fore is that tests for oxidative stress panel can be used to assess autophagy in metabolic syndrome, including diabetes and its cardiovascular complications, at no major cost.EN and PB conceptualized the opinion. EN did the initial draft of main text. PB did the revision as well as the abstract and conclusion. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bacteriophages (phages) are bacterial predators which shape bacterial population dynamics in nature by rapidly killing their host bacterium . Phages Several phage encapsulation studies have explored the potential of various drug delivery systems, which primarily include natural polymers, synthetic polymers, liposomes and electrospun fibers. Polymeric phage encapsulation has been extensively studied in the treatment of gastrointestinal tract infections. These polymers protect phages from harsh acidic conditions, potentially leading to phage inactivation or loss of phage titer. Other than extreme conditions, these polymeric encapsulation materials also protect encapsulated phages from digestive enzymes, bile juices and provide permeability to mucous lining where bacterial pathogens may reside . NumerouStaphylococcus aureus phage K was encapsulated in poly (N-isopropylacrylamide)- allylamine nanospheres. These nanospheres undergo a temperature-dependent phase transition to release phage at an elevated temperature associated with bacterial infections  polymer, which is sensitive to hyaluronidase. During infection state, HAMA is solubilized by hyaluronidase (produced from S. aureus) and release phages in the vicinity of pathogens to clear the infection  domain of LysK endolysin and lysostaphin in a thermally triggered Poly (N-isopropylacrylamide) (PNIPAM) nanoparticles for delivery of CHAPK cargo at a higher temperature, which is a standard indicator of infection  at pH 5  and endolysins (single modular and multi-modular) may lead to considerable variation in the formulation design, release kinetics and therapeutic outcome. Thus, delivery systems are needed to be critically designed and optimized for each phage or endolysin, which may increase the scaling-up efforts and cost in developing such formulations. Sterilization of prepared formulations is a major challenge in the scale-up of these delivery systems as thermosensitive phages, and endolysins cannot undergo high-temperature sterilization. The use of sterile conditions for deigning formulations or UV treatment is another potential alternative, but it also increases the cost as well as logistics difficulties in large-scale production settings. The natural origin of phages categorizes phages into non-patentable entities, making them less profitable and unappealing for pharmaceutical companies. Apart from technological limitations, a regulatory and legal framework is another major hurdle in the clinical progress of phage and endolysin delivery systems. The regulatory and legal framework for phages and endolysin applications is more limited to the local, nationwide boundaries and is yet to be standardized in a global manner . Phage aThe future of phage and endolysin encapsulation systems seems to be bright. With the emergence of antimicrobial resistance, the phage and their antibacterial products have emerged from a forgotten area to become a central research area for healthcare workers. There is a need to make these products more effective as therapeutic agent for treating human infections. Various delivery strategies have been devised to increase the efficacy and applicability of these antimicrobial products to clinical care. Phages have been evaluated in multiple encapsulation systems; however, there is a long road for the endolysins delivery system to prove their therapeutic applicability. Phage and endolysin delivery systems must undergo through a range of animal validation, followed by well-structured large clinical trials to establish their therapeutic outcome. The most obvious challenge for clinical applications of phage and endolysins delivery is the lack of a uniform regulatory framework across the globe. Progression of clinical trials and more scientific evidence may refine the current regulatory processes to a well-structured regulatory and legal framework. These future initiatives can further improve the understanding as well as clinical acceptance of phage and endolysin delivery systems to alleviate the burden of bacterial infections in healthcare. The current antibiotic crisis has driven the shifting of paradigm to phage-based therapies and countering delivery challenges. The next 1–2 decades could be an intriguing time to develop novel phage and endolysin delivery systems and investigate their potential in the healthcare system to combat multidrug-resistant infections.


Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of “permissive hypotension” refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma. Traditionally, the concept of “early and aggressive” fluid administration has been applied to patients with severe trauma, in order to restore circulating blood volume and maintain tissue perfusion. However, this treatment approach may increase hydrostatic pressure in injured vessels, dislodge hemostatic blood clots , 2, indu“Permissive hypotension” is included in the overarching concept of “damage-control resuscitation.” The concept of damage-control resuscitation has been developed with the aim of providing optimal fluid resuscitation and transfusion to patients with hemorrhagic shock secondary to severe trauma –10. The Attention should be brought to the fact that there are several similar-sounding terms included in the concept, such as “permissive hypotension/hypotensive resuscitation,” “restricted/controlled resuscitation,” and “delayed resuscitation” Table . “PermisNeither permissive hypotension/hypotensive resuscitation nor restricted/controlled resuscitation may be indicated in patients with traumatic brain injury (TBI) and/or spinal injury . This isCannon et al. first described the use of permissive hypotension in patients with severe trauma in 1918 . It has Bickel et al. conducted a prospective trial and reported that delaying aggressive fluid resuscitation until operative intervention improves outcomes in hypotensive patients with penetrating torso injury . This prAnother two trials focused on the timing and administration of fluid started in pre-hospital settings or in-hospital in patients with blunt trauma including traumatic brain injury , 25. Of Several researchers have reported the effectiveness of permissive hypotension in clinical and experimental studies. In those studies, target values of blood pressure were various, and systolic or mean arterial pressure was defined as target blood pressure.Dutton et al. compared targeting of blood pressure values within normal ranges to below normal ranges in patients with severe trauma for the first time  Table 22. PatienMorrison et al. conducted a RCT determining the efficacy of hypotensive resuscitation  Table 22. TargetSome animal research has been undertaken in order to provide answers to the clinical questions raised about effectiveness of permissive hypotension/hypotensive resuscitation and investigate the results of clinical trials, as well as to examine the pathophysiological mechanisms and hemodynamics associated with hypotensive resuscitation. Sondeen et al. have shown that there was a reproducible pressure at which rebleeding occurred in a porcine model for penetrating injury . BleedinLi et al. have however simultaneously shown the effectiveness of permissive hypotension in a rat model for splenic injury, induced by transection of the splenic parenchyma and one of the branches of the splenic artery . One hunSchmidt et al. investigated regional organ perfusion in the acute phase by investigating uncontrolled hemorrhage in a rat model for penetrating vascular injury and simulating pre-hospital times in urban trauma . BleedinHowever, Garner et al. have revealed an inverse of these results in a porcine model for primary blast injury . In theiThe evidence from these animal studies suggests that hypotensive resuscitation may lead to improved outcomes in subjects with penetrating injury where bleeding occurs from only one site; on the other hand, it is possible that hypotensive resuscitation may worsen outcomes in blunt injury owing to tissue hypoperfusion. The influence of this technique on the coagulation system has not been sufficiently examined.In the last several years, some retrospective analyses have demonstrated that aggressive resuscitation, often initiated in the pre-hospital setting, may be detrimental to trauma patients –35. ReceBrown et al. examined the effect of high vs low volume crystalloid resuscitation in the pre-hospital setting  Table 22. This sSchreiber et al. performed a randomized pilot trial to compare the effect of controlled resuscitation (CR) with standard resuscitation (SR) in the pre-hospital scene  Table 22. The meThese two trials suggest that controlled resuscitation in patients with blunt injury in the pre-hospital setting may be safe and possibly improves outcomes, especially in patients with pre-hospital hypotension. Whether controlled resuscitation strategies improve survival and coagulopathy is yet to be determined in a large-scale phase III trial.The Cochrane Library has published a systematic review examining the effect of fluid management on mortality and coagulation times in hemorrhagic hypovolemia, comparing both early vs delayed resuscitation and larger vs smaller volumes of fluid . Only twA further meta-analysis  assessedFor patients with major trauma, defined as having an Injury Severity Score of more than or equal to 16, the American College of Surgeons’ Advanced Trauma Life Support (ATLS) guidelines currently advocate “balanced” resuscitation with an initial 1–2 L of crystalloids before definitive/surgical control of bleeding . The mecThere are currently several problems and areas of uncertainty. Firstly, there are similar-sounding terms described in the introduction that are easily confounded, and while they apply to similar concepts, they differ slightly in their approach and targets. Understanding the definitions of these terms is vitally important. Furthermore, unification, standardization, and rearrangement of these terms by the authorities are also needed to ensure they are easily understood.It remains to be seen whether it is actually possible to control blood pressure effectively in patients with active bleeding, where the physiological response attempts to maintain perfusion volume by secreting catecholamines that increase the cardiac output and induce vasoconstriction. In two clinical trials , 27 and The important factor may be the volume of fluid administered as a result of targeting low blood pressure. The strategy of restricted/controlled resuscitation may be more appropriate than that of permissive hypotension/hypotensive resuscitation. In addition, appropriate interventions, devices, and biomarkers for assessing tissue perfusion and ischemic risk do not currently exist, and this presents a difficulty in balancing tissue perfusion with the risk of adverse events in fluid resuscitation. The development of these devices and biomarkers is desired. Moreover, attention should be also paid to factors such as age, mechanism of injury (penetrating or blunt), and severity of injury, with or without the presence hypotension and controlled bleeding, as well as the setting in which trauma is attended to . Permissive hypotension/hypotensive resuscitation may need to be used carefully in elderly patients and patients with chronic hypertension .At present, the effectiveness of permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation has not yet been completely proven. With regard to the resuscitating trauma patients in each study, consideration should be given to age, mechanism and severity of injury, presence or absence of shock, and whether treatment occurred at a pre-hospital or in-hospital setting. It needs to be elucidated what subsets of patients will be most likely to benefit from permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation. The impact of fluid resuscitation on coagulation also needs to be clarified. Achieving a balance between organ perfusion and hemostasis is critical when instituting fluid resuscitation in patients with severe trauma. It is hoped that further research will uncover optimal fluid resuscitation strategies for trauma patients.


