Are nursing homes exposed to potential hurricane-related inundation more likely to meet Centers for Medicare & Medicaid Services criteria for adequate emergency preparedness?In this cross-sectional study of 5914 nursing homes, a higher prevalence of emergency preparedness deficiencies among nursing homes exposed to hurricane-related inundation in the Mid-Atlantic region was observed. Exposure status remained positively associated with the presence and number of emergency preparedness deficiencies after adjustment for facility characteristics, with the converse for facilities within the Western Gulf Coast.These findings suggest opportunities to reduce regional heterogeneity and improve the alignment of nursing home emergency preparedness with surrounding environmental risks. This cross-sectional study estimates the prevalence of nursing homes that are subject to severe hurricane-related inundation within the Coastal Atlantic and Gulf Coast states and evaluates whether exposure status is associated with adherence to emergency preparedness standards across regulatory regions. Whether US nursing homes are well prepared for exposure to hurricane-related inundation is uncertain.To estimate the prevalence of nursing homes exposed to hurricane-related inundation and evaluate whether exposed facilities are more likely to meet Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards.This cross-sectional study included CMS-certified nursing homes in Coastal Atlantic and Gulf Coast states from January 1, 2017, to December 31, 2019. The prevalence of facilities exposed to at least 2 feet of hurricane-related inundation used models from the National Hurricane Center across coastal areas overseen by 5 CMS regional offices: New England, New York metropolitan area, Mid-Atlantic region, Southeast and Eastern Gulf Coast, and Western Gulf Coast. Critical emergency preparedness deficiencies cited during CMS life safety code inspections were identified.The analysis used generalized estimating equations with binomial and negative binomial distributions to evaluate associations between exposure status and the presence and number of critical emergency preparedness deficiencies. Regionally stratified associations (odds ratios [ORs]) and rate ratios [RRs]) with 95% CIs, adjusted for state-level fixed effects and nursing home characteristics, were reported.Of 5914 nursing homes, 617 (10.4%) were at risk of inundation exposure, and 1763 (29.8%) had a critical emergency preparedness deficiency. Exposed facilities were less likely to be rural, were larger, and had similar CMS health inspection, quality, and staffing ratings compared with unexposed facilities. Exposure was positively associated with the presence and number of emergency preparedness deficiencies for the nursing homes within the Mid-Atlantic region . Conversely, exposure was negatively associated with the number of emergency preparedness deficiencies among facilities within the Western Gulf Coast . The associations for the number of emergency preparedness deficiencies remained after correction for multiple comparisons.The findings of this cross-sectional study suggest that the association between exposure to hurricane-related inundation and nursing home emergency preparedness differs considerably across the Coastal Atlantic and Gulf regulatory regions. These findings further suggest that there may be opportunities to reduce regional heterogeneity and improve the alignment of nursing home emergency preparedness with surrounding environmental risks. It is also uncertain whether nursing homes at increased risk of exposure are adequately prepared to safeguard residents upon encountering environmental hazards.Nursing homes’ emergency preparedness is vital due to projected increases in the frequency with which coastal communities are exposed to severe weather events.11 This requires that facility administrators and staff assess, document, and plan for potential hazards, including severe weather events, that are expected to impact their geographical region.11 Emergency preparedness is then audited by state survey agencies, which are overseen by CMS regional offices.11The paucity of information regarding nursing homes’ preparedness for local environmental hazards may be attributed, in part, to the inherent complexity of characterizing small-area variation in environmental exposures. Because environmental exposures vary across communities, the Centers for Medicare & Medicaid Services (CMS) has advised an all-hazards approach to emergency preparedness.12 nursing home management and staff and the superstructure of state survey agencies and CMS regional offices may not be well positioned to appraise and prepare for potential environmental hazards. Therefore, the CMS encourages partnerships with municipal agencies to ensure that nursing homes are embedded within community disaster planning and response.13 Despite this recommendation, nursing home integration into community disaster preparedness efforts remains variable.15 Prior assessments of nursing home emergency preparedness, moreover, have identified widespread deficiencies in critical competencies that include appropriate specification of evacuation routes and preparedness to shelter residents in place.16 These preventable deficiencies heighten the risk of resident morbidity and mortality following exposure to severe weather events.17Considering their competing responsibilities,In this study, we estimate the prevalence of nursing homes that are subject to severe hurricane-related inundation within Coastal Atlantic and Gulf Coast states. We then evaluate whether exposure status is associated with adherence to emergency preparedness standards by nursing homes across regulatory regions overseen by 5 CMS regional offices. The results of this study should inform practices and policies designed to align nursing home emergency preparedness with the hurricane-related inundation risk to which facilities are exposed.STROBE) reporting guideline. This research was deemed exempt from review and informed consent by the Yale University Institutional Review Board under 45 CFR 46.104.This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology , leading to a final analytic sample of 5914 facilities.We utilized the CMS Provider Information Catalog to identify certified nursing homes within states that are at risk of exposure to hurricane-related inundation along the Coastal Atlantic and Gulf Coast regions as per the National Hurricane Center (NHC) (n = 6167).20 Our primary exposure threshold was informed by the US National Weather Service determination that roads are impassable at inundation heights above 18 to 24 inches,21 which would preclude the safe ground evacuation of residents and transport of essential medications or subsistence provisions. The NHC data do not project inundation within levee systems because its predictions are constrained to land that is normally dry.19 We classified the 46 nursing homes within leveed areas as exposed because levee systems are both subject to failure and concentrated in areas with disproportionate risk of severe flooding.22We defined exposed nursing homes as those at risk of at least 2 feet of inundation during Saffir-Simpson Hurricane Wind Scale category 1 to 5 hurricanes as per the NHC storm surge hazard maps.19 Briefly, the NHC storm surge hazard maps aggregate maximum inundation heights, assuming a high-tide initial water level.19 Storm surge events occur when the height of water generated by a storm rises above that of normal astronomical tides.19Inundation, the height of water above the ground surface, is estimated by subtracting the height of land elevation from that of the storm surge.19 The NHC uses the Sea, Lake, and Overland Surges from Hurricanes (SLOSH) model to simulate a representative sample of hypothetical storms, resulting in 2 data products.19 The first, maximum envelopes of water, represents the maximum inundation resulting from tens of thousands of hypothetical storms, with varying meteorological assumptions.19 The second represents the maximum composite value across the maximum envelopes of water.19The methods used by the NHC to model inundation have been described previously.23 From the 252 potential emergency preparedness deficiencies, we selected a subset deemed to be most critical in accordance with prior literature and emergency preparedness guidance . We used LTCFocus (Long-Term Care Focus) data to link lagged (2018) indicators of the payer mix and quantified the percentage of residents within each facility primarily insured by Medicaid.We first estimated the percentage of nursing homes at risk of exposure to at least 2 feet of hurricane-related inundation using their geocoded addresses. We described facility characteristics for the full sample and compared these characteristics among facilities according to their inundation exposure status. We also assessed the prevalence of critical emergency preparedness deficiencies across the nursing homes within each CMS regional office designation (described hereinafter).We evaluated associations between location within an inundation-exposed area and emergency preparedness deficiencies (presence and count) using generalized estimating equations with binomial and negative binomial distributions, respectively, clustered by facility identification numbers, with robust standard errors. To address potential confounding, the models were adjusted for facility characteristics.30 we included fixed effects for state within each stratified model. We used the Benjamini-Krieger-Yekutelli correction to account for multiple comparisons.31 In sensitivity analyses, we reran the models for the 5 regional office strata after increasing the severity of the inundation exposure threshold to at least 4 feet and at least 6 feet. We conducted analyses using ArcGIS Pro (Esri), Python, version 3 (Python.org), and Stata, version 17 (StataCorp LLC). Two-sided P < .05 indicated statistical significance.We stratified our analysis across the 5 CMS regional offices overseeing state survey agencies along the Coastal Atlantic and Gulf Coast. Regional office 1 of the CMS oversees New England ; regional office 2, the New York metropolitan area (New York and New Jersey); regional office 3, the Mid-Atlantic region ; regional office 4, the Southeast and Eastern Gulf Coast ; and regional office 6, the Western Gulf Coast (Louisiana and Texas). Regional office 5 was not evaluated because it oversees Midwestern states. To adjust for state-level variation in inspection practices and patterns,The most common emergency preparedness deficiencies among the 5914 nursing homes related to appropriate emergency preparedness training and procedures, as well as the establishment and maintenance of an emergency preparedness program , exposure status appeared to be protective against emergency preparedness deficiencies. New England facilities  demonstrated a similar pattern for the presence and number of critical emergency preparedness deficiencies, although these associations were not statistically significant. The most prevalent deficiencies are related to the ability of nursing homes to safely shelter in place or evacuate residents. Especially concerning is the high prevalence of inadequate subsistence provisions or standby power systems, as these factors may prompt unnecessary evacuations and thereby compound risks to vulnerable residents.34 The stark regional variation