Pulmonary vein thromboses (PVT) is a complication of lung malignancy and can be complicated by arterial embolic phenomenon. Patient is a 69-year-old female with a history of coronary artery disease and recent pneumonia seen on chest x-ray who presented with progressive headache, left arm numbness and abdominal pain. She was found to have numerous bilateral strokes, bilateral renal infarction and splenic infarction. CT Chest showed a right upper lobe mass compressing the pulmonary veins with filling defects concerning for thrombus. Diagnosis of PVT is made with CT angiogram, echocardiogram and MRI. Treatment consists of anticoagulation and treatment of underlying factors. Pulmonary vein thromboses (PVT) is a described complication of lung malignancy , lung re2Patient is a 69-year-old female with history of coronary artery disease, ulcerative colitis, hypothyroidism, hyperlipidemia and recent pneumonia seen on chest x-ray who presented with progressively worsening headache, transient left arm numbness and abdominal pain. CT head was negative for acute hemorrhage. National Institute of Health Stroke Scale was 1. Neurology was consulted who recommended MRI brain. MRI showed multifocal acute and subacute infarcts in the supratentorial and infratentorial brain; in the bilateral frontal parietal cortical regions; occipital temporal regions; right thalamus and bilateral cerebellum. CT abdomen and pelvis showed bilateral renal infarctions and numerous splenic infarctions. The morning after admission the patient developed acute onset facial droop and slurred speech. CT head showed subacute right middle cerebral artery (MCA) and bilateral posterior cerebral artery (PCA) infarcts without hemorrhage, herniation or mass-effect/midline shift. CT angiogram of the neck was negative for any acute narrowing or aneurysm. CT perfusion showed a moderate sized area of ischemia in the left occipital and right temporal occipital lobes with large surrounding penumbra. CT angiogram of the head showed interval development of two noncalcified, soft thrombi located in the right MCA bifurcation and left MCA. Patient was taken for mechanical thrombectomy of the left MCA with good angiographic results with Thrombolysis in Cerebral Infarction score of 2c. Patient had worsening neurological exam overnight with increased somnolence which prompted repeat imaging. CT head overnight showed subacute right MCA/PCA, left MCA and left cerebellar infarctions, increasing edema with a 2 mm midline shift, no signs of herniation and subarachnoid hemorrhage. Transthoracic echocardiogram was negative for left atrial or left ventricular thrombus. CT Chest showed large right upper lobe mass with associated mediastinal and right hilar lymphadenopathy. The mass was compressing the pulmonary veins with filling defects concerning for thrombus. Due to the extensive stroke burden the patient was unable to receive systemic anticoagulation and the patient was transitioned to comfort measures. Transesophageal echocardiogram, biopsy of the mass and thrombophilia workup were deferred because of the family's decision to transition to hospice care.3PVT can be an unfortunate complication of malignancy, especially pulmonary malignancy. The case demonstrates a large right upper lobe lung mass compressing the pulmonary veins. External compression likely caused stasis and coupled with a hypercoagulable state in the setting of malignancy led to the development of pulmonary vein thrombosis. Subsequent thromboembolic phenomena led to diffuse infarction in multiple organ systems. Due to the acuity of the patient's symptoms and clinical deterioration, the gold standard imaging tests were unable to be obtained. Diagnosis can be challenging but detection of PVT is increasing with improvements in imaging technique. Typically, a combination of imaging techniques are used to best diagnose PVT. CT scan with IV contrast with timing for the pulmonary venous system is the best diagnostic technique . Transes-Patients with diffuse arterial emboli should be evaluated for pulmonary vein thrombosis, left atrial thrombus, left ventricular thrombus and systemic shunts-Workup includes CT imaging with timing of contrast to evaluate the pulmonary veins, MRI/MR venogram, transthoracic echocardiogram and transesophageal echocardiogram-Systemic anticoagulation should be initiated when diagnosis is suspected to avoid diffuse arterial embolizationThis work was performed as part of employment under Naples Community Hospital Healthcare System. The authors listed above are all employed within this system.The authors listed above certify that they have no financial or non-financial interest in the subject matter or materials discussed in this manuscript.


Impaired cognitive ability and its misperception contribute to poor decision-making of older adults; yet their impact on health-related decisions is less known. We examined how self-perceived and actual cognition were associated with chronic disease awareness using a nationally representative sample of Chinese older adults. Blood biomarkers data were collected in 2015 to identify participants’ dyslipidemia and diabetes status. Among participants with identified dyslipidemia or diabetes, disease awareness was defined as self-reported diagnosis of the conditions as of 2018. Objective and subjective cognition were respectively assessed using the Mini-Mental State Examination and self-rated memory. The associations of subjective and objective cognition with chronic disease awareness were determined by weighted logistic regressions. Among 4,578 adults aged 60 and older with complete measurements, 1,442 and 759 individuals were identified having dyslipidemia and diabetes, with proportions of disease awareness being 38.0% and 58.1%, respectively. Individuals with mild  or severe cognitive impairment  had lower odds of dyslipidemia awareness; and those with severe cognitive impairment had lower odds of diabetes awareness  than cognitively intact counterparts. However, adjusting for objective cognition, older adults with better subjective cognition had lower odds of dyslipidemia  and diabetes  awareness. Such associations were stronger for individuals with rural status, lower education, or living without children. Our findings highlight the great challenges deteriorated cognitive function and misperception may pose to chronic disease awareness, as well as the importance of targeted supports particularly for those more disadvantaged.


The incidence and societal burden of cancer is increasing globally. Surgery is indicated in the majority of solid tumours, and recent research in the emerging field of onco-anaesthesiology suggests that anaesthetic-analgesic interventions in the perioperative period could potentially influence long-term oncologic outcomes. While prospective, randomised controlled clinical trials are the only research method that can conclusively prove a causal relationship between anaesthetic technique and cancer recurrence, live animal (in vivo) experimental models may more realistically test the biological plausibility of these hypotheses and the mechanisms underpinning them, than limited in vitro modelling. This review outlines the advantages and limitations of available animal models of cancer and how they might be used in perioperative cancer metastasis modelling, including spontaneous or induced tumours, allograft, xenograft, and transgenic tumour models. In 2020, an estimated 18 million cancer cases were newly diagnosed (excluding nonmelanoma skin cancer), accounting for approximately 10 million cancer related deaths ,4.The original hypothesis that the anaesthetic technique during primary cancer resection surgery of curative intent might influence the risk of cancer recurrence or later metastasis was first proposed over a decade ago . This inTo ultimately prove these hypotheses, large prospective randomised-controlled clinical trials are required to establish if a causal relationship exists between anaesthetic techniques and the risk of cancer recurrence following primary cancer surgery. However, pre-clinical laboratory models, primarily in vivo animal models, retain an important role in translational cancer research for several reasons . FirstlyThe emergence of onco-anaesthesiology as a distinct clinical subspecialty has driven the exploration of translational research utilising animal models of cancer, traditionally undertaken by oncology researchers. Therefore, we aimed to summarise animal models of cancer commonly encountered within in vivo translational cancer research and how they may be applied to ongoing research in onco-anaesthesiology.Animal models of cancer may be classified in a variety of ways. Most simply, they are either spontaneous or induced and mammalian or non-mammalian. Alternatively, they may be categorized by the method of inducing cancer occurrence. However, spontaneously occurring cancers may occur in genetically engineered animal strains or such genetic-engineering may be induced following exposure to various carcinogens, so there is some cross-over in these descriptions. Non-mammalian animals such as zebrafish benefit from being high-throughput and low-cost, ideal for molecular investigation and chemical screening studies, however, significant phenotypical differences limit their usefulness for translational research so they will not be discussed further . Table 1A xenograft model  involvesThe advantages of xenograft models are that they are relatively inexpensive when using commercially available cancer cell lines and attractive for translational research due to the ability to mimic cancer cell biological traits and the direct evaluation of therapeutic targets in human derived cancer tissue ,16. HoweAn allograft model  involvesThe main advantage this has over xenograft models is the ability to evaluate the host animal’s cancer-related immune response when assessing the effect of potential therapeutics. Compared to xenografts, allografts produce larger tumours that metastasize more quickly and reliably, enabling consistency when assessing for clinically relevant endpoints . They doThe preservation of the host immune response underpins why these models are often favoured for investigation in onco-anaesthesiology, where immunomodulation by anaesthetic drugs is one of the most frequently proposed mechanisms to explain how differences in perioperative pharmacotherapy may influence cancer outcomes ,25,26 A Testing potential therapeutics on spontaneous cancers that develop in household pets  is an ofTransgenic models  of canceTransgenic cancer models may play a significant role in onco-anaesthesiology research as they allow for testing of drug effects on the onset and progression of an expected cancer in immunocompetent animals, such as what has already been performed with morphine, which had no effect on the onset of cancer development but did hasten cancer progression . HoweverIn conclusion, there are several in vivo animal models of cancer that may be utilized for conducting translational research in onco-anaesthesiology. Whilst xenograft models are attractive for the ability to tailor the cancer cell biology around the human cancer under investigation, a lack of any representative immune response severely hinders its suitability for onco-anaesthesiology research. Transgenic models demonstrate significant promise in providing representative animal cancers and may be used alone or as donors for allogenic models. Multiple transgenic mouse colonies and cancer cell lines are commercially available to enable rapid integration of in vivo mouse models into novel research, however, due care must be taken to ensure the model chosen is most appropriate for the hypothesis under investigation.