Devil Facial Tumour Disease (DFTD) is an emerging infectious disease that provides an excellent example of how diagnostic techniques improve as disease-specific knowledge is generated. DFTD manifests as tumour masses on the faces of Tasmanian devils, first noticed in 1996. As DFTD became more prevalent among devils, karyotyping of the lesions and their devil hosts demonstrated that DFTD was a transmissible cancer. The subsequent routine diagnosis relied on microscopy and histology to characterise the facial lesions as cancer cells. Combined with immunohistochemistry, these techniques characterised the devil facial tumours as sarcomas of neuroectodermal origin. More sophisticated molecular methods identified the origin of DFTD as a Schwann cell, leading to the Schwann cell-specific protein periaxin to discriminate DFTD from other facial lesions. After the discovery of a second facial cancer (DFT2), cytogenetics and the absence of periaxin expression confirmed the independence of the new cancer from DFT1 . Molecular studies of the two DFTDs led to the development of a PCR assay to differentially diagnose the cancers. Proteomics and transcriptomic studies identified different cell phenotypes among the two DFTD cell lines. Phenotypic differences were also reflected in proteomics studies of extracellular vesicles (EVs), which yielded an early diagnostic marker that could detect DFTD in its latent stage from serum samples. A mesenchymal marker was also identified that could serve as a serum-based differential diagnostic. The emergence of two transmissible cancers in one species has provided an ideal opportunity to better understand transmissible cancers, demonstrating how fundamental research can be translated into applicable and routine diagnostic techniques. During their training, medical students are taught the importance of extracting an accurate patient’s clinical history. The history will reveal valuable clues to a skilled medical practitioner that will inform a potential diagnosis, and the appropriate laboratory tests will confirm the diagnosis. This process is particularly relevant to diagnosing infectious diseases and cancer, as a prompt and accurate diagnosis relies on the correct laboratory test. Veterinary practitioners do not have the luxury of questioning their “patient” and rely on observational skills. However, confirmational diagnosis often relies on the results from multiple laboratory tests.The laboratory identification of infectious diseases and cancer can range from basic to complex procedures. For infectious diseases, microscopy is relatively basic and can be used to directly visualise a stained specimen  for the presence of microorganisms. More complex procedures include the extraction of genetic material, which can be analysed by molecular techniques such as polymerase chain reaction (PCR) and sequencing. PCR requires knowledge of the target organism, whereas sequencing DNA involves bioinformatic analyses but does not require prior knowledge of the microorganism. Less complex procedures include serology, which can indirectly determine the presence of microorganisms based on the antibodies produced by the host in response to the infection.Physical examinations, familial cancer history and imaging techniques  are often the initial procedures used when diagnosing cancer in humans. Laboratory identification and/or confirmation usually requires a biopsy that can be stained in a pathology laboratory. An experienced pathologist will use microscopy to identify the nature of the cancer cells. Biomarkers primarily in the blood  but occasionally in the urine  or in the cerebrospinal fluid  can assist in diagnosis and monitoring. Molecular tests such as PCR, chromosomal analysis, fluorescent in situ hybridisation (FISH) and genetic sequencing provide additional diagnostic data. It should be noted that no single test is sufficient for a reliable diagnosis. An accurate cancer diagnosis is often a complex procedure that involves a range of different diagnostic techniques.Cancer can be suspected in domestic animals based on the owner providing clues  and a veterinarian providing a physical examination. Cancer diagnosis in pets is like a human cancer diagnosis, but it is usually not as elaborate due to economic constraints. The most common are blood tests to identify abnormal cell counts and paraneoplastic syndrome, fine needle aspirates and biopsies to look for abnormal cells and imaging techniques. Advances in cancer genomics have provided a greater understanding of cancer. Initially, a research tool, genomics, identified “one health” similarities between humans and dogs and is gradually being implemented into the cancer diagnosis of dogs . Cancer In 1996, the presence of lesions on the faces of several devils located at wukalina/Mount William National Park in Tasmania’s northeast was noted by a wildlife photographer. Concerns increased as more devils from different areas of Tasmania showed signs of massive tumours, and the devil abundance appeared to be in dramatic decline . It becaImmunohistochemistry, another relatively basic technique that relies on antibody binding to detect specific cells, was used to further diagnose the nature of these unusual tumours. There were no reagents specific for Tasmanian devils available commercially; therefore, a range of antibodies was screened for cross-reactivity with Tasmanian devil tissues. Fortunately, there was sufficient cross-reactivity to produce a refined diagnosis of “undifferentiated, sub-epithelial sarcoma of neuroectodermal origin” . This diLaboratory techniques, such as immunohistochemistry of suspected cancer tissue, led to an accurate identification of DFTD. Of the multiple neuroectodermal markers identified in DFTD, we found that periaxin was consistently expressed by DFTD cells . AlthougChromosomal changes can be associated with many cancers, and a basic karyotype can detect relatively gross changes . Given the specialised nature of this technique and application for limited diseases, karyotyping samples from animals is rare. One notable exception is DFTD, as karyotyping provided the initial evidence that DFTD was a transmissible cancer . ConfirmAn extension