in emergency preparedness by exposed nursing facilities suggests that it may be useful to isolate and disseminate the strategies used by nursing home administrators, staff, and regulators within high-performing regions.35 Because Western Gulf Coast nursing homes exhibited emergency preparedness adherence that was well aligned with the local environmental risks , they could potentially serve as a model for other regions. Possible explanations for the risk-responsive emergency preparedness of nursing homes in the Western Gulf Coast may include reforms following their prior experience in hurricane response.36 For example, Gulf Coast nursing home residents incurred substantial morbidity and loss of life in the wake of Hurricanes Katrina and Rita.36 Ensuing investigations determined that inadequate emergency preparedness and inappropriate evacuation decisions contributed to these costs, prompting increased federal, regional, and state oversight.37Considering the differential susceptibility of nursing home residents to external stressors, emergency preparedness should be better aligned with the likelihood and severity of exposure to environmental hazards, including hurricane-related inundation. Projected increases in the intensity and geographic distribution of hurricanes within coastal regions further heighten the importance of this issue.15 we suggest that state survey agencies and CMS regional offices consider stronger oversight and enforcement of these partnerships. Because it would be impractical for CMS regional offices to appraise and monitor environmental risks, partnerships with local and regional emergency planning agencies should be relied upon to identify facilities exposed to salient regional and local environmental hazards. In turn, regulators could identify which facilities should be prioritized for oversight based upon their historical audit performance. A regulatory framework that is responsive to environmental hazards might involve a relatively greater inspection frequency for facilities that have outstanding critical emergency preparedness deficiencies and are at disproportionate risk of exposure to regionally concentrated environmental hazards .15 Although facilities meeting these criteria should receive more intensive oversight, these changes may produce a cost-effective and more efficient allocation of oversight responsibilities.39 These partnerships may also offer valuable insight as to the alignment between facilities’ exposure risk and their structural ability to withstand inundation, as determined by available building code guidance.40In addition to learning from high-performing regions, improved integration of nursing homes into local disaster planning agencies may better align emergency preparedness with the magnitude of environmental risks to which facilities are exposed. Based on our results, which support concerns that nursing homes may be poorly integrated into community disaster response models under the CMS all-hazards framework,41 Second, physical processes affecting water levels outside of the areas for which the SLOSH models are validated cannot be modeled.19 Because the storm surge hazard maps represent maximum inundation scenarios, without probabilities corresponding to hurricane category, it would be desirable to repeat this analysis with a broader range of risk scenarios as such data products become available. We refrained from incorporating assumptions regarding the respective probabilities of Saffir-Simpson Hurricane Wind Scale categories to avoid compounding uncertainties across distinct climate models as risk projections continue to evolve.42 Third, the NHC data are constrained to hurricane-related inundation and may, therefore, underestimate inundation exposure due to factors including heavy rainfall.43 It would be instructive to replicate this analysis using geospatial data that reflect the risk of severe flooding due to multiple potential causes.This study has some limitations. Our ability to classify exposure is restricted to information aggregated within the NHC storm surge hazard maps. The developers of this resource note several potential limitations regarding the assumptions required to build this product. First, the data products do not account for increases in water levels due to waves, which may result in the underestimation of inundation by 10% to 50%.We cannot exclude the possibility that state surveyors were more vigilant in issuing emergency preparedness deficiencies based on perceived inundation risk. To address this limitation, we conducted sensitivity analyses that evaluated associations between emergency preparedness and increasingly severe exposure thresholds. Because regulators’ sensitivity to exposure increments has not been previously evaluated, we used a multiplicative scale to test the effect of large differences in inundation thresholds. Although the results of our additional analyses did not suggest a dose-response association between exposure severity and the likelihood of critical emergency preparedness deficiencies, they cannot rule out differences in the behavior of state surveyors or regional oversight practices.14 Nonetheless, the CMS standards subsume foundational competencies that are well aligned with national emergency preparedness guidance and prior literature.25 Moreover, inadequate emergency preparedness has contributed to adverse resident outcomes during prior emergencies due to severe weather events.2Our evaluation assumes that administrative deficiencies are reasonable indicators of nursing homes’ emergency preparedness, but adherence to CMS emergency preparedness guidance does not necessarily ensure effective execution of organizational emergency planning or response.Additionally, the observational nature of this study precludes our ability to isolate organizational or regulatory behaviors and practices that may underlie regional differences in the emergency preparedness of nursing homes at increased risk of exposure to hurricane-related inundation. Complementary qualitative analyses may help to elucidate the mechanisms underlying regional variation and identify practices that better align emergency preparedness and local environmental risk.Ensuring adequate nursing home emergency preparedness is vital to the safety and well-being of vulnerable older persons, especially as community exposure to hurricane episodes is projected to increase. We demonstrated considerable regional variability in the emergency preparedness of nursing homes exposed to hurricane-related inundation. We observed an association between emergency preparedness and potential inundation exposure for Mid-Atlantic nursing homes, suggesting that these exposed facilities with critical emergency preparedness deficiencies should be prioritized for remediation. Given their competing responsibilities and lack of formal training in this domain, nursing home administrators and staff may require additional support with their assessment and response to environmental risks under an all-hazards approach. Based on our findings, CMS regional offices may need to enhance enforcement of nursing home partnerships with local emergency planning agencies, which are better equipped to appraise and address environmental risks. Finally, the favorable preparedness of nursing homes within the Western Gulf Coast region suggests that this region could serve as an exemplar of risk-responsive emergency planning and oversight.


Crisis management Managing crises often requires diverging from predetermined plans. In this paper, we investigate how public health authorities in Finland acted, what kind of roles they adopted and how the expected roles and actions appeared in relation to the legislative framework and preparedness plans during the COVID-19 pandemic. Based on inter-country comparisons, Finland has managed COVID-19 pandemic relatively well. The study provides qualitative insights on pandemic governance in a decentralized multi-stakeholder public health system.Semi-structured interviews (n = 53) with key public health actors at central, regional and local levels were conducted during March 2021-February 2022. The data was analysed with thematic analysis.The predetermined roles and duties for pandemic management were not unequivocal in practice and appeared unrealistic considering the resources of the public health system. Responsibility was divided between several actors, but lack of interaction enhanced emerging tensions between them. Local and regional actors experienced national steering intervening in operational decisions. At central level distrust towards the capabilities of local and regional actors was expressed. The pandemic was framed and managed as a health crisis despite of its wider societal effects. This challenged local and regional decision-making, where wider societal impacts had to be considered.Public health authorities in Finland interpreted their roles and responsibilities in pandemic governance in various ways: some actors adopted more active agency than others and the roles were not always in line with the existing regulative framework.• Interpretation of the roles outlined in preparedness plans are context dependent and may lead to conflicts between different actors.• In a system with multiple actors at multiple levels, building trust and improving interaction are important for coordinated action.


Prostate cancer (PCa) is the leading cause of male cancer deaths in Africa. In USA, African American men (AA) experience higher mortality rate compared to European American men (EA). While socioeconomics factors contribute toward these disparities, distinct molecular mechanisms in AA remain important drivers. For example, in previous work, we discovered that PCa form AA men harbored a significantly higher expression of Aminopeptidase N (ANPEP) as compared with EA. Aminopeptidase N regulates immune cell function and mediates tumor cell migration but its role in PCa remains uninvestigated.We explored ANPEP expression related to a range of genomic classifiers in multiple datasets. We then prospectively examined the differentially expressed genes in PCa tissues collected from 120 AA and 120 EA patients enrolled on the VANDAAM clinical trial. We further correlated ANPEP expression with various signatures related to immune and metabolic activity. We also experimentally examined the expression of ANPEP in different components of tumor microenvironment.In the VANDAAM study, ANPEP represents the top differentially expressed gene between AA and EA men. Our data driven approach revealed that ANPEP correlates with signature of cholesterol transport and androgen signaling. Interestingly, these signatures dominate in PCa with high macrophage infiltration. Deconvolution of immune cell content using computational approaches indeed demonstrated that only AA patients with high ANPEP expression significantly accumulated high content of inflammatory macrophages. Further experimental findings showed that ANPEP indeed represents a marker of tumor-associated macrophages, a type of immune cells known to contribute to PCa progression.We have identified ANPEP as a macrophage-related gene with a potential role in cholesterol metabolism and AR signaling in AA. Future work will focus on the functional role of ANPEP activity in the tumor immune microenvironment using Liquid chromatography-high resolution mass spectrometry and explants derived from AA and EA PCa patients.