The COVID-19 pandemic highlighted the significance of vaccination for older adults (OA), however, more health benefits could be gained with vaccination against influenza, pneumococcal disease, herpes zoster and tetanus as their uptake remains rather low. As healthcare professionals (HCP) play an important role in the vaccination decision making of OA, this study identifies obstacles in vaccination communication between HCP and OA.80 in-depth structured interviews have been conducted with HCPs in Hungary (HU), Italy (IT), the Netherlands (NL) and France (FR). Participants were general practitioners, medical specialists, public health physicians, occupational physicians, pharmacists, geriatricians, specialists elderly care and nurses. The interview included questions on HCPs’ perceptions regarding information provision to OA on vaccines. Data were analyzed cross-country, using thematic analysis.Preliminary results reveal that a factor hindering HCPs to initiate conversations with OA on vaccines was lack of time . In hospitals this was often due to (acute) clinical problems taking precedence over discussing vaccines . In ambulatory settings the high number of patients waiting to be seen prevented discussing vaccines with OA (HU). Moreover, HCPs sometimes forgot to discuss vaccines with OA . Patient factors hindering the conversation of HCPs on OA vaccines were a negative attitude  and lack of understanding the information provided . Also, misinformation on vaccines , as well as anti-vax beliefs from patients (NL) or their relatives  hampered the conversation on vaccines. HCPs mentioned their need to learn communication skills to convince OA on vaccines .HCPs encounter various obstacles in communicating with OA about vaccines. Lack of time and not recognizing the opportunity to discuss vaccines are important barriers for initiating vaccine conversations.• Providing HCPs with communication strategies is important to support HCPs in discussing vaccines with OA.• Reminder systems are important to help HCPs remember address vaccination.


Many of the competencies that trainees in psychiatry are required to achieve can be linked to leadership in the broadest sense, yet specific training is not often systematically provided. The West Midlands Psychiatry Leadership Development Programme aims to support the acquisition of important leadership skills already set out in the curriculum through provision of high-quality specialist leadership content within the existing programme. Here we present the findings of a scoping exercise exploring the views and attitudes towards leadership training held by higher trainees in psychiatry within the West Midlands.All psychiatry higher trainees within West Midlands Deanery were invited to complete an anonymous online survey using Survey Monkey in November 2021. This survey incorporated questions about their preferred learning styles, confidence in their leadership skills and barriers to accessing leadership opportunities, generating both quantitative and qualitative data.37 responses were received. All subspeciality training programmes were represented. Almost half of respondents (46%) were ST6 or above and most were in training full time (84%).Trainees expressed a preference for experiential learning about leadership (87%) as well as small group teaching (62%) and interactive workshop style content (62%).Awareness of leadership opportunities was typically via their peer group (81%) or clinical supervisor (60%). Only 52% of trainees were aware of leadership opportunities within the Deanery.Only 54% felt that existing leadership training met their curriculum requirements. Less than half of trainees (46%) felt confident to evidence their leadership experience within their training portfolio.One-fifth of trainees (21%) reported experiencing barriers to leadership development. These included: inadequate awareness of opportunities, lack of senior support, time constraints and difficulty matching interests with available opportunities.Key results included:Trainees expressed interest in the redevelopment of a regional leadership training programme which would support them to achieve their curriculum competencies and prepare them for life as a consultant psychiatrist. The new multi-faceted regional leadership programme will offer resources in a variety of formats including webinars, podcasts, optional interactive workshops and action learning sets. It is hoped that this flexible programme, linked to the Medical Leadership Competency Framework, will better meet the needs of higher trainees as they pursue their own personal leadership journeys.


Previous studies have found relatively good physical health in doctors, whereas several studies now report relatively high levels of stress and burnout among them. With the exception of higher suicide rates, we have less evidence of poorer mental health among doctors than among other professionals. The elevated suicide rate may represent the tip of an iceberg of frustration and inadequate mental health care among medical doctors. There are very few longitudinal studies that can identify possible risk factors and causality. The Longitudinal Study of Norwegian Medical Students and Doctors (NORDOC) has since 1993/94 followed repeatedly two cohorts of medical students (N=1052) in seven waves during 25 years (Facebook: @docsinrush). Outcomes presented here are on mental health, burnout and problematic drinking. There are two main hypotheses with regard to possible risk factors. First, it may be due to individual factors such as personality traits, past mental health problems etc. Second, contextual stress may influence mental health among doctors, whether this be unhealthy working conditions or negative life events (i.e. stress outside of work). The presentation will give and overview of both individual and work-related predictors of stress and mental health problems among Norwegian physicians. Individual and organizational interventions to reduce stress and physician burnout will also be dealt with.No significant relationships.


Evidence suggests that besides having stigmatizing misconceptions towards people with mental illness, medical students and doctors often resist seeking help for their own mental issues. This is a vulnerable group for stress and other mental health problems, due not only to professional burden but also high perfectionism and low self-compassion.To analyse the relationship between mental health stigma (MHS) and other variables related to personality and emotional states in a sample of medical students.634 medicine and dentistry students  answered to a survey including sociodemographic data, self-perception of psychological health/SPPH and the Portuguese validated versions of: Link’s Perceived Discrimination and Devaluation (PDD) scale to assess MHS and its two dimensions - social stigma/SocS and self-stigma/SelS; Depression Anxiety Stress Scale (DASS-21); Neff’s Self-Compassion Scale (SCS); and Big Three Perfectionism Scale (BTPS). Correlations, t-student tests and linear regressions were performed with SPSS 27.0.Stigma correlated negatively to SPPH and positively to DASS, the negative poles of SCS  and BTPS second-order factors . No gender differences in MHS were observed. Participants with higher mean levels of total and SelS had significantly higher scores in all DASS dimensions and lower SPPH; participants with higher SocS also scored higher in DASS, but didn’t reveal lower SPPH. Isolation was a significant predictor of SocS ; isolation and narcissistic perfectionism were significant predictors of SelS .Our results highlight the importance of including MHS as a main need in the curricula of future doctors.No significant relationships.


Mental disorders, such as depression, anxiety, and autism, have become one of the leading causes of disability worldwide with a high lifetime prevalence. Individuals with these disorders exhibit marked social and cognitive impairments, which are often closely associated with brain alterations both structurally and functionally. However, success rates of pharmacological and behavioral interventions vary widely and affected individuals often suffer from residual symptoms. Further, some of these interventions are characterized by severe side effects and induce high drop-out rates. Therefore, innovative brain modulation approaches that can directly target and regulate the involved brain circuits are of great translational potential for these disorders.Kerr et al. explored an innovative dyadic rt-fMRI NF protocol in which mothers attempted to down-regulate the anterior insula activity of their children. Based on an independent support vector machine-based classifier, Pereira et al. trained patients with depression to match their own neural activity with the neural activity corresponding to the “happiness emotional brain state” of a healthy participant via rt-fMRI NF training and found improvement in clinical symptoms associated with training success. Orth et al. conducted a systematic review of rt-fMRI NF studies targeting brain activations within the frontostriatal circuitry given that it is a common target for the treatment of aberrant behaviors in various psychiatric and neurological disorders. Their overview emphasizes the relevance to address network connectivity rather than localized excitability only.Our Research Topic aimed to improve our understanding of how innovative brain modulation approaches affect human behavior and neural responses and provide an overview on recent progress in the field. The articles that were published in this Research Topic bring us new insight on how brain modulation approaches such as real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback (NF) training, transcranial magnetic stimulation (TMS), and transcranial direct current stimulation (tDCS) can be applied to modify emotion regulation and brain activity/connectivity in healthy or clinical populations. More specifically, in a proof-of-concept study on emotion regulation Cheng et al. investigated the asymmetric role of the bilateral ventrolateral prefrontal cortex (VLPFC) in cognitive reappraisal and found that while the left VLPFC is responsible for the semantic process of generating and selecting appraisal strategies based on the goal of emotion regulation, the right VLPFC is mainly involved in inhibiting inappropriate negative emotions and thoughts. Huang et al. demonstrated that a 4-week intervention of high-frequency repeated TMS on the left dorsolateral prefrontal cortex (lDLPFC) decreased the temporal variability of resting-state functional connectivity (rsFC) in the cortico-thalamo-cerebellar circuit (CTCC), with higher alteration in rsFC temporal variability between the left DLPFC and right posterior parietal thalamus predicting a higher remission ratio of negative symptom severity. Importantly, in the support vector regression analysis the pattern of rsFC temporary variability within the CTCC predicted the efficacy of high-frequency rTMS intervention on negative symptoms of schizophrenia. By combining tDCS with TMS, Alkhasli et al. revealed that excitatory intermittent theta-burst (iTBS) to a tDCS-inhibited lDLPFC yielded more robust functional connectivity to various areas as compared to excitatory iTBS to a tDCS-enhanced DLPFC. This suggests feasibility of using tDCS to modulate subsequent TMS effects on the DLPFC which may be of translational potential for the treatment of depression. In addition to these direct brain modulation approaches, Wang et al. demonstrated that open motor skill training (table tennis experts vs. matched non-experts) may be associated with greater activation in brain regions involved in visual processing during language processing tasks (word and semantic judgement tasks). These findings bridge the complex interplay between short- and long-term neuromodulation and behavioral training effects.Using the online single-pulse TMS technique, In conclusion, studies in the Research Topic applied highly innovative approaches to modulate human brain functions in healthy or clinical populations, with some of them reporting promising improvement in clinical symptom severity. We believe findings from these studies does not only improve our understanding of neural mechanisms underlying these brain modulation approaches, but also inspire future studies aiming to translate neuromodulatory approaches from different disciplines into clinical applications.SY and KM drafted the manuscript. JZ and XZ critically revised the manuscript. All authors contributed to the article and approved the submitted version.


Evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous and persons of color. Yet, little is known about mechanisms for these disparities. This presentation examines the mechanisms for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL disparities across these facilities. The presentation uses data from a 5 year mixed-methods project involving 96 resident interviews; 61 staff interviews; and 614 hours of observations in high proportion BIPOC facilities in MN, coupled with resident clinical Minimum Dataset assessments linked with survey data on residents’ QoL. The findings show significant racial/ethnic disparities in QoL with need for system level changes. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.