of karyotyping is “chromosome painting”, whereby the DNA on individual chromosomes can be fluorescently labelled, each chromosome a different colour. Chromosome painting is particularly useful for identifying chromosomal rearrangements unique to specific cancers, DFTD being one example. The chromosome painting on DFTD tumour strains determined the origins of marker chromosomes and rearrangements of DFTD karyotypes . Using sIn 2016, we published the description of a second transmissible DFTD cancer . With chDFT2 tumours also presented evidence of allograft transmission and clonality, being karyotypically and genetically different from both DFT1 tumours and their host. DFT2 karyotypes exhibited identical complex structural abnormalities  13]. Wh. Wh13]. All DFTD tumours are tentatively diagnosed by the appearance of macroscopic tumours, but the differentiation between DFT1 and DFT2 provides a diagnostic challenge. Once a tumour biopsy or a fine needle aspiration sample is collected, multiple complementary laboratory techniques are required to confirm DFTD and to differentiate between DFT1 and DFT2. Histopathology demonstrated that DFT1 tumours are composed of pleomorphic round cells with a high central nucleus and indistinct cell borders, arranged in bundles or nests and surrounded by a thin fibrous pseudocapsule . In contThe unprecedented discovery of two transmissible cancers in Tasmanian devils prompted studies into their genesis. DFT1 and DFT2 were originally classified as neuroectodermal cancers due to their high expression of tissue markers such as vimentin, neural-specific enolase and S100 ,16. FurtThe identification of DFT2 as a Schwann cell cancer was initially surprising due to the low expression of myelin-specific proteins such as periaxin by this cancer . HoweverThe contrasting phenotypic states of DFT1 and DFT2 could potentially be harnessed to distinguish the cancers. We proposed that detection of the Schwann cell lineage marker SOX10 be included in immunohistochemistry protocols with periaxin detection to diagnose and distinguish DFT1 and DFT2 . AlternaThe gold standard method to diagnose different types of cancers is based on solid (tumour) biopsies, which can be highly invasive and potentially increase the risks of haemorrhage and metastasis, hampering serial monitoring ,29. FurtConsidering the promise that EVs offer to discover cancer biomarkers, they have recently been explored in the DFTD system. In our experience, we found that cultured DFT2 cells released EVs in significantly greater numbers than cultured DFT1 cells . These DBlood tests have been routinely used to assist in the diagnosis of cancer. An example from human medicine is the early detection of pancreatic cancer by detecting the CA19-9 biomarkers in fluids, such as blood . ProstatOne of the main advantages of serum tests is the potential to detect cancer at the early stages . The anaThe CATH3 biomarker has several advantageous characteristics for clinical use as an early DFTD diagnostic test. Firstly, it can be measured in EVs isolated from small amounts of frozen serum, which is readily and routinely collected from wild devils; thus, a test based on the biomarker would be widely applicable. Secondly, a high diagnostic power can be achieved from a single protein rather than a multi-biomarker panel, conferring clinical practicality. Simultaneously achieving early cancer detection sensitivity and specificity levels on par with these results is uncommon with a single protein biomarker described in clinical studies ,47,48,49Implementing a preclinical biomarker into a diagnostic test to detect latent stages of DFTD would immediately aid conservation actions to preserve Tasmanian devils in the wild. Firstly, it will ensure that only healthy wild devils will be introduced into insurance populations. By pre-screening latent infected animals, the cost of maintaining devils in quarantine can be significantly reduced, which is currently required for at least 15 months . Secondly, it will improve the capacity of ongoing monitoring programs that are critical for early warning and management responses and underpin research on the epidemiology and evolutionary dynamics of this unique disease system. A three-to-six-month advantage in identifying new outbreaks will improve the capacity to respond appropriately. Finally, early detection of DFTD is critical for the effective implementation of any potential vaccination or other therapeutic intervention in the future .Each omics approach has intrinsic strengths and weaknesses. Mass spectrometry-based proteomics can detect and quantify changes in the abundance of several thousand proteins but cannot (yet) approach the sampling depth of transcriptomics by mRNA-seq. Conversely, an altered gene expression manifested at the mRNA level does not necessarily predict changes at the level of protein function, particularly toward the lower range of protein abundance . WorkfloMulti-omics datasets can represent the flow of biological information from the genomic to proteomic levels, including post-translational modifications and the flux of metabolic end products. Although the integration of disparate multi-omics datasets may seem like a daunting challenge, it can yield a holistic understanding of a biological system. Research into the origin and methods to identify DFTD has led to a greater understanding of the disease process of transmissible cancers. A translation of the research techniques has led to improvements in the diagnostic tests and the potential to develop valuable techniques for preclinical or pre-diagnostic testing. Although DFTD is a rare transmissible cancer, the knowledge gained has implications for other species, including humans. The development of rationally designed immunohistochemistry panels using cross-reactive antibodies, initially developed for the studies of human cancer, may enhance veterinary/wildlife cancer identification. Furthermore, advanced molecular techniques such as RNA-seq and proteomics may provide additional insight into disease processes and origins, and the application of EV proteomics could be applied more generally for the early diagnosis of human and veterinary/wildlife tumours.