Freezing of gait (FoG) is a paroxysmal and sporadic gait impairment that severely affects PD patients’ quality of life. This review summarizes current neuroimaging investigations that characterize the neural underpinnings of FoG in PD. The review presents and discusses the latest advances across multiple methodological domains that shed light on structural correlates, connectivity changes, and activation patterns associated with the different pathophysiological models of FoG in PD. Resting-state fMRI studies mainly report cortico-striatal decoupling and disruptions in connectivity along the dorsal stream of visuomotor processing, thus supporting the ‘interference’ and the ‘perceptual dysfunction’ models of FoG. Task-based MRI studies employing virtual reality and motor imagery paradigms reveal a disruption in functional connectivity between cortical and subcortical regions and an increased recruitment of parieto-occipital regions, thus corroborating the ‘interference’ and ‘perceptual dysfunction’ models of FoG. The main findings of fNIRS studies of actual gait primarily reveal increased recruitment of frontal areas during gait, supporting the ‘executive dysfunction’ model of FoG. Finally, we discuss how identifying the neural substrates of FoG may open new avenues to develop efficient treatment strategies. There hAlthough FoG in PD patients is more prevalent when the patients are OFF dopaminergic treatment (60%) than when ON (36–38%) , FoG shoNotably, the prevalence of PD in our aging population is predicted to substantially increase by approximately 30% by 2030 , with a 1.1The knowledge about the neural mechanisms controlling human gait is still incomplete, mainly due to the complexity of the human locomotor system and the technical limitations of studying locomotion. Accordingly, the current knowledge about the neural control of human gait is primarily derived from animal models. Studies on gait regulation in animals revealed widespread neural circuitries spanning different nervous system levels, including cortical, subcortical, brainstem, and spinal cord structures . HoweverThe neural networks that govern human gait are organized in an evolutionary hierarchy see  that proThe top of the gait control hierarchy comprises higher-level control centers in the cerebral cortex and the basal ganglia (BG) that modulate indirectly and directly the locomotor regions’ activity in generating efficient volitional gait regulation. At rest, the globus pallidus internus (GPi) and the substantia nigra reticularis (SNr) provide constant GABAergic inhibitory signals to the MLR/PPN that restrict the information flow in the spinal cord and prevent unwanted movements. During motor activity, input from frontoparietal areas can amplify or reduce these inhibitory signals . In partIn conclusion, the neural systems underlying gait control in humans comprise complex mechanisms with intertwined structures, in which higher-order cortical areas indirectly regulate the output of the locomotor regions via established reciprocal connections with subcortical structures. This hierarchical bi-directional organization allows the human gait control system to adapt its motor output to changing intentions and environments flexibly. However, this flexible planning and execution of walking movements is deficient in PD patients since the underlying neurodegenerative disease process affects the gait control system at different levels.1.2Five non-exclusive pathophysiological models have been proposed to explain the origin of FoG in PD . These mabnormal gait pattern generation’ hypothesis proposes that the asymmetric and uncoordinated gait preceding episodes of freezing . Due to the deficient cortico-subcortical crosstalk, the signals from the cognitive, motor, and limbic cortical areas overwhelm the limited processing capacity of the striatum in PD patients and lead to an overinhibition of brainstem structures, eventually manifesting in FoG (decoupling’ between posture preparation (SMA) and step initiation (the motor cortex) causes multiple dysfunctional anticipatory postural adjustments that are manifested as knee trembling during FoG  ‘freezing  results g in FoG . Anotherring FoG . The bre changes . This mo changes . Finallye of FoG . AccordiThe apparent heterogeneity of the mechanisms underlying FoG in PD proposed by the five non-exclusive pathophysiological models of FoG indicates that consensus on the neurological underpinnings of FoG is far from reach and, consequently, extensive research is warranted to unravel the complexities of this phenomenon. Studies employing imaging techniques contribute valuable new data for a better understanding of the physiology and pathophysiology of human gait control. Identifying major neural substrates of FoG may open new avenues for developing novel and efficient treatment strategies for FoG in PD patients. This review summarizes and critically evaluates the recent imaging studies on FoG in PD across multiple methodological domains to shed light on structural correlates, connectivity changes, and activation patterns associated with the pathophysiology of FoG in PD patients. Furthermore, the disparate imaging results are related to current pathophysiological models of FoG in PD. For a complementary review that discusses electrophysiological findings in light of the pathophysiological models of FoG, the reader is referred to the recent review by 2The review encompasses articles not previously covered or thoroughly discussed by recent reviews on FoG in PD patients . The incThe PubMed database and Google Scholar were used to collect the articles with the search queries ‘Parkinson’ AND ‘Freezing of gait’ AND . After a systematic assessment of the articles’ eligibility, the total number of reported articles in this review is 40 articles. These articles were divided into 18 resting-state MRI studies , 13 task-based MRI studies , and 9 functional near-infrared spectroscopy (fNIRS) studies.In order to further assess the quality of evidence provided by the different imaging studies, we systematically graded each reported study based on six pre-defined criteria, i.e., studied sample, clinical groups, FoG/gait assessment, correction for multiple comparisons, control for differences in covariates, and experimental design  structural connectivity investigate abnormalities in WM tracts by diffusion tensor imaging (DTI) and examine mainly mean diffusivity (Md) and fractional anisotropy (FA). Several findings have emerged from different WM connectivity studies, despite differences in experimental methods and analysis approaches, namely whole-brain voxel-wise analysis and region of interest (ROI) correlation analysis.Several structural connectivity studies report patterns of WM abnormalities that constitute potential biomarkers supporting the ‘interference model’, i.e., deficient crosstalk between cortical areas and the BG. Notably, structural imaging studies revealed a distributed pattern of reduced WM tracts connecting subcortical structures, encompassing the cerebellum , subthalper se but may be related to other confounding factors such as cognitive impairment and general (motor) deficits associated with Parkinson’s disease.Other structural imaging studies align with the ‘executive dysfunction’ model of FoG, which proposes a decoupling between the frontal lobe and the BG. These studies report WM tract disruptions between frontal areas and subcortical structures  and dist3.2A promising approach to investigate the neural mechanisms underlying FoG in PD patients is resting-state fMRI (rs-fMRI). This neuroimaging approach has been extensively used in studying the neural correlates of FoG in patients with PD as it permits the assessment of the whole brain without an experimental task. Rs-fMRI quantifies the functional connectivity between spatially disparate neural networks  by detecting fluctuations in spontaneous BOLD signals across the whole brain . The parSeveral rs-fMRI studies reveal a reorganization of the intrinsic functional connectivity (FC) within higher cortical regions  and subcIt is well established that PD patients, and those suffering from FoG in particular , rely moDysfunctional network connectivity between subcortical and cortical areas extended beyond cognitive and sensorimotor areas, also affecting visuospatial networks. In PD patients with FoG, abnormal FC was observed between the visual cortex, mainly of the right hemisphere, and left caudate , right PSeveral studies converge in reporting a decrease in resting-state FC between several cortical areas along the dorsal stream of visuomotor processing . In partThe significant findings derived from resting-state fMRI (rs-fMRI) studies primarily support the ‘interference’ or the ‘perceptual dysfunction’ models of the pathophysiology of FoG in PD. These findings should nevertheless be treated with caution, given several inherent limitations of the rs-fMRI method in FoG in PD. On the one hand, rs-fMRI studies of FoG mainly adopt a cross-sectional approach that compares the neurophysiological changes of PD patients with FoG with those of healthy controls or PD patients without FoG at a given time. A fundamental shortcoming of such a cross-sectional approach is the failure to consider the contribution of interindividual variability in FoG severity within groups of PD patients with FoG. In particular, the sole comparison of resting-state FC changes in PD patients with FoG versus healthy controls can be even more problematic than the comparison of PD patients with FoG with PD patients without FoG, as the former comparison cannot differentiate between specific neuroanatomical/-physiological changes related to FoG and those related to other more general deficits  in Parkinson’s disease. To circumvent these limitations of cross-sectional approaches, the alternative study design adopted by On the other hand, rs-fMRI studies can only indirectly correlate resting state FC to FoG measures, as these studies relate neurophysiological changes measured when lying supine in the MRI scanner to objective or subjective gait assessments obtained outside the scanner. Except a few studies that related resting-state FC changes with objective measures of FoG recorded during a turning or walking task before the scanning session, most of the rs-fMRI studies on FoG in PD related resting-state FC changes with subjective self-reports of FoG, i.e., using the FoG-Questionnaire. However, the reliability of subjective recall of FoG symptoms may be hampered by cognitive deficits. An alternative objective assessment tool of FoG that can be considered in future rs-fMRI studies is the rating instrument developed by 4Task-based fMRI studies can detect real-time correlations of neurophysiological alterations with gait-related performance measured during the scanning session. These studies mainly adopt virtual reality (VR) and motor imagery (MI) paradigms that correlate neurophysiological changes with foot-pedaling performance and with the mental simulation of pre-instructed (gait-related) actions, respectively. In addition to VR and MI paradigms, a recent study adopted a novel paradigm of dorsal or plantar foot-flexion movement in response to auditory stimuli, which meant to approximate the sensorimotor activity during normal gait without inducing episodes of FoG . Importa4.1In combination with functional neuroimaging, virtual reality (VR) paradigms were used in several studies to explore the underlying pathophysiology of FoG in PD patients. Virtual reality is supposed to permit an objective and safe evaluation of FoG in PD patients in an ecologically valid environment. The reported VR paradigms consist of first-person perspective navigation. Participants navigate using MRI-compatible foot pedals through a virtual environment that displays several triggers known to produce FoG in PD patients . In these studies, FoG is measured as an episode of motor arrest, consistently defined across studies as an abnormally long period of between-footstep latency compared to the mean between-footstep latency computed during normal walking. Measures of these motor arrests were positively correlated with self-reported severity of FoG , suggestShine and colleagues conducted a series of VR studies revealing consistent alterations in BOLD activation levels and functional connectivity (FC) changes between cortical and subcortical regions of PD patients with FoG. Increased activation in frontoparietal regions was negatively related to