The process of matching skeletal muscle blood flow to metabolism is complex and multi-factorial. In response to exercise, increases in cardiac output, perfusion pressure and local vasodilation facilitate an intensity-dependent increase in muscle blood flow. Concomitantly, sympathetic nerve activity directed to both exercising and non-active muscles increases as a function of exercise intensity. Several studies have reported the presence of tonic sympathetic vasoconstriction in the vasculature of exercising muscle at the onset of exercise that persists through prolonged exercise bouts, though it is blunted in an exercise-intensity dependent manner . The collective evidence has resulted in the current dogma that vasoactive molecules released from skeletal muscle, the vascular endothelium, and possibly red blood cells produce local vasodilation, while sympathetic vasoconstriction restrains vasodilation to direct blood flow to the most metabolically active muscles/fibers. Vascular smooth muscle is assumed to integrate a host of vasoactive signals resulting in a precise matching of muscle blood flow to metabolism. Unfortunately, a critical review of the available literature reveals that published studies have largely focused on bulk blood flow and existing experimental approaches with limited ability to reveal the matching of perfusion with metabolism, particularly between and within muscles. This paper will review our current understanding of the regulation of sympathetic vasoconstriction in contracting skeletal muscle and highlight areas where further investigation is necessary. As mentl muscle . Consisteceptors .1-adrenergic receptor agonist, phenylephrine, was only reduced during heavy-intensity exercise, whereas the vascular response to the selective α2-adrenegic receptor agonist, clonidine, was diminished during mild- and heavy-intensity exercise. P2X-receptor responsiveness was attenuated during heavy-intensity exercise, whereas NPY-Y1 receptor responsiveness was blunted across exercise intensities -adrenergic receptors, it is theoretically possible that NE binding to β-adrenergic receptors may oppose SNS mediated vasoconstriction. However, sympathetic vasoconstrictor responsiveness was not augmented following β-adrenergic receptor blockade in male and female rats, indicating that β-adrenergic receptors do not oppose sympathetic vasoconstriction in contracting skeletal muscle or contribute to functional sympatholysis .Collectively, the available data related to changes in receptor responsiveness during exercise suggest that the distribution of post-synaptic receptors between muscles and in different vascular segments combined with muscle recruitment patterns may result in local modulation of vascular resistance that would serve to distribute blood flow between and within muscles and facilitate perfusion to metabolism matching during exercise. However, the definitive study to demonstrate this has not been completed.2 catalyzed by the enzyme NO synthase (NOS), which exists in endothelial (eNOS), neuronal (nNOS), and inducible (iNOS) isoforms . Tetrahydrobiopterin (BH4) is an essential cofactor required for NO production by NOS enzymes (4 administration. A reduced ability to inhibit sympathetic vasoconstriction during muscular contraction has been reported in humans with duchenne muscular dystrophy (The cellular mechanism(s) responsible for a decline in receptor responsiveness during exercise has not been fully elucidated, however the vasoactive molecule nitric oxide (NO) and intravascular adenosine triphosphate (ATP) have been the focus of investigation . NO is p enzymes . eNOS anisoforms . Tetrahy enzymes . Several enzymes . In cont enzymes . Acute uystrophy  and in gystrophy  that do ystrophy .Exercise training has also been used to investigate sympatholysis . In ratsGiven that NOS enzymes are expressed differentially across skeletal muscles , it seem+ channels) does not alter the ability of exogenous ATP to blunt α-adrenergic receptor mediated vasoconstriction , contrast enhanced ultrasound (CEU), and diffuse correlational spectroscopy (DCS/NIRS).NIRS-ICG has been applied to investigation of blood flow in skeletal muscle and the results compare favorably with dye dilution MRI methods during knee extension exercise . The tecContrast enhanced ultrasound requires infusion of microbubbles which are smaller than red blood cells to allow them to pass through the skeletal muscle microcirculation. As described by Diffuse correlational spectroscopy (DCS) is an emerging noninvasive technology that has been applied during exercise by several laboratories . CombiniAn example of how these techniques might be employed would be to apply DCS/NIRS sensors bilaterally to one limb that remains resting and the other limb which performs contractions across a range of exercise intensities. Sympathetic nerve activity could be activated reflexly to both limbs by using lower body negative pressure (LBNP) or cold pressor stimuli. Greater vasoconstriction in inactive skeletal muscle compared to active skeletal muscle would support redistribution of blood flow.The above example suggests an experimental approach to demonstrate redistribution of blood flow between muscles. Finding a method to study redistribution of blood flow within a muscle to more active fibers is more problematic. The fundamental problem is that microvascular units are not precisely aligned with muscle motor units. Constriction of a terminal arteriole reduces perfusion to all the capillaries supplied by that arteriole which means that perfusion cannot be exclusively directed to active muscle fibers or a single fiber type .Although not discussed in this focused review, there is ample evidence that aging, sex, obesity and various disease states modulate sympatholysis and impairments in sympatholysis have functional consequences for exercise performance. Further exploration of the effects of sympatholysis in these populations/conditions is warranted.Our current understanding is that the matching of skeletal muscle blood flow to metabolism involves a complex interplay between local vasodilation and sympathetic vasoconstriction that restrains local vasodilation and directs blood flow to active muscles, while also maintaining total peripheral resistance and blood pressure.The presence of tonic vasoconstriction in inactive tissue and exercising limbs is well established, and some studies have demonstrated that tonic vasoconstriction contributes to the distribution of blood flow within the limb during exercise. Numerous studies in a variety of experimental models have also demonstrated that sympathetic vasoconstriction is blunted in contracting muscle (sympatholysis). While investigators have done outstanding work to characterize the phenomenon of sympatholysis and identify some potential mechanisms involved in the process, direct experimental evidence that sympatholysis is involved in the matching of perfusion to metabolism is lacking.Despite the sound logic that sympatholysis would facilitate the distribution of blood flow between and within muscles during exercise, currently available technology and experimental approaches make the definitive study to demonstrate that sympatholysis contributes to the matching of perfusion to metabolism infeasible in the dynamically exercising animal or human. Until there is new evidence provided, researchers should refrain from speculating that functional sympatholysis can redirect blood flow to active fibers within a muscle.


Invasive hemodynamic assessment of patients with an LVAD may improve readmission rates, but early detection of nonresponders-to-therapy can lead to earlier LVAD therapy and transplant listing.18.See Article page Left ventricular assist devices (LVADs) constitute important advanced therapy for patients with heart failure. Despite improvements in LVAD technology, optimal hemodynamic management remains challenging. In addition, frequent readmission, hemocompatibility-related adverse events, and thromboembolic complications limit the effectiveness of LVAD therapy.3The development of implantable hemodynamic monitoring (IHM) allows continuous, remote measurement of pulmonary artery pressure, which is known to improve outcomes in patients with heart failure.Utilization of IHM technology for ongoing monitoring and optimization of LVAD therapy in the outpatient setting is reviewed. A patient vignette describes IHM use in a patient before and after LVAD therapy to demonstrate improvement in pulmonary artery pressures after LVAD implantation, thereby allowing cardiac transplant listing. However, limited evidence to date does not support a recommendation for routine use of IHM in patients with an LVAD. Further study of IHM in this patient population is suggested.,Current era LVAD complications that limit transplant potential include pulmonary hypertension  but are increasingly related to gastrointestinal bleeding, blood transfusion, and sensitization events or debilitating stroke.Increased adoption of IHM in patients with an LVAD (and advanced heart failure) has the potential to alter the transplant landscape by improving listing candidacy or status justification for patients in outpatient settings. These benefits may potentially lower waitlist time and mortality with earlier transplantation, obviating the need for prolonged hospital admission before cardiac transplantation.Lambert and Teuteberg


Venous anomalies are typically asymptomatic and may be discovered unexpectedly at the time of implantation of a cardiac implantable electronic device. We report a case of leadless pacemaker implantation in a patient with hypoplasia of the left brachiocephalic vein who had previously undergone multiple interventions for relapsing right-sided breast cancer. The prevalence and etiology of this anatomic variant remain unknown. However, awareness of its existence may prevent complications during left-sided interventions. such as placement of a central venous line or a cardiac implantable electronic device. Alternative diagnostics and implantation strategies are discussed. Venous anomalies  are typically asymptomatic and may be discovered unexpectedly at the time of implantation of a cardiac implantable electronic device. Rarely, venous anomalies result from chemotherapy or radiotherapy. We report a case of leadless pacemaker implantation in a patient with a severely hypoplastic left brachiocephalic vein who had previously undergone multiple cycles of radiotherapy for relapsing right-sided breast cancer.A 78-year-old woman with symptomatic transient third-degree atrioventricular block was referred for dual-chamber pacemaker implantation. The patient had a history of 2 right-sided breast cancer relapses, for which she underwent repeated surgeries and radiation therapy cycles between 1983 and 1993. A venogram at the time of implantation showed the absence of a left brachiocephalic vein, with drainage of the left jugular and subclavian veins into a left hemi-azygous vein (,,The prevalence of this anatomic variant remains unknown, and the etiology of an absent or hypoplastic brachiocephalic vein remains speculative.•An absent or hypoplastic left brachiocephalic vein is rare, but this possibility should be kept in mind when performing left-sided interventions.•The major tributaries of the superior and inferior vena cava derive from distinct embryologic veins.•Venous anomalies are most often solitary. When a venous anomaly is discovered, alternative transvenous implantation strategies should be considered.•Leadless pacemaker implantation can be successfully performed in patients with abnormal upper-body venous drainage as an alternative to surgical epicardial leads.We report a rare case of brachiocephalic vein hypoplasia discovered at the time of left-sided pacemaker implantation. Although this anatomic variation is rare, knowledge of its existence may allow avoidance of vascular complications. In this patient with a history of repeated right breast cancer surgery, alternatives included implantation of a leadless pacemaker, a transvenous femoral pacemaker, or epicardial leads. Investigation of the lower-body venous drainage anatomy revealed no further anomalies, and a leadless pacemaker was implanted.