Epigenetic changes can influence chromatin structure and, in turn, the accessibility of genetic information as well as the stability of the whole genome. As a result, epigenetic modifications are important to many biological processes, and disruption of epigenetic configuration can lead to developmental abnormalities in plants and mammals, such as failure in tomato fruit ripening  methyltransferase, resulted in increased levels of reactive oxygen species and impaired proliferation of mouse spermatogonial stem cells.On one hand, cellular processes with important functions can be mediated by epigenetic modifications at the transcriptional level. For instance, Arabidopsis thaliana due to lowered levels of DNA methylation and histone H3K9 dimethylation , suggesting a novel connection between the DRD1-dependent dopaminergic system and epigenetic regulation. In Arabidopsis thaliana, Zhu et al. observed genome hypomethylation caused by chemical inhibition of the target of rapamycin (TOR), thereby pointing to a connection between epigenetic regulation and this evolutionarily conserved master regulator, which integrates multiple cellular processes to promote growth in all eukaryotes (Dobrenel et al., Ye et al., the transcription factor ZNF143, which shows higher expression in cancer cells than normal cells, connects promoters to distal regulatory elements and thereby mediates chromatin looping.On the other hand, epigenetic features can be affected by other important biological processes. Certain cellular processes are inherently required for epigenetic modifications, especially DNA methylation and histone post-transcriptional modifications, which are enzymatic processes that involve not only the chromatin but also donor molecules for the modifications. For instance, disruptions in the folate biosynthesis pathway impair the supply of methyl groups for DNA methylation and for histone methylation, resulting in transcriptional desilencing at certain genomic loci in 6-methyladenosine that carries many functions in plants as reviewed by Zheng et al., as well as the newly identified miRNAs that silence an important regulator of apoptosis in the report by Coccia et al. Epigenetic regulation of the chromatin are often closely related to RNA metabolism. As reviewed by Zhang J. et al., a crosstalk exists between epigenetic regulation and alternative RNA processing including alternative splicing and alternative polyadenylation. Apparently, the interplay between epigenetic regulation and certain cellular processes can be bidirectional.Many important biological processes involve RNA metabolism, such as NThe interplay between epigenetic regulation and diverse cellular processes has become increasingly valued over the past few years. While this theme is highlighted by the articles in this Research Topic, the need for a thorough understanding of the epigenetics-connected cellular network continues to urge more discoveries and new insights in this important research area.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Are there differences in reinforcement learning between patients with mood and anxiety disorders and control individuals?In this systematic review and meta-analysis, a novel computational simulation method showed differences in reinforcement learning between patients and control individuals. In particular, patients showed elevated punishment learning rates compared with control individuals.These findings show that patients may be more likely than control individuals to modify their behavior in response to punishments, suggesting a possible mechanistic treatment target for negative affective bias symptoms. This meta-analysis evaluates differences in reinforcement-learning behaviors between patients with depression and anxiety and control individuals. Computational psychiatry studies have investigated how reinforcement learning may be different in individuals with mood and anxiety disorders compared with control individuals, but results are inconsistent.To assess whether there are consistent differences in reinforcement-learning parameters between patients with depression or anxiety and control individuals.reinforcement learning) AND  AND (depression OR anxiety OR mood).Web of Knowledge, PubMed, Embase, and Google Scholar searches were performed between November 15, 2019, and December 6, 2019, and repeated on December 3, 2020, and February 23, 2021, with keywords .A total of 27 articles were included . In the conventional meta-analysis, patients showed lower inverse temperature than control individuals , although no parameters were common across all studies, limiting the ability to infer differences. In the simulation meta-analysis, patients showed greater punishment learning rates  and slightly lower reward learning rates  relative to control individuals. The simulation meta-analysis showed no meaningful difference in inverse temperature between patients and control individuals .The simulation meta-analytic approach introduced in this article for inferring meta-group differences from heterogeneous computational psychiatry studies indicated elevated punishment learning rates in patients compared with control individuals. This difference may promote and uphold negative affective bias symptoms and hence constitute a potential mechanistic treatment target for mood and anxiety disorders. Part of the difficulty in developing and improving treatments is that we have an incomplete understanding of the mechanisms underlying anxiety and depression. However, a growing number of proposed mechanisms of mood and anxiety symptoms have emerged from a field known as computational psychiatry.11Anxiety and depression are major individual and public health burdens.13 This theory situates the computational approach within clinical psychology concepts that date back to the 1960s14 and provides a mechanistic and falsifiable hypothesis for how clinical phenomena like negative affective bias may emerge.The basic premise of computational psychiatry is that variations in how the brain performs computations  may, over time, generate emergent symptoms that are observed in various psychiatric disorders. For example, one theory is that individuals with a higher learning rate for negative stimuli  might learn more from each negative event they experience, producing the negative affective bias that is frequently associated with depressive and anxious disorders.15 and this type of computational model has some notable strengths. Namely, quantities computed by these models may be encoded in the phasic firing of dopamine neurons,16 providing a bridge between brain and behavior.15 Moreover, reinforcement-learning models can accurately mimic highly complex human behaviors.18 Further, there is a large body of evidence20 suggesting that those with depression and anxiety may show differences in processing rewards and/or