freezing severity, whereas reduced activity in the BG, thalamus  and pre-In agreement with the findings reported by Shine and colleagues, further VR studies revealed abnormal functional connectivity (FC) patterns between cortical and subcortical structures . NotablyMost of the above-reported abnormalities concentrate on the ‘hyper-direct’ pathway see , comprisDespite differences in the implemented VR experimental paradigms, most of the neuroimaging findings revealed by task-based VR paradigms support the predictions made by the 'interference model' . Taken t4.2Motor imagery (MI) paradigms are adopted to assess and modulate gait impairments in PD patients. MI is defined as the mental simulation of action without overt execution . MI simuFollowing the reported hypoactivation in subcortical regions in VR studies , imagingSeveral MI studies revealed abnormal patterns of activation encompassing cortical areas along the dorsal visuomotor pathway that were more pronounced in the right hemisphere of PD patients with gait impairments . During Studies adopting MI paradigms report various neurophysiological changes that primarily show agreement with either the ‘interference’ or the ‘perceptual dysfunction’ models of FoG in PD. The variability in observed findings across MI studies is partly due to the differences in complexity across the implemented MI paradigms and differences in the studied samples of PD patients. The latter is particularly problematic for a cross-studies comparison since the included patients show a wide range of disease severity. Moreover, the lack of FoG assessments in some MI studies renders it difficult to precisely distinguish between neurophysiological changes associated with general symptoms of PD and those mainly linked to FoG in PD.4.3Functional near-infrared spectroscopy (fNIRS) is a neuroimaging method that recently gained popularity in studying the neurophysiology of gait impairments and FoG in PD. Like fMRI, this technique detects hemodynamic changes (of oxygenated and deoxygenated hemoglobin) in cerebral blood flow produced by neurovascular coupling. Being both portable and wireless, fNIRS permits measurements of brain activity during actual walking, i.e., while being in an upright position, thus having the advantage of also assessing the postural and balance control mechanisms involved in bipedal gait (in contrast to the supine position when lying in an MRI scanner). Moreover, fNIRS studies allow the direct correlation of neurophysiological changes with real-time behavioral gait metrics measured by wearable gait sensors. Studies investigating prefrontal activity with fNIRS during a walking task converge on reporting higher activity within the PFC  and the Furthermore, studies assessing the effect of dopamine treatment on the recruitment of executive functions during gait indicate that PD patients with FoG exclusively employ executive functions to alleviate the loss of movement automaticity, as evidenced by increased recruitment of the PFC during gait . In contSince all fNIRS studies to date were restricted to the investigation of frontal brain regions associated with executive functions, i.e., the PFC and the DLPFC, their findings are largely discussed in light of the ‘executive dysfunction’ model of FoG in PD. Nevertheless, some fNIRS results indicate a potential reliance on other strategies, e.g., visuospatial strategies, to compensate for the loss of gait automaticity in PD patients with FoG. Given that dual-task turning requires higher cognitive control than single-task turning and, consequently, higher activation of the PFC, the counterintuitive observation of lower recruitment of PFC in PD patients suffering from FoG during dual-task turning  suggests5meta-analysis of neuroimaging studies revealed that gait impairments in PD are associated with lower SMA and higher CLR activation  in PD patients and discusses the neural correlates in light of the different pathophysiological models of FoG. Although the imaging findings do not converge on a single pathophysiological model of FoG, evidence suggests that FoG in PD is associated with more than a single neural mechanism. The studies converge on highlighting functional decoupling between cortical and subcortical regions as well as abnormal activation patterns, particularly within frontoparietal and parieto-occipital regions and the striatum. The current review demonstrates that despite multiple pathophysiological insights across the different studies, systematic comparisons are limited due to differences in neuroimaging modalities and targeted brain mechanisms. Notably, the potential differential neural substrates underlying FoG during walking and FoG during gait initiation remain unaddressed. Thus, developing novel experimental paradigms that tackle this distinction is warranted. Besides, future studies should adopt multimodal neuroimaging and address the above-mentioned limitations that currently hamper comprehensive imaging studies of FoG in PD patients. These future imaging studies will hopefully permit the improvement of current treatment strategies and set the ground to devise novel treatments for FoG in PD that are tailored to the individual patient and thus more efficient.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Ecologists usually find that plant demography  changes along with plant size and environmental gradients, which suggests the effects of ontogeny-related processes and abiotic filtering. However, the role of functional traits underlying the size– and environment–demography relationships is usually overlooked. By measuring individual-level leaf traits of more than 2700 seedlings in a temperate forest, we evaluated how seedling traits mediated the size– and environment–demography relationships. We found leaves were larger for taller seedlings; leaf economics traits were more conservative in taller seedlings and under high-light and low-elevation conditions. Structural equation modelling showed that a higher survival probability for taller seedlings was indirectly driven by their larger leaf area. Although taller seedlings had lower growth rates, larger and more resource-conservative leaves could promote the growth of these tall seedlings. Environmental variables did not influence seedling survival and growth directly but did influence growth indirectly by mediating trait variation. Finally, species-specific variation in traits along with size and environments was associated with the species-specific variation in seedling survival and growth. Our study suggests that not only plant ontogeny- and environment-related ecological processes, but functional traits are also important intermediary agents underlying plant size– and environment–demography relationships. The seedling stage is a bottleneck stage for plant survival and growth because of the production of more individuals than could occupy open spaces and their general susceptibility to surrounding abiotic and biotic environments . Given tWith the increasing number of studies exploring seedling survival and growth, especially in permanent forest dynamics plots, most studies find that seedling height is the most important factor influencing survival and growth, and superior to other biotic and abiotic factors . Ac; )


Transcatheter heart valve (THV) embolization is a rare complication of transcatheter aortic valve implantation (TAVI) generally caused by malpositioning, sizing inaccuracies and pacing failures. The consequences are related to the site of embolization, ranging from a silent clinical picture when the device is stably anchored in the descending aorta to potentially fatal outcomes . Here, we present the case of a 65-year-old severely obese woman affected by severe aortic valve stenosis who underwent TAVI complicated by embolization of the device. The patient underwent spectral CT angiography that allowed for improved image quality by means of virtual monoenergetic reconstructions, permitting optimal pre-procedural planning. She was successfully re-treated with implantation of a second prosthetic valve a few weeks later.


Editorial on the Research TopicAdvances in rehabilitation intervention after limb amputationThe tenth anniversary of the Boston Marathon Bombings is soon approaching on April 15, 2023. This mass casualty event highlighted the extraordinary role of bystanders and first responders who applied tourniquets, highly skilled trained trauma teams at the five Boston level I Trauma academic medical centers, followed by high quality, coordinated acute rehabilitation care in ensuring the best possible outcomes for the survivors  pressures and residuum muscle activation after transfemoral osteomyoplastic amputations (OTFA) during brisk and self-paced gait compared to the performance with that of intact controls. They showed that RSI pressures were distributed throughout the residuum-socket and that muscles were engaged and often co-contracted at key times during the gait cycle. Their recommendations include enhancing specific therapeutic exercises as part of OTFA rehabilitation to improve control activation of hip adductors, hamstrings, and quadriceps in the intact and distal-residual limbs, thereby optimizing overall gait performance stability and reducing excessive energy expenditure. This study highlights that new reconstruction techniques require that new, patient-centered rehabilitation protocols be developed and studied.Efforts to incorporate newer technical developments in amputation surgery and reconstruction demonstrate a shift toward an outcomes-oriented approach in amputee care –13. SurgKhetarpaul et al. focuses on the interdisciplinary team approach (Frontiers | Socioecological model-based design and implementation principles of lower limb preservation programs as partners for limb-loss rehabilitation programs—A mini-review. Their review article can be helpful to healthcare institutions and organizations seeking to develop, expand, or refine their ability to provide comprehensive limb care. The model system of care includes presurgical planning, postsurgical and early pre-prosthetic rehabilitation care, and prosthetic and lifelong care. Rehabilitation care includes coordination with community resources, such as peer support, and vocational, recreational, and driving assessment. The emphasis on prior mental health concerns and new concerns that arise with limb loss should also be addressed by mental health professionals in the multidisciplinary care provider team model.When treating individuals with severe limb trauma, important decisions around limb salvage vs. amputation and optimal amputation level are ideally made through an interdisciplinary approach to optimize both surgical and functional outcomes . The lasapproach  as the mWe are confident that this series of articles will advance the multidisciplinary surgical and rehabilitation care that takes place before and after limb amputation and will provide a successful framework for ongoing research.


Drosophila. We use embryos that greatly differ in length and, importantly, possess distinct length-scaling characteristics of the Bicoid (Bcd) gradient. We systematically analyze the dynamic movements of gap gene expression boundaries in relation to both embryo length and Bcd input as a function of time. We document the process through which such dynamic movements drive both an emergence of a global scaling landscape and evolution of boundary-specific scaling characteristics. We show that, despite initial differences in pattern scaling characteristics that mimic those of Bcd in the anterior, such characteristics of final patterns converge. Our study thus partitions the contributions of Bcd input and regulatory dynamics inherent to the AP patterning network in shaping embryonic pattern's scaling characteristics.How patterns are formed to scale with tissue size remains an unresolved problem. Here we investigate embryonic patterns of gap gene expression along the anterior-posterior (AP) axis in  PatternDrosophila, the maternally-derived morphogenetic protein Bicoid (Bcd) forms a concentration gradient along the AP axis to instruct embryonic patterning .Prof Jun Ma was supported by National Key R&D Program of China [2021YFC2700403 & 2018YFC1003203], National Key R&D Program of China [2021YFC2700403 & 2018YFA0800102], 10.13039/501100001809National Natural Science Foundation of China [31871249].Prof Feng He was supported by Data will be made available on request.The authors declare no competing interests.