An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention. An 85-year-old male presented to the emergency department (ED) after a motor vehicle accident with abdominal pain, neck pain, and stool incontinence. The patient’s medication list included prasugrel, but it was unclear whether he was taking it. Exam was notable for cervical and thoracic spine tenderness, decreased rectal tone, decreased bilateral upper extremity sensation, and mild weakness of the right lower extremity. Cervical spine computed tomography (CT) demonstrated dorsal epidural thickening from the second through seventh cervical vertebrae .On reassessment, the patient had loss of sensation below the seventh thoracic dermatome and markedly diminished bilateral lower extremity strength and reflexes concerning for ascending paralysis due to spinal cord compression. Magnetic resonance imaging (MRI) of the complete spine showed a cervicothoracic epidural hematoma .Orthopedic spine surgery performed emergent decompression, and the patient experienced rapid postoperative improvement in strength and sensation.A spinal epidural hematoma is a collection of blood between the spinal canal dura and vertebrae.3Given the non-specific clinical findings, spinal epidural hematomas are challenging to diagnose.5What do we already know about this clinical entity?A spinal epidural hematoma is a collection of blood between the spinal canal dura and vertebra that presents as back or neck pain with progressive neurological deficits.What is the major impact of the image(s)?Cases of traumatic spinal epidural hematomas are part of a small subset of neurological emergencies that benefit from early recognition and surgical intervention.How might this improve emergency medicine practice?Correlation of presentation with computed tomography and magnetic resonance imaging is essential to diagnose spinal epidural hematomas.


The no-touch saphenous vein with surrounding pedicle tissue harvesting techniquepreserved endothelium and vessel wall integrity and demonstrated improvedlong-term saphenous vein conduit patency that was comparable to internalthoracic artery conduit patency. Despite improved saphenous vein conduit patencyrates, there is a possibility that no-touch saphenous vein harvest may increasewound complication rates by increased tissue disruption, including venous andlymphatic channels. Comprehensive strategies to minimize leg wound complicationsafter no-touch saphenous vein harvest are discussed. An elasticated bandage was applied to the legwound after surgery and was replaced by a compression stocking from the2nd postoperative day. The compression stocking was kept in placefor 1 to 2 months postoperatively for prevention of leg swelling. TheJackson-Pratt drain was removed when the amount of drained fluid decreased to< 10 mL daily. Leg wound complications in the SV harvesting site were definedas infection or wound disruption that needed additional repair or secondaryintention healing. Leg wound complications developed in eight of 518 patients(1.5%) who received no-touch SV graft and underwent wound closure using theaforementioned strategies from 2017 to 2021 (unpublished data). All eightpatients recovered after secondary intention healing.After protamine administration to normalize the prolonged activated clotting timeat the end of CABG, a Jackson-Pratt drain was inserted into the SV harvestingsite and the leg wounds were closed in layers: interrupted 3-0 absorbablesutures to the subcutaneous tissue, interrupted 4-0 subcuticular absorbablesutures, and additional staples or zip surgical closure method for the skin. Zipskin closure  is a noninvasive skin closure system, and it has several advantages forwound healing such as providing better cosmetic results, facilitating woundhealing, and reducing infection riskThe rate of wound complication after not-touch SV harvest may be minimized bypreoperative evaluation of lower limb vascular status, selection of an adequatevein, creation of a precise skin incision, careful harvesting of the vein, placementof a drain in the vein harvest site, and meticulous closure of the skin wound.


Physical activity contributes to the prevention of chronic illness as well as promotion of physical and mental health, but most adults remain inactive. Chronic illness affects mainly middle aged and older adults, and very little objectively measured data on physical activity behaviours and associated health outcomes of this population is published. The aims of this study are to: 1. Objectively measure physical behaviour outcomes of adults participating in the Move for Life study; 2. Develop distinct activity profiles based on six behaviour variables; 3. Investigate whether health outcomes differ across the activity profiles.Participants were Irish adults aged 50 years and older. Using the activPAL, objectively measured data were collected on average daily: light intensity physical activity (hours); moderate to vigorous intensity physical activity (minutes); step count; time in bed (hours); standing time (hours); and waking sedentary time (hours). Data were obtained on chronic illness and health service utilisation. Validated questionnaires were used to collect data on wellbeing, loneliness and social isolation. Hierarchical cluster analysis using squared Euclidian distance was used to cluster behaviours based on similarity, using SPSS version 26. Regression models explored associations between health outcomes and activity profiles, adjusted for age and sex.Data from 485 participants were analysed, and four activity profiles were identified: sedentary , low active , moderate active  and higher active . We will present the differences across the activity profiles for chronic illnesses, multi-morbidity, health service utilisation and validated health tools, comparing to data from the Irish Longitudinal Study on Ageing (TILDA) and the English Longitudinal Study on Ageing (ELSA).The use of physical activity behaviour clusters may identify people with multi-morbidity and higher utilisation of health services. These findings could be factored into the development of future targeted physical activity interventions.


Coastal wetlands are not only among the world’s most valued ecosystems but also among the most threatened by high greenhouse gas emissions that lead to accelerated sea level rise. There is intense debate regarding the extent to which landward migration of wetlands might compensate for seaward wetland losses. By integrating data from 166 estuaries across the conterminous United States, we show that landward migration of coastal wetlands will transform coastlines but not counter seaward losses. Two-thirds of potential migration is expected to occur at the expense of coastal freshwater wetlands, while the remaining one-third is expected to occur at the expense of valuable uplands, including croplands, forests, pastures, and grasslands. Our analyses underscore the need to better prepare for coastal transformations and net wetland loss due to rising seas. Landward migration of coastal wetlands under rising seas will transform coastlines but not compensate for seaward losses. Societal perspectives of the value of coastal wetlands have changed greatly in the past century  coasts . Of the Our analyses indicate that freshwater forested wetlands and freshwater marshes collectively represent two-thirds of the total area available for wetland migration across the conterminous United States . Upland One of the critical limitations of prior landward migration studies is that they have focused exclusively on tidal saline wetlands without explicit consideration of adjacent freshwater wetlands . AlthougSome freshwater wetlands can migrate landward along river corridors into adjacent freshwater wetlands. However, that migration does not result in new wetland formation because it occurs at the expense of other freshwater wetland classes. Coastal freshwater wetlands that cannot migrate landward into uplands due to topographic barriers are particularly vulnerable to rising sea levels that lead to the landward migration of tidal saline wetlands . For exaTo complicate matters, there is much uncertainty regarding the long-term stability and potential extent of tidal saline wetland migration into adjacent freshwater wetlands. Many of these freshwater wetlands are positioned at elevations that may be equivalent to, below, or just slightly higher than tidal saline wetlands. Thus, these coastal freshwater wetlands are also highly vulnerable to coastal drowning under higher sea level rise rates. Further, in areas with organic-rich biogenic soils, there are critical questions regarding the likelihood of landscape-scale tidal saline migration given the potential for peat collapse and conversion of freshwater wetlands to open water that is too deep for plant establishment and the landward migration of tidal saline wetlands  through biogeomorphic feedbacks between inundation, plant growth, and sedimentation. The second process involves the landward migration  of wetlands into adjacent upslope or upriver lands. Our analyses focus exclusively on the second process—the landward migration of wetlands.https://coast.noaa.gov/slr), the NOAA Office for Coastal Management has produced several related products including national-scale tidal datum data, derived from NOAA’s vertical datum transformation tool , and Coastal Change Analysis Program (C-CAP) land cover class migration data at 0.1524-m net sea level increments. We obtained these data, which we used in combination with other land cover, elevation, and levee data sources, to identify areas available for the landward migration of tidal saline wetlands and freshwater wetlands.Our landward migration analyses examine the upslope and upriver movement of two broad wetland classes: (i) tidal saline wetlands and (ii) freshwater wetlands. To our knowledge, there is not a national-scale dataset that quantifies the migration potential of these two broad wetland classes into adjacent freshwater wetland and upland land cover classes. However, as part of the NOAA Sea Level Rise Viewer  effort  the inland limit of the MSLRMM-derived future estuarine land cover classes  to define the upper boundary of the future tidal saline wetland zone (table S3) and (ii) the MSLRMM-derived future freshwater wetland classes  to define the upper boundary of the future freshwater wetland zone (table S4). However, for some areas , we developed complementary analyses using the MSLRMM approach in combination with elevation data and MSLRMM-derived future MHWS data (tables S5 and S6).To define the lower boundary of the future tidal saline wetland zone, we used the upper boundary of the current estuarine land cover classes , which was determined using NOAA’s 2016 C-CAP data . The state and estuary-scale data are available as a U.S. Geological Survey Date Release (