punishments. Reinforcement-learning models may allow us to better understand this phenomenon.The most common class of computational models tested in this field to date are reinforcement-learning models. Reinforcement learning can be defined as learning to obtain rewards and avoid punishments,23 or reduced reward sensitivity.24 While either of these differences would produce a negative bias toward the processing of punishments rather than rewards, the specifics can actually have considerable implications for how we treat such symptoms. For instance, reduced reward sensitivity in patients would require treatments that focused on how much the individual liked experiencing positive events, while treatments for elevated punishment learning rates would seek to encourage individuals to avoid immediately changing their behavior in response to negative outcomes.We are now at the point where the body of case-control research investigating reinforcement-learning parameters in mood and anxiety disorders is sufficiently extensive that looking for overall patterns is possible. However, findings are varied. For example, different studies have argued that anxiety or depression may be associated with increased punishment learning rates25 hypothesizing that there will be a difference in reinforcement-learning parameters across groups. We first present the results of a conventional meta-analysis. However, this analysis was unsatisfactory for the modeling approaches used in computational psychiatry, as studies use both different tasks and different models to obtain their results.26 Is there a more principled way to combine the effect sizes from different tasks, models, and parameters?The aim of this meta-analysis is therefore to assess consistencies across these reinforcement-learning studies and generate more highly powered estimates of the underlying group differences,To this end, a benefit of the modeling approach is that rather than simply taking a summary statistic over participants, individual-level trial-by-trial data are used to generate a proposed model of the underlying mechanisms. This generative model also provides precise predictions about how each individual’s behavior might generalize outside of the specific reported context. It is therefore possible to invert a reported model and simulate data for participants, even on tasks that they did not perform in the original study. As such, we can simulate performance for participants across studies on standardized benchmarking tasks, removing task inconsistencies across studies. We can then compare parameters across consistent models in our newly standardized data, removing model inconsistencies across studies. This method can increase the generalizability of these parameters, as we obtain model parameter estimates in this common space and use them to meta-analytically estimate parameter differences across groups. Thus, the aim of this article is to leverage the unique advantages of computational modeling to create a novel simulation-based meta-analytic method, which can be used to test the hypothesis that there are case-control differences in reinforcement learning across mood and anxiety disorders.The procedure used in our meta-analysis is summarized below and in Articles were included if they met the following criteria:Human participants.Reported choice data from a cognitive task with monetary or point-based rewards or punishments.Fit reinforcement-learning models to choice data.Used a case-control design comparing control individuals with individuals with mood and/or anxiety disorders.Reported sufficient statistics of all parameters in the models or made individual-level parameters available.MOOSE) reporting guideline  or that they came from 2 separate underlying populations . We performed fixed-effects meta-analyses on the most common parameters for illustrative purposes to allow us to visualize consistency of effect sizes across approaches.50 The total number of participants included was 3085, 1242 of whom were patients with mood and anxiety disorders. A PRISMA diagram and a summary of the studies included, as well as an assessment of study quality, can be found in the eResults in the After a systematic search, 27 articles were included.2) and the approximate proportion of total variability (I2) , including group, study, and task as main effects. Each of these indicated that there was a main effect of group , suggestThere were also effects of study and task. We describe the effect of task further in the eResults in the We examined the effect of group for the parameters that were represented most frequently after bayesian model averaging. Statistics are shown in the eResults in the Here, we report the standardized mean differences for the 4 most highly represented parameters from our simulation meta-analysis using bayesian model averaging, combined using a fixed-effects meta-analysis. Across analysis methods , we saw Subgroup analyses that investigate how these results varied by participant group, and meta-regressions controlling for study quality, year of publication, and parameter-level uncertainty, are in the eResults in the Our conventional meta-analysis suggested the only difference in reinforcement-learning parameters between patients and control individuals was in inverse temperature, with patients showing lower inverse temperature. However, the limitations of conventional methods when applied to computational modeling research were apparent: many articles did not have parameters in common. Using our novel meta-analytic method to estimate parameters for all articles across consistent task space and model space, we found meaningfully higher punishment learning rates and slightly lower reward learning rates in patients than in control individuals. This was seen alongside negligible group differences in inverse temperature.The primary finding from our simulation meta-analysis was that those with mood and anxiety disorders showed a different balance between reward and punishment learning rates compared with control participants. Specifically, patients updated their learned values meaningfully more than control individuals after receiving a punishment and slightly less than control individuals after receiving a reward outcome. This association with learning rates was not apparent in our conventional meta-analysis; however, only half (14 of 27) of the original studies included the parameters (separate reward and punishment learning rates) that we required to test this using conventional methods. This highlights a key strength of our new simulation approach, as we were able to test for differences in these parameters across all studies.51 which propose that depression is associated with reduced reward sensitivity  and that anxiety is associated with increased punishment sensitivity .The second key finding is that we did not