Liver diseases are responsible for over 2 million deaths each year and the number is rapidly increasing. There is a strong link between edibles, gut microbiota, liver fat and the liver damage. There are very limited therapeutic options for treatment specifically for Alcoholic liver disease (ALD) and Non-Alcoholic liver disease (NAFLD). Recently, identified Edible Exosomes-like nanoparticles (ELNs) are plant derived membrane bound particles, released by microvesicular bodies for cellular communication and regulate immune responses against many pathogens. Many studies have identified their role as hepatoprotective agent as they carry bioactive material as cargoes which are transferred to recipient cells and affect various biological functions in liver. They are also known to carry specific miRNA, which increases the copy number of beneficial bacteria and the production of lactic acid metabolites in gut and hence restrains from liver injury through portal vein. Few in-vitro studies also have been reported about the anti-inflammatory, anti-oxidant and detoxification properties of ELNs which again protects the liver. The properties such as small size, biocompatibility, stability, low toxicity and non-immunogenicity make ELNs as a better therapeutic option. But, till now, studies on the effect of ELNs as therapeutics are still at its infancy yet promising. Here we discuss about the isolation, characterization, their role in maintaining the gut microbiome and liver homeostasis. Also, we give an outline about the latest advances in ELNs modifications, its biological effects, limitations and we propose the future prospective of ELNs as therapeutics. Liver diseases have pathological spectra ranging from simple steatosis to hepatitis to cirrhosis and hepatocellular carcinoma. Non-alcoholic fatty liver disease is one the most common diet and fat associated non-communicable disease. Presently, 25%-35% and 5%-15% of the general population of Western and Asian countries, respectively, are affected by this disease. This proportion is even higher in people with type 2 diabetes (60%-70%), and in those who are obese or morbidly obese (75%-92%) compared to the general population. Like alcoholic liver disease there is no effective treatment to date for NAFLD. In the absence of a proven effective therapy, we must follow a multi-disciplinary approach in NAFLD treatment. Treatment is mainly directed towards weight loss and risk factor reduction, as most patients are obese or have metabolic syndrome. Dietary modification plays a key role since a carbohydrate-rich diet, especially with high fructose, is the major cause of obesity, insulin resistance and NAFLD development.in vitro and in vivo are related to gastrointestinal cell lines or diseases such as inflammatory bowel diseases, gastric cancer, colitis, etc. so far reported.Liver disease patients also exhibit gut bacterial overgrowth, enhanced gut permeability and increased paracellular leakage of gut luminal antigens, factors that promote liver damage. A dietary intervention in obese or overweight subjects, consisting of administering an energy-restricted high protein diet during six weeks, increased the diversity of species in the gut, along with decreased adiposity, which reverted to basal levels after the diet was stopped. Dietary components are not only consumed by the host (humans) but also by the gastro-enteric microbiota. The kind of diet we consume effects the microbiota composition as well as the nutritional, toxicological, and biochemical components availability after processing of food in the gut. Though hepatoprotective dietary products have been identified, there is still a need for further investigation to completely understand the mechanism of action of various components in the diet. The major problem is that to attain a certain amount of nutrient, gut microbiota modulation, a large quantity has to be consumed. Hence, a prospective solution to it can be Edible exosomes-Like Nanoparticles (ELNs). ELNs are small membrane vesicles which carry various biomolecules as cargoes The liver is one of the vital organs which readily acts as scavenger, contributes in immune surveillance, and is the only organ to have regenerative property. Gut derived products transported into liver by portal vein to liver and in feedback gut receive bile hence forming the interface of gut-liver axis. This interface maintains the gut homeostasis by maintaining the gut microbiota and host immune cells. Mostly in liver diseases this barrier has found disrupted leads to invasion of microbes and microbial particles inside host tissue. There are many therapeutic options which are available for various liver diseases are based on synthetic drugs, prebiotics, probiotics and synbiotics. In this review, we have summarised about ELNs in accordance to their structure, biochemical composition and bio-availabity to target cells, and their promising future therapeutic applications in liver diseases as this could be one of the potent prebiotics which will be safe, efficient and affordable for the treatments.For isolation of ELNs, there exist various methods, among which differential ultracentrifugation is considered the gold standard. Firstly, edible part of plants are grounded in to juice using mixture then further procedure followed to remove large plant debris or fibres and other unwanted aggregates. Differential ultracentrifugation involves a multistep process that includes low speed centrifugation i.e. 1000 × g to get rid of larger particles or fibres, followed by medium- speed centrifugation of 10,000 × g for removal of larger debris and intact organelles. At last, high-speed ultracentrifugation of 100,000- 150,000 × g was used for pelleting down exosomes or exosome-like particles Like other mammalian EVs, ELNs can be characterized by various ultrasensitive microscopic methods that are Transmission Electron Microscopy (TEM), Scanning Electron Microscopy (SEM) or Atomic force Microscopy (AFM) and for structural analysis at subcellular level ELNs ultrastructural analysis has been reported by cryo-Electron Microscopy. Where the cup shaped spherical subcellular structures can be seen with their double membranous lipid bilayer and hence identified as ELNs. Characterization of mammalian EVs is also possible by Flow-cytometry as they have specific markers according to their cell of origin. But for ELNs till now there are no specific markers reported, hence this restricts us from using various methods for their characterization. For determination of size and charge of these particles, Dynamic Light Scattering (DLS) has been extensively used. Now days to analyse their size along with concentration Nanoparticle Tracking Assay (NTA) has been followed as it can analyse the Brownian motion of these particles with respective size and concentration. To determine the dispersity or their repulsive nature to avoid aggregation along with stability Zeta analyser can be used to calculate their membrane potential Fig. .The variable surface glycoprotein and lipid compositions among all EVs acts as ligands which are responsible for bio-distribution and specific binding to target cells. Mostly, ELNs uptake had been identified by various ways such as membrane fusion, phagocytosis, macro-pinocytosis and receptor mediated endocytosis. Membrane fusion generally depends on same membrane fluidity of both ELNs and membrane of target cell which requires a low pH 5 Lactobacilus, PC- enriched grapefruit derived ELNs and these were preferentially taken up by Ruminococcaceae whereas the PA and PC depleted vesicles are not taken up by these bacteria. Considering the in vivo bioavailability of this ELNs PA enriched vesicles generally accumulate in gut whereas PC enriched vesicles reach out to liver when given orally. Still the need of understanding the effect of membrane lipid composition in uptake of ELNs by their target cells is open for research.Bio-distribution mainly depends on several factors like parent cell source, uptake mechanism of ELNs by target cells and their retention in circulation along with the membrane composition. Studies of mammalian EVs, RBC-derived EVs showed a gradual uptake by liver (44.9%), bone (22.5%), skin (9.7%), muscle (5.8%), spleen (3.4%), kidney (2.7%) and lung (1.8%). EVs of mammalian cells have specific markers or receptors according to their parent cells which helps them in easy availability to their target cells with the respective ligands for interaction In vivo oral administration of ELNs are well explained by pharmacodynamic study of Acerola ELNs (AELNs) using PKH26 fluorescent dye. They mainly reach out to mice intestine, liver, bladder and ovary after 1hr of consumption All plant derived EVs have been reported to carry different types of proteins, and nucleic acids as cargos which play a substantial role in intercellular communication. Nucleic acids i.e. miRNAs have been detected. EVs also carries DNA, that can be used for identification of translational biomarkers or mutational modifications in parent cells but their physiological significance is currently unknown.In 2006, for the first time presence of functional extracellular RNA was reported in murine stem-cell derived EVs Lactobacillus rhamnassus GG (LGG) that results in production of lactic acid and its derivatives which acts as ligands to activate anti- inflammatory pathways in host  mitigates Clostridioides difficile infections (CDI) which is a leading cause of antibiotic resistant colitis Clostridiaceae, Ruminococcaceae and Lachnospiraceae hence regulate the production of short chain fatty acids (SCFAs) that helps in enhancing intestinal immunity in mice Plant derived ELNs are present in our diet and reach the gut with daily intakes. They can also able to withstand the digestive juices and the harsh condition during digestion of food, hence maintains their integrity at gut. Many studies reveals the therapeutic implications of various plant- derived ELNs in mitigating diseases concerned to intestinal barrier and gut microbiota homeostasis such as colitis, inflammatory bowel diseases, colorectal cancer. Ginger derived ELNs carrying miR396e were successfully taken up by ost Fig.  30. At tMany therapeutic studies using ELNs have been reported till date. Most studies explaining the biological significance of ELNs reported against dextran sulphate sodium (DSS) induced colitis, inflammatory bowled diseases and on gut- microbiota. ELNs had shown their potentials like anti-inflammatory, anti- cancerous and anti-oxidant effects by changing the fate of recipient cells. There are few clinical trials which are already registered for liver diseases Table .Zhuang et al. 2015 reported the hepatoprotective effect of ginger-derived ELNs (GELNs) against alcohol-induced liver damage in mice. They identified Shogaol, the dehydrated analogue of gingerol activates the nuclear factor erythroid 2-related factor 2 (Nrf2) in a TLR4/ TRIF-dependent manner lead to the expression of liver detoxifying/ antioxidant genes like HO-1, NQO1, GCLM, and GCLC. Apart from antioxidant defences, Nrf2 also have critical roles in modulating various cellular processes like hepatocyte