Applications of dual-energy computed tomography and virtual non-contrast technique in neuroimaging are still emerging. While the role of DECT in differentiating parenchymal hemorrhage and contrast media after mechanical revascularization is well recognized, the value of DECT in evaluation of brain ischemia in post resuscitation patients who have received intravenous (IV) iodinated contrast is not well documented. We present a challenging case where DECT helped explain hyperattenuation in cortical grey matter and deep grey nuclei as well as cerebellar hemispheres in a comatose patient post cardiac arrest following massive pulmonary embolism. Applications of dual-energy computed tomography (DECT) and virtual non-contrast (VNC) techniques in neuroimaging are still emerging. While the role of DECT in differentiating between brain parenchymal hemorrhage and leaked contrast media after mechanical revascularization is well recognized 19-year-old female with no significant past medical history with only reported medication intake of oral contraceptive pills initially reported increasing dyspnea for 1-2 weeks preceding collapse with initial return of consciousness following bystander cardiopulmonary resuscitation. She subsequently lost consciousness, and Emergency Medical Services found her to be in ventricular fibrillation followed by pulseless electrical activity. She underwent pan-CT scanning with IV contrast earlier in the management which demonstrated massive pulmonary embolism resulting in right heart strain and manifestations of multi-organ failure. Within 24-hours of presentation the patient underwent percutaneous pulmonary artery thrombectomy and inferior vena cava filter placement. Serial head CTs performed are discussed below. Patient expired, following a short course, from multisystem failure.Serial CT imaging of the head was obtained  that demDECT facilitates material differentiation based on different peak voltage acquisitions (high and low). Materials demonstrating equal Hounsfield densities at 120 kVp imaging can be distinguished by assessing energy dependent changes of attenuation of respective materials In our case, serial non-contrast CTs of the head demonstrated progressively increasing attenuation of the subarachnoid spaces that was attributed to pseudo subarachnoid hemorrhage appearance (vascular engorgement) secondary to severe diffuse cerebral edema and recent resuscitation from cardiopulmonary arrest, as has been previously described The VNC technique proved 2 things. First, the subarachnoid hyperattenuation was from contrast retention within the vasculature, and second and more importantly, the extensive hyperattenuating brain parenchymal areas that were bright on iodine maps were hypodense on the subtracted VNC images representing ischemic tissue retaining contrast. The VNC images confirmed underlying areas of brain infarction with extensive hypoattenuation in a pattern typical of diffuse hypoxic/ischemic insult. Hence DECT helped reveal widespread cerebral and cerebellar infarctions by confirming contrast retention in the areas of infarction.In conclusion, DECT with VNC is valuable in assessing brain parenchymal hyperdensities seen on a non-contrast CT in the setting of post resuscitation hypoxic/ischemic injury with prior history of IV iodine contrast administration. It differentiates contrast retention from hemorrhage and reveals underlying parenchymal infarction.Written informed consent for all pertinent details of this case was obtained from patient's representative.