observe any robust evidence of meaningful differences in inverse temperature or outcome sensitivity across patients and control individuals using our novel simulation method. It is worth bearing in mind that these parameters incorporate noisiness, participant exploration, and sensitivity to outcomes and thus are perhaps not pure estimations of either choice stochasticity or outcome sensitivity. This null finding is also made unclear by the poorer recovery of sensitivity effect sizes using our pipeline  may be effective through preventing the individual from performing their habitual behavioral responses to a negative outcome, rather than by tuning down their aversive response  to the exposure .Furthermore, the results we have presented may be relevant to how clinicians target cognitive interventions. Rather than encouraging individuals with depression or anxiety to downweigh the subjective experience of negative outcomes or to sit with and tolerate resulting distress ,57 Notably, the learning rate may be an emergent property of neuromodulators, and in particular catecholamines, such as dopamine and noradrenaline.59 This has implications for drug interventions for depression and anxiety: if the balance of catecholamines modulates learning rates, pharmacological agents that affect learning rates may be of benefit to patients. Much previous work has focused on neuromodulators in depression and anxiety, following articulation of the monoamine hypothesis in the 1960s.62 Indeed, many of the first-line treatments for these disorders are selective serotonin reuptake inhibitors,64 which are associated with both serotonin and dopamine.65 However, many of these agents were discovered serendipitously, and the mechanisms by which they act on mood and anxiety symptoms are still unclear.66 As a result, there are few intermediate end points that have been validated for use in drug discovery. The results of this meta-analysis may point to a genuine intermediate end point: learning rates. In particular, individualized measures of learning rate balance could be obtained using straightforward behavioral tasks, thus allowing dose personalization and early indications of drug efficacy for individuals. This end point is also translationally valuable, as learning rates can also be measured in animals, potentially allowing preclinical drug discovery work.67 This meta-analysis therefore provides a possible first step toward connecting different levels of analysis in mental health research, from behavioral symptoms to the underlying neurobiology and pharmacology.One of the strengths of reinforcement-learning models is that key quantities  predicted by these models are thought to be reflected by neural activity.26 We relied on this assumption for our conventional meta-analysis, although for our simulation meta-analysis we only required that parameters generalized across tasks and samples. Specifically, we assumed that it was possible to use a model that captured behavior on one task to simulate behavior on another. It is unlikely, however, that this is straightforwardly possible,26 which is reflected in the consistent effect of study we found on all parameter values. Particularly concerning is recent empirical evidence suggesting that parameters may not be stable within individuals either over time68 or across different tasks.69 In addition, parameters may not be stable even within a task; learning rates are known to adjust with the volatility of the environment,71 which also changes between tasks, along with other variables . Furthermore, parameters defined for different tasks with different underlying statistics may play different roles in new tasks. Understanding how the parameters derived from one task relate to another—perhaps by establishing task-specific parameter norms or by testing the same individuals across multiple tasks—will allow stronger inferences about parameters to be drawn in this kind of meta-analytic approach. If parameters from one task do not relate at all to each other, this will be a serious issue for the use of reinforcement-learning models in computational psychiatry. An implicit assumption is that these parameters are representative of underlying generative processes across tasks and are thus more relevant to real-world behavior than summary statistics, such as mean accuracy. Perhaps a more realistic assumption is that parameters do generalize, but imperfectly, between tasks. This can be observed in related families of models, such as drift diffusion models, the parameters of which do mostly generalize across tasks,72 including in clinical populations.73 It is nevertheless promising that we were able to observe consistent parameter effect sizes across different analytic methods despite this substantial source of noise.This study has several limitations. A core assumption of the field of computational psychiatry is that parameters and models generalize across tasks, samples, and model parameterizations .74 that are often observed clinically. Future work might therefore measure general executive function alongside reinforcement learning to disentangle the contribution of learning-specific associations from overall cognitive function.76 However, the conventional meta-analysis was also limited by the lack of commonality across parameters, reducing the amount of usable data, and by lack of generalizability across task space and model space, which was the motivation behind the development of our novel method. Future work will be needed to fully assess and compare the conventional method with our novel one  and gain a mechanistic insight into how psychological therapy may work.


The survival factor renalase (RNLS) is a recently discovered secretory protein with potent prosurvival and anti-inflammatory effects. Several evolutionarily conserved RNLS domains are critical to its function. These include a 20 aa site that encodes for its prosurvival effects. Its prosurvival effects are shown in GI disease models including acute cerulein pancreatitis. In rodent models of pancreatic cancer and human cancer tissues, increased RNLS expression promotes cancer cell survival but shortens life expectancy. This 37 kD protein can regulate cell signaling as an extracellular molecule and probably also at intracellular sites. Extracellular RNLS signals through a specific plasma membrane calcium export transporter; this interaction appears most relevant to acute injury and cancer. Preliminary studies using RNLS agonists and antagonists, as well as various preclinical disease models, suggest that the immunologic and prosurvival effects of RNLS will be relevant to diverse pathologies that include acute organ injuries and select cancers. Future studies should define the roles of RNLS in intestinal diseases, characterizing the RNLS-activated pathways linked to cell survival and developing therapeutic