proliferation during liver regeneration, inflammation [Nrf2 is involved in maintaining hepatocyte identity during liver regeneration] Fig.  and drug in vitro.CD98 have a potential role in Non- alcoholic fatty liver diseases (NAFLD), hence co-localization of garlic ELNs indicates to be a promising target for both therapeutic and drug therapy in vivo, but due to the reduced absorption of triglycerides at jejunum, helps in systemic reduction of lipid which might lead to amelioration of steatosis. With increase in gene expression of junctional proteins such as CLD1, OCLN, ZO1 it also enhance the recovery of barrier permeability in colitis. Its contribution in concentration of amino acids and bioactive lipids in the jejunum, which are deficient in obese patients, could accelerate the restoration of intestinal functions during weight loss in obese patients.In context to metabolic syndrome diseases like hyperlipidaemia, obese- associated intestinal complications, OELNs increases the villi size in jejunum by lowering the fat absorption and chylomicrons production by targeting microsomal triglyceride transfer protein (MTP) hence reduced the plasma lipid concentration. It also acts upon angiopoietin-like protein-4 (ANGPTL4) Apart from oral administration of ELNs, the effect of Shiitake mushroom ELNs intraperitoneally alleviates haemorrhage and cell death in fulminant hepatic failure within 6 hrs administration Clostridial clusters IV and XIVa of Firmicutes helps in lowering the pH of colon thereby inhibit growth of pathogens In vivo studies using OELNs also suggests inhibition in lipid absorption at intestinal epithelia and at liver as well which also makes them perfect candidates to mitigate metabolic syndromes associated to liver diseases Lactobacillus, Bifidobacteria, Enterobacter, Bacteroides, Clostridium produces bileFaecalibacterium prausnitzii along with Bifidobacterium releases cholines Lactobacilluslactobacillus and streptococcus as well along with push them to produce metabolites which help in inter-bacterial communication in the gut E.coli they also strengthen the gut immunity and proof their selves as potential therapeutic elements. Hence targeting gut microbiota using ELNs for therapeutic interventions like probiotics could help in developing chronic liver diseases and the metabolic syndromes that are associated to liver. Apart from gut microbes in gut-liver axis, from physiological point of view there exist a strong correlation between High fat Diet and insulin resistance in development of Type 2- Diebetes Various studies suggested that alteration in gut microbiota i.e. gut dysbiosis leads to several diseases. Small intestinal bacterial overgrowth (SIBO) results into production of endotoxins leads to damage intestinal epithelia known as leaky gut and this translocation resulting into hyper inflammation, bacterial peritonitis, hyperdynamic or portal hypertension states. The strategic distal position of liver downstream to gut makes it the most effective organ by the endotoxins or microbiota produced components among other distal organs lactobacillus rhamnassus GG (LGG) used as probiotics and found to give promising results in recovery of disordered gut hence improving liver disease conditions. Before reaching to their site of action i.e. intestinal region live probiotic bacteria had to tolerate the bactericidal effects of various gastric juices, one of the challenges in applications of probiotics. Their preservation in different climatic zones accordance with transportation also found as obstacles. The gut microbiota varies from one person to another the species of bacteria could be same but the strains varies accordingly. Hence considering probiotics as a common solution cannot be fruitful.Interface of gut-liver axis constitute the multilayer defence of physical, humoral and immunological barrier to protect the body from primary exposure of endotoxins and other infectious particles that entered through gut. Liver diseases resulted due to alcoholic and non- alcoholic associated parameters. Alcohol breaches the barrier and this injury compels specific changes in gut microbiota that can enhance alcohol induced liver diseases. Continuous alcohol consumption increases endotoxin producing bacteria and reduction in autochthonous taxa that produces short- chain fatty acids (SCFAs) leads chronic liver disease to cirrhosis and alcoholic hepatitis Considering the therapeutic approaches, scientists surmount many challenges mainly safety delivery of therapeutic molecules to reach specific target site, low toxicity and economic production costs. Formation of such cost effective pharmaceutical molecules or nanoparticles with low immunogenicity, cytotoxicity needs complex fabrication processes In development of pristine plant derived nanovesicles (PNVs), the major concern was the preparation of uniform-sized with efficient loading of desired drug molecules to reach specific target site. For which researchers employed the Bligh and Dyer technique based on hydration of a lipid that earlier used for the fabrication of liposomes  in vivo have seen to be effective against brain GL- 26 brain tumour Aiming to the specificity and biocompatibility with lesser side effects PNVs encapsulated with desired molecules has been implemented against various diseases. It improves the delivery of therapeutic drug molecules that mainly involves hydrophobic drugs, siRNAs, miRNAs or proteins as they easily penetrate into tissues and with an enhanced circulation period. Grape fruit EVs (GfEVs) has been found as efficient carriers for the delivery of exogenously loaded Alexa fluor tagged Bovine Serum Albumin (BSA) and Heat Shock Protein 70 (HSP 70) into Peripheral Blood Mononuclear cells and colon cancer cells. They found as safe, potential and effective carrier for the delivery of exogenous proteins as compared to the proteins without EVs ELNs can be considered as the future of therapeutics specially for the gut and liver diseases. With the advancement of technology, the techniques to isolate, enumerate and characterize makes it much easier to use it as therapy. Not only this, the cargoes information in ELNs, and its association with restoration of gut microbiome homeostasis, hepatoprotective role makes it more potent as treatment option Fig. . With re


Methods and Applications in Exercise Physiology aimed to highlight the latest experimental techniques and methods relating to research and practice. In this series, we capture recent advances in measurement techniques for 1) cardiorespiratory exercise testing, 2) athletic performance, and 3) health monitoring.Exercise physiology is pivotal in optimizing health and performance as it influences various aspects of life, from sports performance to clinical rehabilitation and occupational health. 2peak measured by a single graded exercise test (GXT) is representative of an individual’s true maximum capacity, Hebisz et al. found no appreciable differences with verification tests performed 15 min after the GXT (cycling) or on a separate day. The ventilatory threshold and respiratory compensation point are other common markers of cardiorespiratory fitness measured during GXTs. Kim et al. developed and validated an automated method to identify these inflection points objectively. Together, these studies help to improve the way we measure key indicators of cardiorespiratory fitness.Valid assessment of maximum oxygen uptake and ventilatory threshold have been hallmarks of cardiorespiratory exercise testing for assessing athletic performance. Investigating whether VOHu et al. analyzed the results of twelve studies, concluding that although tDCS does not significantly improve upper limb muscle strength, significant improvements in upper limb endurance performance  can be achieved. Alternatively, the study by Lu et al. shows that tDCS can significantly improve muscle strength and explosive force of the non-dominant knee. Taken together, tDCS shows promise in offering an avenue to improve indicators of muscular performance.Improvements in athletic performance are synonymous with enhanced muscular strength and endurance. Recent research has sought to elucidate if non-invasive brain stimulation technology can promote these outcomes. Transcranial direct current stimulation (tDCS) induces focal and transient changes in cortical excitability by applying a low-intensity direct current to the scalp. In a systematic review, Date et al. have shown that surface EMG of Brachialis muscle activity accurately reflects intramuscular EMG. As such, surface EMG offers a non-invasive, easy to perform, less uncomfortable technique for research and clinical practice. On the sports field, COD performance plays a pivotal role in match-winning situations. Among youth basketball players, Chen et al. demonstrated that 505 COD performance measured with the COD timer app could be used to accurately capture timing data, compared to more expensive timing gate methods. Confirmation that these less expensive methods are valid and reliable will enable a broader range of applications for these performance assessments.Simpler and more accessible approaches have also been proposed for measuring muscle activity and change of direction (COD) performance. While monitoring muscle activity has conventionally involved intramuscular electromyography (EMG), which is invasive and requires specialized expertise, Zhang et al. examined the accuracy of a flash glucose monitoring device among overweight/obese persons during sitting and walking before, during, and after an individual’s postprandial peak. Although absolute glucose readings from the flash glucose monitoring device underestimated plasma glucose, its overall accuracy was clinically acceptable during postprandial sitting and walking conditions in overweight or obese young adults, highlighting the potential for this technique to have widespread health-monitoring implications.To help individuals with diabetes or poor glucose control improve glycemic control, continuous glucose monitoring has increasingly been adopted as a novel and feasible tool. Potter et al. investigated whether an abdominal circumference-focused method of percent body fat estimation accurately represented dual-energy x-ray absorptiometry. Their large-scale study of participants from the US Marine Corps concluded that the abdominal circumference estimate of percent body fat provides a field expedient method to classify individuals for obesity prevention but was not suitable for research-grade assessments.Body composition assessment has been an important aspect of research in exercise physiology for decades. Assessment techniques range widely in expense, required expertise, and validity. In favour of developing low-cost and readily applicable measurement techniques, Overall, this special issue on the methods and applications used in exercise physiology showcases the many diverse advances being made to the techniques used in research and practice. Less expensive methods that require minimal expertise and can be easily applied in field settings will continue to enhance our ability to measure, understand, and enhance human health and performance.