The sympathetic nervous system maintains metabolic homeostasis by orchestrating the activity of organs such as the pancreas, liver and white and brown adipose tissues. From the first renderings by Thomas Willis to contemporary techniques for visualization, tracing, and functional probing of axonal arborizations within organs, our understanding of the sympathetic nervous system has started to grow beyond classical models. In the present review, we outline the evolution of these findings and provide updated neuroanatomical maps of sympathetic innervation. We offer an autonomic framework for the neuroendocrine loop of leptin action, and we discuss the role of immune cells in regulating sympathetic terminals and metabolism. We highlight potential anti-obesity therapeutic approaches that emerge from the modern appreciation of SNS as a neural network vis the historical fear of sympathomimetic pharmacology, while shifting focus from post- to pre-synaptic targeting. Finally, we critically appraise the field and where it needs to go. Anatomical dissections in the 17 Oxford)  and subs Oxford) . Jacques Oxford) . Neurons Oxford) . By the esponse)  and the The canonical model of bivalent and oppositional autonomic function is inadequate in describing metabolic control, as some metabolic tissues receive innervation exclusively from sympathetic neurons, including brown adipose tissue (BAT) and white adipose tissue (WAT), and in others like the liver, the sympathetic innervation seems to play the crucial role in hepatic homeostasis. While the SNS has long been acknowledged as an essential arm of metabolic control, the modern experimental toolkit has afforded a more consolidated appreciation of the sympathetic contribution to metabolic homeostasis. In this review, we first outline how sympathetic neurons control the metabolic activity of the pancreas, liver, and adipose tissues. Then, we describe how these processes are related to immune function and dysregulated by the inflammatory responses that characterize metabolic diseases. Finally, we highlight emerging therapeutics targeting key sympathetic processes to reverse metabolic disease.Sympathetic innervation is crucial for the regulation of pancreatic insulin and glucagon release and the control of glucose homeostasis, particularly by protecting against hypoglycemia during fasting and by increasing blood glucose during periods of elevated demand, such as by physical, inflammatory or psychological stress.panel A). Preganglionic sympathetic fibres in the greater thoracic splanchnic nerves provide inputs to coeliac ganglia neurons, which in turn provide postganglionic fibres to the pancreas. In addition, the vagus nerve provides preganglionic parasympathetic supply to a network of intrapancreatic ganglia. Neurons from the intrapancreatic ganglia then provide postganglionic cholinergic innervation to the exocrine and endocrine pancreas. Both vagal and spinal sensory fibres carry afferent sensory information from pancreas with their cell bodies in the nodose and dorsal root ganglia, respectively.Gross anatomical dissections and histological analyses of fixed pancreatic tissue, primarily in dogs and cats, provided an early anatomical framework for sympathetic, parasympathetic and somatic pancreatic innervation  Figure , panel AMethodological limitations in classic histology – namely poor stain tissue specificity and inadequate image resolution – led to conflicting reports regarding the distribution of sympathetic nerve fibres within pancreas . Improvepanel B). Still, tissue sectioning an entire organ is laborious and tracing filamentous structures across serial sections is both time consuming and prone to artefacts. Tissue clearing, light sheet microscopy and image analysis have enabled the best 3-dimensional imaging and quantification of pancreatic innervation to date. Studies applying these methods in mice highlight sympathetic innervation to intrapancreatic ganglia, islets and vasculature (panel B). Quantification of TH+ innervation across hemipancreata confirmed relatively even distribution through the pancreas but suggested TH+ innervation is enriched in mouse islets compared to the exocrine pancreas, representing 3% of islet volume + sympathetic fibres allowed for 3D reconstruction and quantification of sympathetic innervation across the entire pancreas. In mice, such studies showed TH+ fibres distributed evenly throughout the pancreas  and the culature . Sympathculature  , together with neuropeptides such as galanin  and neurStudies examining the roles of pancreatic sympathetic nerves on glucagon release have been more consistent. Splanchnic and pancreatic nerve stimulation increased pancreatic glucagon release into either the portal or systemic circulation in many species, including humans . In someHowever, splanchnic nerve stimulation and pharmacological studies do not specifically target pancreatic innervation, and it is possible that effects on other organs innervated by the coeliac ganglia, such as the liver, or modified by systemic adrenergic receptor antagonists may indirectly alter pancreatic insulin release. An additional challenge is discerning which changes to beta cell function are due to direct sympathetic neuronal signalling, and which are secondary to changes in islet blood flow, as evidence amounts for the parallelism of insulin secretion and vasodilation . FurtherSome studies have assessed whether sympathetic innervation also regulates the exocrine functions of the pancreas. Early studies in guinea pigs suggested so since NA administration potentiated cholecystokinin-induced amylase release . HoweverRecent intriguing work has suggested that pancreatic sympathetic innervation may play a role in the development, maintenance and remodelling of islet structure. Genetic or pharmacological ablation of sympathetic innervation in mice altered pancreatic islet structure reduced plasma insulin and impaired glucose tolerance. The effects on islet structure were partly reversed by beta-adrenergic receptor agonists . In addiUnlike the liver or adipose tissue, the pancreas receives dense parasympathetic innervation and islet expression of cholinergic receptors M2 and M3. Studies using electrical stimulation of the efferent vagus nerve lowered blood glucose  while acdb/db mice, recent work reported remodelling of pancreatic ducts close to islets and increased sympathetic innervation of the islet-duct boundary  nerves, but not the vagus branch innervatin the liver (parasympathetic), would inhibit this effect . Followial cells . Electroal cells . In addial cells .T. Belengeri, Forssman and Ito used fluorescence microscopy to show sympathetic nerve fibres in close apposition to hepatocytes in the peripheral zone of the lobule where parenchymal cells, sinusoidal lining cells and Kupffer cells also appeared to be innervated  specific staining suggested cholinergic hepatic input to hepatic vessels, bile ducts and intralobularly in close apposition to hepatocytes and sinusoids . In modenervated . Auto-ra Mulatta . However Mulatta .Retroviral PRV tracing studies have mapped the neuroanatomical origin of hepatic sympathetic nerves. Two studies report sympathetic neurons originating from the coeliac superior mesenteric complex, aorticorenal and suprarenal ganglia, which are in turn innervated by splanchnic preganglionic neurons located in the intermediolateral column of the spinal cord (T7–T12)  Figure . PerhapsSince Claude Bernard’s early lesion studies, a more consolidated appreciation on the function of hepatic autonomic innervation has been sought. In the 1960s, Shimazu and colleagues established that electrical stimulation of rabbit splanchnic nerve was sufficient to increase the hepatic gluconeogenetic enzymes glycogen phosphorylase and glucose-6-phosphatase . FurtherDespite the evidence that the liver is strictly innervated by the sympathetic nervous system, recent functional studies defend different perspectives. In one study, it was shown that surgical resection of the hepatic branch of the vagus nerve in rats would prevent the effects of brain-infused insulin on hepatic glucose production . Since ten passant fibres related to the sympathetic nervous system, impacted afferent signals, or have influenced surrounding organs, such as the adrenal glands or the pancreas. Even though the authors show no changes in corticosterone and glucagon one hour after the illumination, blood glucose increased quickly (within 15 min) and it is possible that hormone levels were affected in the first minutes.Another study used optogenetic approaches to identify the circuit by which pro-opiomelanocortin (POMC) neurons control blood glucose . In a fiBrown Adipose Tissue (BAT) performs non-shivering thermogenesis by dissipating the mitochondrial H+ gradient across the mitochondrial inner membrane while circumventing ATP synthase. Metabolic substrate is thus oxidised without generating chemical stores of energy, instead generating heat . BAT is BAT was recognised as relevant to the physiology of rodents and human infants as their large surface area to volume ratios required additional support in maintaining core body temperature . Only wiBAT has an impressive ability to use energy – it consumes more glucose per gram than any other peripheral tissue when stimulated, except perhaps the brain  and estiSympathetic innervation has emerged as an important regulator of BAT thermogenesis - since the initial descriptions of the central role of sympathetic stimulation for maintenance of body temperature upon cold exposure  and its Ucp1 mRNA , increases weight without affecting feeding behaviours and inhibits physiological responses to cold challenges. In denervated subjects - all of these processes can be acutely resolved via NA injection . More recp1 mRNA , but theUnderstanding structural, functional, and molecular changes associated with upregulated BAT thermogenesis could help unearth important pathways for potentiating its activity in humans. Imaging studies utilizing sectioning methods reported that cold exposure increases sympathetic nerve density and arborisation of BAT  but modebeiging in WAT  premotor neurons expressing POMC/CART in the hypothalamus , DMH and VMH nuclei) and in the brainstem, ii) spinal cord and iii) stellate ganglion . Additio obesity . By cont outflow , suggestGiven the complexity of hypothalamic networks, the precise signalling involved in downstream activation of sympathetic activity still needs to be further understood - however, it should be noted that its investigation has been focused on central pathways and assumed noradrenergic signalling as the single effector mechanism responsible for the observed phenotypes, a major caveat also present in studies investigating sympathetic functions in other tissues.(Nrg4) was significantly upregulated with BMP8b overexpression, and down-regulated in BMP8b knockouts. Exogenous application of NRG4 promoted sympathetic axon growth and branching, suggesting BAT could dynamically remodel surrounding tissue in response to BMP8b  in mice increases sympathetic innervation and BAT vascularisation, even in mice housed at warm temperatures . Transcrto BMP8b . Similarto BMP8b . CLSTN3ßto BMP8b . AdipocyFinally, emerging evidence suggests BAT is an integrated metabolic tissue with endocrine functions  and roleNoradrenergic signalling has long been known to cause WAT lipolysis. Challenges presented by imaging adipose tissues and manipulating its function have meant that an understanding of how NA is supplied and regulated within WAT has been elusive until recently. Early imaging studies suggested that WAT received some innervation  but the Only with recent advances in two-photon imaging and tissue clearing it has been possible to visualise entire sympathetic arborizations as well as confirm the presence of neuro-adipose junctions. In 2015, Zeng and colleagues used optical projection tomography approach to reconstruct 3D images of entire inguinal fat pads. Two photon microscopy of catecholaminergic reporter mice labelled with lipophilic dye showed that 50% of all neurons innervating fat pads were sympathetic, and bouton-like structures innervated 8% of adipocytes. Advanced tissue clearing preparations have allowed for direct imaging of entire fat pads . In 2017More macroscopically, retrograde tracing techniques have aimed to map the neuroanatomical origin of pre- and post-ganglionic fibres innervating WAT and suggest that distinct fat pads receive innervation from distinct populations of neurons. Early fluorogold retrograde tracing studies in Siberian Hamsters claimed dense cell bodies projecting to inguinal WAT (iWAT) from T13 abdominal sympathetic ganglion, although the study did not provide representative micrographs of ganglia . More moet al. likely caused tracer to diffuse via the inguinal canal to infect abdominal organs, highlighting a common pitfall in retrograde viral tracing studies.While most neuroanatomical studies tend to present harmonious findings, a 2017 study received a lot of attention and offered a different framework of iWAT neuroanatomy. The authors used an Alexa-dye-conjugated Cholera Toxin Subunit B (CTB) injection into iWAT and reported labelled neurons almost exclusively in the coeliac ganglia – a structure providing visceral sympathetic innervation to kidney, liver and GI organs. The authors reported very few cells innervating iWAT originating from either the spinal cord or lumbar dorsal root ganglia . These rSome deeper adipose pads also appear to be supplied by post-ganglionic neurons that synapse not in the paravertebral sympathetic chain but in mid-line autonomic ganglia. Using a green fluorescent protein labelled adeno-associated retrograde virus tracing technique, Cardoso et al observed cell bodies of the efferent sympathetic nerves innervating gonadal WAT (gWAT) in the aorticorenal ganglion . In addiIndirect evidence of sympathetic-induced lipolysis has existed for over 60 years - plasma free fatty acid concentrations were noted to increase with noradrenaline administration in rats and with electrical stimulation of adipose nerves in dogs, and these changes were inhibited by trimethaphan camphorsulfonate ganglionic blockade and peripheral ß-adrenergic antagonism . The anaDirect evidence that sympathetic activation was sufficient to drive lipolysis has only emerged since the advent optogenetic and chemogenetic techniques that can stimulate or inhibit the activity of molecularly defined neuronal populations. By crossing TH-Cre mice to a Cre-dependent ChR2 line, Zeng et al showed optogenetic activation of tissue specific sympathetic neurons released NA (as measured by ELISA assay) and chronic stimulation depleted fat mass in illuminated areas . SimilarSimilarly, the functional spatial control of SNS signalling is poorly understood. The apparatus for spatially restricted control of lipolysis is present – WAT is innervated from discrete spinal levels and sympathetic ganglia and local SNS-WAT communication is performed at the Neuron-Adipose Junction. Functional evidence based on limited NATO methods do support the notion of some regional specialisation in lipolysis. In response to a 16 hour fasting challenge, sympathetic outflow is significantly higher in iWAT over epididymal WAT (eWAT) , while iFinally, ambiguity still surrounds the morphological changes to sympathetic axons during cold and fasting challenges – namely, whether sympathetic arborisations change their density or localisation to facilitate lipolysis. Earlier studies suggested an increase in neuronal arborisations and increases in TH+ neuron density in WAT after cold acclimatization but these observations were based on analysis of tissue sections that poorly represent the entire fat pad . Whole t2 of iWAT per sample, while Chi’s protocol lasted only for 7 days and analysed ten cubic ‘representative’ areas of unspecified size. In addition, Blaszkeiwicz used the pan-neuronal marker PGP9.5 for neuronal quantification, whereas Chi used TH, specific for sympathetic neurons. Recently, Willows and colleagues quantified neurite densities across entire adipose tissues using mechanical compression method, and found a non-significant increase in neurite densities in cold adapted mice, but only examined four mice in a proof-of-concept study  that appears to play important roles in the regulation of metabolism. Because BeAT exhibits increased mitochondriogenesis and expresses a significant amount of UCP-1, it is thought that it has the capacity to generate heat through uncoupling of the electron transport  expression which could be replicated by β3 adrenoceptor agonism . UCP-1 p beiging .beiging and thermogenesis. 