agents that can increase or decrease RNLS in relevant clinical settings. Renalase (RNLS) was first identified through the Mammalian Gene Collection Project . Early wInitial studies of RNLS function examined whether it could reduce the effects of CRF using a murine model of acute kidney injury (AKI) that was treated with exogenous recombinant RNLS (rRNLS) . The rRNMurine models of acute pancreatitis, using both isolated cells and in vivo preparations and treatments with cholecystokinin orthologue, cerulein, are often used for preclinical studies . In the Subsequent studies by others have suggested that RNLS may have a role in mediating other forms of gastrointestinal injury. RNLS was shown to reduce oxidative liver injury in cellular and an in vivo murine model of ischemia/reperfusion injury that was superimposed on models of fatty liver disease . SimilarThe prominent prosurvival effects of RNLS on multiple cell types raised the possibility that it might have a similar role in cancer. RNLS mRNA levels were increased in PDAC and melanoma and other cancers. Our first study examined a potential role for RNLS in pancreatic cancer (PDAC) using human tissues, cultured cells, and a murine model . TissuesCollectively, these models of acute injury and cancer show prosurvival roles for RNLS. Depending on the disease context, RNLS could either be of benefit (in acute injury) or detriment (in cancer) to the organism.The biologic activities have been examined by using sequence homology analysis and studies specific regions of the RNLS protein. Most relevant to this review, its cell growth and anti-inflammatory activities are found in a 20 amino acid peptide (aa 220 to 239 of human RNLS), which is referred to as the RP-220 peptide . The criTogether, these studies provided compelling evidence of key regulatory roles for RNLS as a prosurvival factor and modulatory of inflammatory responses in preclinical models of acute tissue injury as well as in cancer. To understand RNLS’s mechanism and as a critical step in developing agents that could modify or mimic its biologic activities, we have begun to study its structure and complex effects on cells including its links to distinct intracellular signals. This will be the subject of the remainder of this review.The human RNLS (hRNLS) gene contains approximately 300,000 nucleotides across 11 exons and is located on chromosome 10 . Two majIn contrast to the two RNLS isoforms expressed in humans, only one form is found in murine tissues; the murine form is most similar to human RNLS1 (hRNLS). hRNLS1 and hRNLS2 only differ in their C-terminal domains, and the key functional domains are conserved between the isoforms . This inSoon after the discovery of RNLS in 2005, investigations into the evolutionary history of the protein yielded surprising findings. One study of cyanobacteria-originated metazoan/fungi proteins (COPs) developed a hypothesis that RNLS originated from nuclear-localized plastid-like DNA (nupDNA) fragments from cyanobacteria . This stPan troglodytes (chimpanzee) and Rattus norvegicus (rat). The RNLS N-terminus is thought to be necessary for FAD-binding and some of the oxidase activity of RNLS . Th. Th12]. Some of the same signaling pathways activated by RNLS and RP-220 have also been linked to PMCA4b signaling. These include the Ras/Raf/MEK/ERK, p38, NOS, NF-κB, cAMP, and AKT pathways ,53,54,552+ levels to NO production and other cells signals [PMCA4b has a PDZ domain, a protein motif that often links transmembrane proteins or proteins that concentrate near membranes. In the case of PMCA4b, it can link the calcium exporter to other signaling pathways . For exa signals  More rec signals . This vaThe PMCA4b PDZ domain appears to enable the membrane protein GPER (G-protein estrogen receptor) to be coupled in a regulatory manner to PMCA4b through the linker protein, PSD95 (post-synaptic density 95). Activation of GPER by estradiol results in the tyrosine phosphorylation of PMCA4b and downregulation of its calcium-export activity ,67. ThisThough discovered and primarily studied in the kidney, RNLS gene expression can be found in virtually every organ including those of the gastrointestinal tract. Our preliminary studies have also detected RNLS in select gastrointestinal tissues using immunocytochemistry. For example, we used the m28 antibody to detect immunoreactivity protocol  in colonThere is growing evidence that immune cells are an important target for RNLS signaling ,71,72. MIn a study in the liver, a marker of mature macrophages, Adgre1, was found to be significantly higher in RNLS KO mice during the progression of nonalcoholic steatohepatitis (NASH). It is suggested that this hepatocyte dysfunction and hepatic fibrosis progression could be connected to the absence of RNLS. Additionally, the absence of RNLS may cause an increase in oxidative stress and bring on macrophage infiltration in these tissues .As discussed in It has been established that RNLS has a potent prosurvival role in several different systems. The distinct enzymatic and signaling properties of RNLS have potentially profound effects on injury and recovery. Since RNLS is abundantly found in many non-diseased tissues, it seems certain that it will also have a role in tissue homeostasis. That tissue RNLS levels can be modified by environmental factors such as a high-fat diet suggests such changes could modify injury responses. The RNLS properties that modulate acute injury responses likely have key roles in the malignant behavior of some cancers. Although direct effects of RNLS on parenchymal cells  and cancer cells (pancreatic and melanoma) have been observed, it is likely that RNLS acts on other cell types that modulate disease responses. Thus, though the immunologic effects of RNLS are still being described, they likely have a role in modulating injury responses and establishing and maintaining tumor niches.Our studies of RNLS as a potential therapeutic tool for use in the treatment of acute injury as well in select cancers have focused on the extracellular RNLS pool. Delivery of intact RNLS has been shown to decrease the severity of a range of acute injuries. RNLS inhibition using a specific monoclonal antibody has been shown to reduce the growth of select cancers. Although these findings represent attractive avenues to therapy, a more refined understanding of RNLS function may allow for the creation of more effective and specific therapeutic tools. This includes understanding details of the RNLS signaling pathways and structure–function relationships of the molecule.In closing, RNLS is a multi-functional protein with activities that are broadly important for maintaining tissue homeostasis and for resolving acute tissue injury. It is also a driver for select cancers. Developing agents that are RNLS agonists or antagonists might have broad therapeutic applications.