Aedes aegypti [Dengue is a mosquito-borne viral infection transmitted to humans, caused by four types of dengue virus (DENV)  and primarily carried by the species Pakistan first reported an epidemic of Dengue fever in 1994 and since November 2005 annual recurrence has become apparent . AccordiThis higher than usual monsoon rainfall raises an alarming concern for a potential outbreak of dengue fever in the country. Pakistan is already dealing with 6th wave of COVID-19 and an outbreak of Cholera , hence aNone required.None.Muttia Abdul Sattar, Hadia Nadeem. All authors contributed the same.None.Name of the registry:Unique Identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Muttia Abdul Sattar.None required.


Digital solutions to HPV vaccination by Hopfer S, Dyda A and Brandt HM. (2022). Front. Digit. Health. 4:972234. doi: 10.3389/fdgth.2022.972234Editorial on the Research Topic The rapid growth and diffusion of digital solutions, technologies and online media consumption is changing the landscape of implementing health behavior change campaigns and interventions as well as how individuals and families access and consume health information , 2. NoveMassey et al.; Zhang et al.; Sundstrom et al.; Buller et al.; Hopfer et al.). The special issue also presents feasibility studies on web-based or mobile applications  that tailor vaccine information to parents, adolescents, and young adults through a variety of approaches. Most digital solutions presented are stand-alone, yet one intervention presents digital efforts integrated as a component of a multi-level clinic intervention to reach rural populations and reduce missed HPV vaccine recommendation opportunities . Other studies  suggest that mobile apps could be used to complement clinical pediatric well-child visits or could be disseminated by state health departments, school health officials, and pharmacy chains. The advantages of digital health not only become apparent by the structural channel affordances that lend themselves to greater engagement and tailoring with audiences but also accommodate busy schedules of parents and young adults.This special issue showcases predominantly social media studies as digital solutions that show promise for reaching parents and youth about HPV vaccination , such as those reported by Sundstrom et al. and Buller et al., to deliver vaccine messaging through trusted peers presents a promising approach for increasing HPV vaccination. Another benefit of digital interventions is the ability to deliver vaccine messaging in other languages e.g., Spanish to Latinx communities  or target vaccine messaging via parent personas . Social media studies delivered vaccine messaging across multiple channels testing the impact of disseminating through different platforms  in private and public groups, synchronous/asynchronous discussion groups, webinars, bi-weekly emails, weekly messaging, and lifestyle messaging .Digital approaches inherently hold promise to make vaccine information more accessible for many populations who might otherwise not be reached and where messaging can be targeted to reach subgroups. Digital strategies may be delivered Zhang et al.), another study focused regionally on South Carolina  and yet another on rural Colorado (eno & Dempsey). These U.S. regions are characterized by low HPV vaccination rates and high HPV-cancer incidence.Geographic targeting can also be achieved with digital messaging: one study focused on Northern rural California with low vaccination and high cancer rates , showcases the potential to take advantage of answering parent and youth questions real-time and debunking misinformation, but also answering questions asynchronously through newsletters, blogs, discussion forums, chat rooms, and portals . A devoted moderator who can respond real-time to questions and correct misinformation was a recurring theme in combination with more automated digital interventions. The flow of unsolicited, real-time comments from parents give insight into vaccine concerns as well as exposure to circulating rumors and misinformation. Predominant vaccine concerns remain around HPV vaccine confidence and HPV complacency.Engagement, as observed through analysis of comments and posts  while another study applied dialog theory to segment HPV vaccine videos and adapt them to the social media environment . An ideal area of opportunity lies in strengthening the integration of theoretical foundations into digital health solutions in HPV vaccination.Communication and behavior change theories were adapted to understand the digital health environment: these ranged from social cognitive theory (SCT), diffusion of innovation (DOI), extended parallel process model (EPPM), 3C model of vaccine hesitancy, and a champion network approach. One study integrated persona theory with health communication and human-centered design , highlighting the emerging nature of digital solutions to increase vaccination. However, data on outcomes was also presented with results from randomized trials . This accrued evidence from the studies in this special issue on digital solutions highlights the various ways in which digital approaches are likely to increase HPV vaccination rates particularly in relation to increasing access and improving health promotion reach, through peer- and trusted channels and messengers. Use of narratives and informal peer dialogue  show promise to increase user engagement in the digital environment while also being able to answer and debunk circulating rumors real-time . Social media platforms offer one strategy to make information accessible . Additional strategies of using peer-champions , point-of-care delivered vaccine messages , and real-time tailoring  also show promise as digital solutions to increase HPV vaccination.A number of these studies were in the development or piloting stage (


Migraine is a highly prevalent disorder with significant economical and personal burden. Despite the development of effective therapeutics, the causes which precipitate migraine attacks remain elusive. Clinical studies have highlighted altered metabolic flux and mitochondrial function in patients. In vivo animal experiments can allude to the metabolic mechanisms which may underlie migraine susceptibility. Understanding the translational relevance of these studies are important to identifying triggers, biomarkers and therapeutic targets in migraine.Functional imaging studies have suggested that migraineurs feature metabolic syndrome, exhibiting hallmark features including upregulated oxidative phosphorylation yet depleted available free energy. Glucose hypometabolism is also evident in migraine patients and can lead to altered neuronal hyperexcitability such as the incidence of cortical spreading depression (CSD). The association between obesity and increased risk, frequency and worse prognosis of migraine also highlights lipid dysregulation in migraine pathology. Calcitonin gene related peptide (CGRP) has demonstrated an important role in sensitisation and nociception in headache, however its role in metabolic regulation in connection with migraine has not been thoroughly explored. Whether impaired metabolic function leads to increased release of peptides such as CGRP or excessive nociception leads to altered flux is yet unknown.Migraine susceptibility may be underpinned by impaired metabolism resulting in depleted energy stores and altered neuronal function. This review discusses both clinical and in vivo studies which provide evidence of altered metabolic flux which contribute toward pathophysiology. It also reviews the translational relevance of animal studies in identifying targets of biomarker or therapeutic development. Migraine is a highly prevalent and disabling disorder, affecting over 1 billion people worldwide . In addiMigraine is a prevalent feature of both mitochondrial and metabolic disorders , which Sensitization of the trigeminovascular system and cortical hyperexcitability are two mechanisms thought to be crucial to pathophysiology of migraine.The trigeminovascular system is composed of trigeminal sensory neurons innervating the dura mater as well as cerebral and pial blood vessels. They synapse in the pars caudalis of the ipsilateral spinal trigeminal nucleus. The main projection of these nociceptive fibres is the ventral posteromedial thalamic nucleus, which then relays to the primary sensory cortex. This system is fundamental to nociception and migraine pathophysiology . TrigemiHyperexcitability of the cerebral cortex is also thought to contribute towards migraine pathophysiology . It has Glucose is the major energy substrate of the brain. It diffuses across the blood–brain-barrier via the glucose transporter GLUT1 and can be taken up by neurons via GLUT3 . Its majGlucose metabolism is fine-tuned within and among cells to ensure maintenance of adequate concentrations of substrates. At rest, the metabolism of the brain is compartmentalised between neurons and astrocytes; neurons can rely on both glycolytic and oxidative metabolism, whereas astrocytes tend to be primarily glycolytic and can metabolically support neurons . At timeIn vivo murine models have been useful in providing in-depth understanding of mechanisms linking abnormal glycolysis and migraine Table . In rodeIn clinical practice, migraineurs often report that attacks are precipitated by fasting or skipping meals,  and indeThe gold standard to assess cerebral glucose uptake in vivo in patients is 18F-Fluorodeoxyglucose PET (18F-FDG PET) which has provided further evidence for the role of downregulated glycolysis in migraine. The cerebral areas affected by glucose hypometabolism appear to be different in episodic migraineurs compared to chronic patients. In episodic migraineurs both with and without aura, hypometabolism has been detected in temporal , and froIn the absence of sufficient oxygen, lactate is produced via anaerobic glycolysis of pyruvate Fig. , hence, 1H-MRS) studies during CSD, [Results of animal and clinical studies suggest that lactate excess may be related to CSD. This hypothesis was corroborated in rat proton magnetic resonance spectroscopy , –61 with Importantly, such direct associations with cholesterol and LDL may provide an explanation for the increased cardiovascular and stroke risk in migraine , 64. TheAn association between obesity and headache is also evident in secondary headache disorders including idiopathic intracranial hypertension (IIH). IIH is characterised by raised intracranial pressure and features headache with migraine-like characteristics . Over 90Prolonged activity neurons leads to upregulated β-oxidation and consequently increased reactive oxygen species (ROS) and peroxidated fatty acids , 75. UsiFatty acids also play a role in modulating neuroinflammation, which is a function potentially of benefit in neurodegenerative diseases . Hence, Healthy neurons rely primarily on oxidative phosphorylation for energy, a process hosted by mitochondria which are vital organelles.