3D imaging of tissue cleared iWAT shows adipocyte-specific PRDM16 knockouts are unable to keep the regional differences in SNS density within the different sub-regions in iWAT, whereas the WT control showed a notable regional difference in medial vs lateral sub-regions of iWAT , a transcriptional regulator, is sufficient to initiate differentiation of beige adipocytes in subcutaneous WAT , and imp of iWAT ; this re of iWAT . BidirecHomeostatic neuroendocrine feedback loops maintain homeostasis via afferent (sensory) signals that are integrated and processed centrally to generate efferent (motor) outputs. In the context of metabolism, leptin is the primary afferent signal, information regarding metabolic state is computed primarily in the hypothalamus, and the SNS signalling acts as the effector arm .Leptin is an adipokine synthesised proportionally to adipose tissue mass. Global increases in fat mass raise plasma leptin concentrations to increase energy expenditure and reduce food intake . ConversImmediately following leptin’s discovery , the preSympathetic signalling is an important mechanism by which leptin increases energy expenditure. Early studies noted that chronic β3-adrenergic agonist treatment mimicked leptin application, reducing adipose tissue mass and leptin expression while sparing lean tissue mass in mice . Some muBy deduction, SNS signalling was the most likely mediator of leptin’s effects on energy expenditure. This was bolstered by studies showing intravenous (IV) infusion or intra-hypothalamic delivery of leptin increases nerve activity to BAT. These measurements came from extracellular electrodes implanted over local neurovascular peduncles, so the activity of non-sympathetic neurons was also measured . Similaret al. (Leptin crosses the blood–brain barrier (BBB) to bind to Leptin receptors (LepR), predominantly in the ARC, VMH, DMH and medial preoptic nuclei (MPO)  and latet al. . Functioet al. . Also, cet al. . In addiet al. . Intereset al. , and thoet al. . Specifiet al. ), regulaMPO LepR+ neurons have recently been implicated in regulating both energy expenditure and thermogenesis in response to internal energy state . SimilarThe advent of techniques that allow tissue-specific control of neurons has yielded direct evidence of the necessity of SNS function to elicit leptin-induced energy expenditure. In 2015, Zeng and colleagues found tissue-specific genetic ablation of sympathetic neurons within a fat depot inhibited the lipolytic effect of leptin . SimilarLeptin resistance – a blunted response to leptin signalling, a weakened effector arm of this neuroendocrine homeostatic feedback loop – has emerged as an important pathological change in the development of obesity . This stInsulin resistance and hyperinsulinemia are associated with obesity and are connected with hypertension problems in obese subjects. However, similarly to leptin resistance, the mechanisms involved in the dysregulation of this neuroendocrine loop are still under study. Insulin resistance and hyperinsulinemia are associated with obesity and are associated with hypertension problems in obese subjects. However, similarly to leptin resistance, the mechanisms involved in the dysregulation of this neuroendocrine loop are still under study.Central insulin signalling is another important afferent signal in the metabolic feedback loop. There is accumulating evidence that insulin crosses the BBB into the brain and regulates different peripheral tissues and systemic metabolism  and deletion of insulin receptors in the brain increases food intake and promotes obesity . ICV insHowever, other studies have shown the opposite. Insulin action in the brain is a critical regulator of WAT metabolism with inhibitory effects on sympathetic output. Thus, in lean rats, the sympathetic outflow to fat tissue is reduced and lipolysis suppressed after central insulin administration; but, like an inverse regulation, mediobasal hypothalamus insulin increases de novo lipogenesis in adipose tissue . NeverthStudies with neuron-specific insulin receptor knockout models have postulated some neuron populations as key players integrating the insulin signal. Thus, insulin signalling in POMC and NPY/AgRP neurons has an important role in regulating energy balance . InsulinSympathetic innervation of metabolic tissues is essential for maintaining metabolic health, but metabolic dysregulation increase the propensity for neuropathy within these tissues. Such an autonomic neuropathy may trigger or exacerbate metabolic diseases, initiating a positive feedback cycle seemingly difficult to break.Peripheral sensorimotor neuropathies are common in patients with metabolic syndromes, especially diabetes. While obese adipose tissue takes on a fibrotic quality that is difficult to image , 3D imaget al to observed liver neuropathy  or in leptin deficiency . Liu anduropathy . In aliguropathy . In thisuropathy .Understanding the mechanisms by which SNS signalling to metabolic tissues is altered in disease states remains an important question in designing effective therapeutics. In recent years, the interactions between SNS, metabolic organs and local immune cells have emerged as a key contributor to pathological signalling changes. The central role of these interactions have led to the development of the growing field of neuroimmunometabolism, which investigates how these systems are interconnected and how these connections can be explored for therapeutic interventions.The presence of the relevant apparatus for SNS signalling, immune cells and adipokines to interact has been known for some time. All primary and secondary immune organs are innervated by postganglionic sympathetic nerves  and bothAlbeit only a few studies have investigated the interplay between sympathetic signalling and immune modulation in the pancreas, recent work has supported a role for pancreatic sympathetic innervation in immune modulation and protection from autoimmune diabetes in mice . In one et al. used three-dimensional immunoimaging to evaluate the liver sympathetic innervation in samples from NAFLD patients, and revealed increased sympathetic axonal sprouting associated with mild nerve degeneration in the early stages of disease and a significant loss of sympathetic innervation in advanced steatohepatitis  specialized in phagocytosis and participating in the innate responses. Interestingly, these cells were shown to be innervated by sympathetic fibres and to express adrenergic receptors . Evidencepatitis . They al  increase from 10% of the adipose tissue resident immune cells to 50% and tend to change from M2 anti-inflammatory to a M1 pro-inflammatory phenotype, producing proinflammatory cytokines including IL-6, IL-1β and TNF-alpha and paracrine factors. Proinflammatory ATMs were indirectly associated with insulin resistance, vascular remodelling, and increased adiposity, but over the last decade their role as architects of lipolytic signalling has been increasingly accepted. Indeed, among the tissues discussed in the present review, the adipose tissue is the one in which immune populations and their interplay with autonomic signaling are most extensively described .beiging of WAT and causing a significant and sustained weight loss in obese mouse models  . Cruciale models . Likewise models  reportede models .et al.  onto adipocytes and incubated with Met-Enk to onserve an upregulation of Ucp1  data from WAT  . Paralelipocytes . Ultimatutgrowth . Thus, bCollectively, these findings establish a novel homeostatic role of tissue macrophages and other immune cells that can control sympathetic innervation. Any disruption between this neuroimmune crosstalk might impact the nerve integrity and tissue function with a considerable final effect on metabolism.Obesity is a leading cause of morbidity and mortality globally, but until recently, anti-obesity pharmaceuticals have had poor therapeutic efficacy and tolerance. The prolipolytic signalling of the sympathetic nervous system has attempted to be exploited by sympathomimetics - compounds that stimulate sympathetic nerves by inhibition of MA uptake or direct stimulation of peripheral adrenoceptors . They haClassically, the mechanism of action of sympathomimetic-induced weight loss was thought to be central, by suppressing appetite and promoting locomotion. The addictive properties of sympathomimetic are due to nigrostriatal monoamine release; cardiovascular toxicity is thought to be caused by a combination of central and peripheral stimulation. This view was challenged by Mahú and colleagues, who brought attention to the contribution of the brain on the peripheral readouts of sympathomimetics , while pß3-adrenoceptor agonists have also received attention due to their ability to promote BeAT differentiation and formation in rodents, but poor selectivity and systemic administration of early ß3 agonists caused intolerable side-effects .Recent attention emerged surrounding Mirabergon, a specific ß3 agonist already used to treat urinary urge incontinence. In 2015, Cypess and colleagues measured 18F-FDG uptake in PET scans to show a 200mg dosing regimen of Mirabegron increases human BAT metabolic activity, while also increasing BAT glucose uptake and increasing resting metabolic rate by 230±40 kcal/day . SubsequRelative to brain research, sympathetic neuroscience is lagging several decades behind - owing to the dispersed and difficult anatomical access and technical limitations that the developments we envision will likely surpass. These will be necessary to overcome the conceptual barrier that stagnated in the era of adrenergic receptor pharmacology, which solely accounts for post-synaptic adrenergic targeting in organs. Although such models account for the action of a few adrenergic drugs that are routinely used in the clinic , sympathetic nerves are seldom considered as a neural circuit, whereby pre-synaptic manipulations of a node within the network might not be predicted by post-synaptic adrenoceptor agonism or centrally acting sympathomimetics which have a widespread top-down action. Moreover, the assessment of adrenoceptor subtype expression across cell types mainly originates from bulk tissue techniques that do not account for expression by resident immune cells. Only single nuclei sequencing has parsed apart tissue heterogeneity, particularly that of WAT&BAT, which cannot be analyzed by conventional cell sorting.Moreover, the linearity of post-synaptic agonism falls apart as adrenoceptors are also expressed in sympathetic neurons, suggesting that feedforward or feedback circuits may exist among ganglia. Whether intra- and inter ganglionic circuitry exists is an open question, despite the highly suggestive TH+ axon bundles between every two ganglia along the paravertebral sympathetic chain. Such ganglionic circuits can be influenced by resident immune cells that cleanse norepinephrine or produce neuromodulators such as opioids. Thus, the field needs to rise from the era of post-synaptic adrenoceptor pharmacology to that of neural networks. As such, the classic view that SNS is responsible for the ‘fight or flight’ response antagonised by the PNS is an incomplete description of autonomic metabolic control in light of the modern neuronal network theory. Not only do adipose tissues and liver  receive innervation exclusively from the SNS, but PNS in the heart can act as a cardioprotective buffer whilst sympathofacilitator drugs exert effective control of metabolic tissues to facilitate weight loss and restore the homeostasis of the neuroendocrine loop of leptin action.Current molecular genetic technologies widely used in the brain have had limited success with SNS circuits. Dissections of the murine paravertebral sympathetic chain of ganglia are complicated, and retrograde tracing with a non-replicative non-polysynaptic virus has low transduction efficiency, perhaps due to the cleansing of viral particles by immune cells resident in sympathetic tissues. PRV retrograde tracing pioneered mapping the efferent postganglionic sympathetic innervation of BAT, which seems consensual across species. However, the innervation of WAT is more variable across species and the location of the fat depot. Similarly, the origin of the sympathetic innervation of the liver is inconsistent and seems restricted to the perivascular space. Unlike liver and adipose tissues, and more aligned with conventional autonomic paradigms, the pancreas possesses both sympathetic innervation and parasympathetic innervation with opposing effects. Differential sympathetic activation would be advantageous for selective targeting and treatment of organ-specific dysfunction, including immune and metabolic pathologies. Except for central leptin action, it is debatable whether manipulations of upstream brain circuits would recruit a top-down response that is cardioneutral and specific to metabolic organs. Centrally acting sympathomimetics such as amphetamines and MCR8 agonists recruit widespread and cardiotoxic sympathetic drive, indicating that higher-order manipulations may not be more targetted than those of lower order at the postganglionic level. Drawing a parallel with the organization of other descending axes such as sensory-motor circuits: lesions or stimulations of higher order brain structures produce effects that are more widespread relative to peripheral manipulations, for instance, when comparing the sensory-motor deficits originating from the stroke of the central medial artery to those arising from peripheral lesions. This organizational principle could also apply to the sympathetic axis, whereby peripheral postganglionic targeting may be more specific than higher-order pre- sympathetic central circuits. Thus, manipulations of sympathetic postganglionic neurons may be a means to achieve metabolic control while identifying neural circuits, or nodes within them, that preserve cardiovascular health. Critical to this endeavour will be to generate transgenic CRE/DRE driver lines for subpopulations of neurons that could be systematically used as molecular handles for remote activation/inhibition via minimally invasive technologies, such as chemogenetics or magnetogenetics, for a causal assessment of the exact neuronal pathways of the sympathetic-metabolic axis. Realistic maps with single-neuron resolution akin to the MouseLight Project are still missing. A functional understanding of SNS circuitry in-vivo will require the development of non-invasive genetically encoded activity reporters that can be sensed in deep-seated sympathetic ganglia – possibly capitalizing on optoacoustic as an enabling technology.Obesity-induced sympathetic neuropathy is a cause and effect of metabolic disease – weakening the sympathetic efferent arm in the neuroendocrine loop of leptin action. Reversing obesity-induced sympathetic neuropathy may be a step towards re-establishing body weight homeostasis, and this will require deciphering the cross-talk among sympathetic-resident immune cells. This prospect promises “sympathoprotective” immunotherapeutic targets and could offer a new generation of safe and effective anti-obesity treatments.


Colorectal cancer (CRC) represents the third most prevalent cancer worldwide and a leading cause of mortality among the population of western countries. However, CRC is frequently a preventable malignancy due to various screening tests being available. While failing to obtain real-time data, current screening methods (either endoscopic or stool-based tests) also require disagreeable preparation protocols and tissue sampling through invasive procedures, rendering adherence to CRC screening programs suboptimal. In this context, the necessity for novel, less invasive biomarkers able to identify and assess cancer at an early stage is evident. Liquid biopsy comes as a promising minimally invasive diagnostic tool, able to provide comprehensive information on tumor heterogeneity and dynamics during carcinogenesis. This review focuses on the potential use of circulating tumor cells (CTCs), circulating nucleic acids (CNAs) and extracellular vesicles as emerging liquid biopsy markers with clinical application in the setting of CRC screening. The review also examines the opportunity to implement liquid biopsy analysis during everyday practice and provides highlights on clinical trials researching blood tests designed for early cancer diagnosis. Additionally, the review explores potential applications of liquid biopsies in the era of immunotherapy. According to the GLOBOCAN database, colorectal cancer (CRC) is the third most prevalent cancer worldwide, representing the second leading cause of cancer-related mortality around the globe . Albeit Despite the high mortality rates observed in the advanced stages, CRC is frequently a preventable malignancy through screening methods . The vasEven with the various screening technologies available, with colonoscopy representing the gold standard, adherence to CRC screening programs remains suboptimal among some populations ,10. EndoThe aim of this article is to review the existing data on liquid biopsies and their clinical application in detecting early-onset CRC. In addition, the review discusses the available methods for implementing liquid biopsies in everyday practice and offers highlights on clinical trials investigating blood tests designed for screening and early cancer detection. The review also discusses the challenges met during the analysis of liquid biopsy components and its potential future applications in the era of immunotherapy.Recent research has been shedding light on a new diagnostic approach suited for cancer patients, the liquid biopsy. Liquid biopsy comes as a simple, minimally invasive diagnostic tool, attempting to overcome the limitations of conventional tissue biopsy by providing more comprehensive data on tumor heterogeneity and dynamics at different junctures in cancer development . Liquid Originally described in 1869, CTCs are now gaining clinical importance in the management of patients with cancer . Tumor cCTCs can be successfully enriched through various procedures that exploit the dissimilarities observed between tumor cells and other circulating blood cells. These methods attempt to isolate CTCs based on their particular physical characteristics and their contrasting expression of cell surface proteins .Positive enhancement methods, also known as label-dependent, use specific antibodies targeting molecular markers expressed by CTCs (cell-surface antigens). The membrane protein most commonly used during positive enhancement selection is the epithelial cell adhesion molecule (EpCAM), however, other cytoplasmic markers expressed by CTCs may be exploited  . EpCAM iOnce the sample has undergone enrichment processes, CTCs require individual recognition. CTC detection can be achieved through immunocytology, molecular biology, or functional assays . The mosCTCs can be extensively characterized using a range of techniques. Profiling proteins expressed by CTCs represents one of the most commonly used methods and it requires immunostaining with antibodies to specific markers of cell proliferation and apoptosis . A diffeThe available scientific data showed the importance of CTCs in different CRC stages. In the nonmetastatic setting, the CTCs count was found to be lower, therefore, the cutoff for many of the clinical trials conducted was set for ≥1 CTC/7.7 mL of blood, while in the metastatic setting, the cutoff was set higher (≥5 CTCs/7.5 mL of blood) . Even ifIn this regard, a prospective clinical study was presented at ASCO GI 2018 . The stuMoreover, CTCs were shown to evaluate patients’ prognoses and predict metastasis and recurrence. A meta-analysis including 1847 patients from 11 studies revealed that an increased CTC baseline count represents an independent and strong prognostic factor for OS  and PFS  in metastatic CRC . By analHowever, despite promising results reported by clinical trials, the scientific community will have to overcome several limitations in order to further use the information provided by CTCs in clinical practice.The analysis of circulating nucleic acids (CNAs) represents a novel minimally invasive approach, able to assess the tumor and its molecular characteristics while allowing a more accurate description of tumor heterogeneity and evolution in time. CNAs, more specifically, circulating tumor DNA (ctDNA) and circulating microRNA (miRNA), are generally isolated from blood; however, other biological fluids could represent a source of CNAs  . CNAs enNumerous amounts of cell-free DNA (cfDNA) fragments are detected in blood plasma as a result of cellular death, with sizes ranging between 180 and 200 base pairs . It has The blood samples collected require a series of manipulations in order to identify ctDNA and then further analyze the material for genetic aberrations. Firstly, samples are subjected to sequential centrifugation, isolating plasma as the main source for cfDNA . ctDNA iExtensive research focusing on circulating DNA (cDNA) analysis has successfully discovered its clinical utility in CRC screening. A series of markers indicative of aberrant DNA methylation have been described and utilized to detect CRC in early stages and precancerous lesions  Table 1Table 1.Tumor suppressor gene septin-9 (SEPT9) is one of the most widely researched methylation markers in CRC pathogenesis. A study conducted by Warren et al.  evaluateSeveral multi-cancer detection tests have been thoroughly analyzed as potential screening tools in a new era of preventive medicine . CancerSCirculating miRNAs represent the purpose of extensive research focusing on cancer biomarkers. miRNA can be identified in biological fluids as a result of tissue injury and apoptosis or following active selective secretion by CTCs and tumor cells from the primary site or metastases ,93. The Even though the interest in miRNA as a liquid biopsy biomarker is relatively novel, research has already found its potential value for CRC screening .Several miRNA clusters appear up-regulated in CRC , of whicPresent in all biological fluids, exosomes represent cell-derived nanovesicles with sizes ranging from 30 to 150 nm in diameter . ExosomeAn increasing amount of evidence has identified exosomes as essential participants in cancer development processes. Exosomes secreted by tumor cells have been found responsible for alterations in the immune response that lead to suppression of antitumor response . In addiExosome concentration in biological fluids is relatively low, thus making their isolation, detection and further analysis relatively challenging. Isolation of exosomes can be achieved based on their physical properties (size and density), electromagnetic characteristics, or according to their immunological properties . IsolatiExosomal microRNAs have been attracting considerable attention as promising biomarkers suitable for cancer diagnosis. Multiple exosomal miRNAs have been studied, with some of them showing substantial value in identifying early cases of CRC .Research has identified several significantly up-regulated miRNAs in the setting of CRC, including cases of early-stage disease. One study found miRNA-23a to have an important diagnostic accuracy with an area under the curve (AUC) of 0.953, while miRNA-1246 and miRNA-21 also showed encouraging results . OverexpOver the past few years, immunotherapy has changed the treatment paradigm for many cancer types. In CRC, the MSI-high phenotype was associated with a significant response to immune checkpoint inhibitors (ICIs) . MoreoveTo date, liquid biopsies are investigated for use as biomarkers to predict and evaluate the response to immunotherapy. CTCs, circulating DNA (cDNA), circulating RNA (cRNA) and exosomes hold a generous amount of tumor-related information. Moreover, liquid biopsies may provide a more comprehensive and dynamic overview of the tumor microenvironment and heterogeneity than single-site tissue biopsies . The utiA better selection of the patients receiving immunotherapy could be guided by specific somatic mutations detectable in cDNA. In this regard, a genomic mutation signature was developed to characterize immunophenotypes and predict response to immunotherapy in gastrointestinal cancers . As mentRAS assessment in mCRC is essential to select patients suitable for anti-EGFR therapy. The concordance between tissue detection and somatic mutations detected in ctDNA appeared high in patients with advanced tumors, supporting blood-based testing. Moreover, ctDNA was shown to be highly useful for monitoring treatment response. However, some clinicopathological features, including tumor histology (mucinous) and metastatic sites , negatively influenced RAS detection in ctDNA . Along wImmunotherapy and targeted therapy are major therapeutic breakthroughs in cancer care, and one of the most challenging concerns is proper patient selection. To overcome these shortcomings, liquid biopsy-based biomarkers represent a promising tool, hence they require detection methods with sufficient specificity, sensitivity and predictive power .Despite many pieces of scientific evidence highlighting the potential benefits of liquid biopsies in cancer care, numerous limitations remain for their clinical use.CTCs have great potential as diagnostic, prognostic, predictive, as well as monitoring tools. However, their translation into clinical practice is still restricted amid their isolation from the bloodstream . To corrFor exosomal segregation, ultracentrifugation is thought to be the most efficient method. Although convenient and requiring reasonable costs, ultracentrifugation encounters several limitations. A significant concern is the co-purification of lipoproteins and protein aggregates along with EVs . Hence, ctDNA is a small fraction representing about 0.01% of cfDNA. One of the main logistical reasons limiting the extensive use of cDNA-based analysis is represented by their feasibility outside the academic cancer centers . The avaEven if several logistic and biological limitations are encountered at the present moment, liquid biopsies will more likely become a fundamental tool in the management of CRC patients in all stages of disease-related interventions. Evaluation of ctDNA levels in patients with stage II CRC has led to a decrease in adjuvant chemotherapy administration while maintaining a favorable recurrence-free survival (DYNAMIC II study) . AdditioDespite the implementation of extensive programs designed to diagnose CRC in the early stages, the adherence of the general population to screening protocols remains unsatisfactory. Liquid biopsy comes as a novel, minimally invasive tool, adequate for early diagnosis of malignancy while also attempting to overcome the limitation showed by traditional CRC screening and tissue sampling methods. Research has proved that liquid biopsy analytes and biomarkers offer valuable information regarding carcinogenesis and could indeed single out individuals at risk for developing CRC or those presenting early-stage CRC otherwise undetected during conventional screening tests.Since FDA has taken the necessary steps to approve CellSearch System for CTC detection and enhancement during clinical studies, the scientific community could soon implement the test in everyday clinical practice. In addition, studies have identified numerous methylation markers indicative of malignancy. In this regard, the detection of SEPT9 gene methylation in DNA fragments derivative from tumor masses is the most widely explored sequence and therefore experiences more promising results. As a result of thorough research, the SEPT9 methylation model comes within reach of validation for current practice, with tests such as Epi proColon expressing significant diagnostic values for CRC early detection. Several extensively researched miRNAs are also approaching clinical utility in everyday practice. miRNA-92a proves relevant sensitivity and specificity values in detecting early CRC cases, as well as advanced adenomas, while panels including multiple miRNAs show improved accuracy when compared to single markers. Additionally, exosomal miRNA-23a has been shown to differentiate patients with early-stage disease with high accuracy, indicating that protocols defining its clinical applicability could be imminent.However, in order to successfully isolate compelling biomarkers, blood samples require complex manipulation techniques that often show unsatisfactory efficiency and prove to be time-consuming and costly. Studies conducted thus far have demonstrated encouraging accuracy, yet further research is critical in order to validate liquid biopsy as a screening and early diagnostic technique. Furthermore, the utility of liquid biopsies in the era of precision medicine is an important frontier that demands thorough inquiry.