+ allows quantification of changes in mitochondrial redox potential [For the investigation of mitochondrial function in vivo, most models utilise CSD as a mechanism of migraine. Use of two-photon fluorescent imaging to measure the ratio of autofluorescent reduced NADH to non-fluorescent NADotential . Using totential , 83, 84.otential . Moreoveotential . Dural eotential . In thes31P-MRS). Studies in migraine have consistently highlighted primary mitochondrial dysfunction in patients as evidenced by increased ADP in those with aura and FHM [31P-MRS studies of mitochondrial cytopathies and some neurodegenerative conditions such as amyotrophic lateral sclerosis [31P-MRS data in patients may reciprocate findings in CSD animal models, since migraine with aura patients most frequently demonstrate alterations in mitochondrial function. Results regarding changes in ATP concentrations remain divided, with most studies either not reporting ATP levels, or concentrations remaining unchanged or similar to that of controls [The modality of choice to investigate mitochondrial function in vivo in humans is 31-Phosphorus magnetic resonance spectroscopy  supplementation. CoQ10 is an electron acceptor in the electron transport chain which has been shown to improve mitochondrial respiration in mitochondrial cytopathies . SeveralInsulin has become a hormone of interest in migraine since numerous studies have identified insulin resistance in patients –109. ResAnimal studies have revealed that insulin may potentially modulate the release of CGRP. In particular, insulin can induce the release of CGRP via sensitization of neuronal Transient Receptor Potential Cation Channel Subfamily V Member 1 (TRVP1—Fig. CGRP is also able to regulate insulin secretion  via TRPVAlthough antagonism of CGRP signalling has demonstrated significant efficacy in migraine prophylaxis, the effects on insulin function have not yet been assessed in patients. CGRP receptor antagonism in mice has shown moderate improvements in oral glucose tolerance . CGRP-α Amylin is a pancreatic hormone co-released with insulin in response to food intake . It loweWhilst CGRP has become a popular target for migraine therapeutics, the therapeutic potentials of amylin antagonism have not yet been fully explored. Pramlintide, an amylin receptor agonist, is currently licensed for diabetes in the United States . It may The pathophysiology of migraine is evolving and may also feature mitochondrial and metabolic deficits. Moreover, migraine is prevalent in those with mitochondrial disorders and structural and biochemical impairments in electron transfer chain have been identified in migraineurs . Interes


Endovascular therapy for acute ischemic stroke secondary to large vessel occlusion (LVO) is time-dependent. Prehospital patients with suspected LVO stroke should be triaged directly to specialized stroke centers for endovascular therapy. This review describes advances in LVO detection among prehospital suspected stroke patients.Clinical prehospital stroke severity tools have been validated in the prehospital setting. Devices including EEG, SSEPs, TCD, cranial accelerometry, and volumetric impedance phase-shift-spectroscopy have recently published data regarding LVO detection in hospital settings. Mobile stroke units bring thrombolysis and vessel imaging to patients.The use of a prehospital stroke severity tool for LVO triage is now widely supported. Ease of use should be prioritized as there are no meaningful differences in diagnostic performance amongst tools. LVO diagnostic devices are promising, but none have been validated in the prehospital setting. Mobile stroke units improve patient outcomes and cost-effectiveness analyses are underway. Endovascular therapy (EVT) using mechanical thrombectomy with or without intravenous thrombolysis (IVT) has been proven superior to standard medical care, including IVT alone for patients with acute ischemic stroke secondary to large vessel occlusion (LVO) , 2. MoreIn 2021, a multi-society consensus statement from leading stroke and emergency medical services (EMS) experts recommended that regional stroke destination plans prioritize the transportation of suspected LVO patients to Comprehensive Stroke Centers (CSC) for emergent EVT when within acceptable transportation times . CSCs prEMS transportation of IVT and EVT eligible LVO stroke patients to a closer non-EVT center may facilitate faster IVT; however, IVT recanalization rates are low for LVO stroke, and interfacility transfers for EVT are associated with treatment delays and worse outcomes –15. In sThis review details the use of varying methods of LVO identification in patients with suspected stroke, including updates in clinical prehospital stroke scales performed by EMS personnel, various portable medical devices, and mobile stroke units.The American Heart Association (AHA)/American Stroke Association (ASA) provides the Mission Lifeline: Stroke EMS Acute Stroke Routing Algorithm as a model for prehospital LVO triage using currently available prehospital stroke scales . The firWith consensus statements and triage algorithms now available, the remaining question is which validated stroke severity tool to use. Overall, the data quality has dramatically improved since the 2018 systematic review that determined there is insufficient evidence to conclude that any single severity tool is better than the others . This isThe ACT-FAST Stroke Algorithm created by Zhao et al. has also been validated in the prehospital setting and includes a unique treatment eligibility screen step. The algorithm provides a binary positive or negative result with relatively high and balanced sensitivity (75.8%) and specificity (81.8%) when using an extended definition of LVO that includes proximal LVOs plus M2s, P1s, and symptomatic stenoses. However, direct comparisons with the severity tools prospectively and simultaneously evaluated in the studies above are difficult because ACT-FAST was omitted. Most striking is the difference in positive predictive values (PPVs), which exceeded 50% for the ACT-FAST extended LVO definition. In comparison, most severity scores studied by Nguyen et al. in the Netherlands had PPVs in the 20% range . DiffereGiven the similarities in stroke severity tool performance and goal of widespread adoption by EMS providers, ease of use is a reasonable consideration when choosing among them. The easiest approach in the USA would be to change the CPSS, which is currently used as a positive or negative prehospital stroke identification screen, into a stroke severity tool with scores ranging from 0 to 3 , 31. TheWith so many reasonable choices, our focus should shift from which severity tool to use to clarifying our diagnostic and patient care priorities. Most prehospital stroke severity tools have multiple possible scores and choosing a lower score cutpoint would allow for higher sensitivity (not missing an LVO treatment opportunity) to be prioritized over specificity. More false positives would accompany this shift in priorities because these tools are not simultaneously sensitive and specific. However, it is important to prioritize sensitivity in highly morbid diseases with time-sensitive and profoundly effective interventions like EVT for LVO stroke.This is not as daunting as it may seem. Multiple modeling studies have found that LVO triage may not result in overwhelmed stroke centers or missed thrombolysis opportunities , 36, 41.Ultimately, prehospital stroke severity tools are limited by their sensitivity and specificity tradeoffs. Hopefully, the addition of the technologies discussed below will someday allow for highly sensitive and highly specific LVO triage that will expedite access to EVT while minimizing false positives.There has been increasing interest and research in portable and non-invasive external diagnostic devices for prehospital LVO stroke identification and triage. We will briefly discuss various forms of biometric devices reported in the peer-reviewed literature, including electroencephalography with or without somatosensory evoked potentials, transcranial Doppler, cranial accelerometry, and volumetric impedance phase-shift spectroscopy .Electroencephalography (EEG) analyzes normal and abnormal brain electrical activity by transducing electrical potential differences on the patient’s scalp. EEG is primarily used to diagnose seizures and manage epilepsy. It has been used to monitor cerebral ischemia, particularly in the intraoperative setting during carotid artery surgery and, more recently, in acute ischemic stroke . EEG canA recent publication by Sergot and the EDGAR Study Group investigated a portable LVO-detection device (PLD) that used EEG combined with somatosensory evoked potentials (SSEPs) to identify LVO stroke in emergency departments •. The stTranscranial Doppler (TCD) is a safe ultrasound-based method of evaluating cerebral hemodynamics and documenting blood flow in the middle cerebral artery. A pulsed Doppler ultrasound transducer is used to assess intracerebral blood flow through cranial “windows” . A systeCranial accelerometry is used to measure the headpulse and has been investigated as a tool to diagnose LVO stroke by the authors of this review. Headpulse refers to nearly imperceptible head movements with each cardiac contraction cycle in response to blood flow forces transmitted via the carotid and vertebral arteries. This is measured using accelerometers in contact with the skull combined with electrocardiogram leads. Patients with LVO stroke may have chaotic head pulse patterns that do not correlate with cardiac contraction cycles; this is hypothesized to be due to the obstruction of blood flow on one side by the LVO. Cranial accelerometry alone  was 73% sensitive and 87% specific for LVO in an initial study . In a suVolumetric impedance phase-shift spectroscopy (VIPS) technology involves passing low-power electromagnetic waves through the brain to detect asymmetries and electrolyte concentration changes . A devicAt present, none of the LVO devices in development have reported the results of external validation, prehospital feasibility, or diagnostic accuracy studies in ambulances with suspected stroke patients. As investigators design these studies, it will be critical to follow the Standards for Reporting of Diagnostic Accuracy Studies (STARD) guidelines. Many peer-review journals require completion of the STARD checklist during submission, and more importantly, adherence to their guidance will reduce the impact of avoidable biases, increase transparency, and enable researchers to draw meaningful conclusions from new studies as the field advances .The concept of mobile stroke units (MSUs) was published in 2003 by Fassbender to “bring treatment to the patient, rather than the patient to the treatment” and was first established in Germany in 2008 . MSUs tyA recent publication by Ebinger and colleagues in Berlin demonstrated an association between MSUs and improved functional outcomes in acute ischemic stroke patients . They coThe BEST-MSU study is the first multicenter randomized controlled trial comparing standard ambulance care versus MSU care, including prehospital thrombolysis. It began in 2014 in Texas and has demonstrated the safety and feasibility of MSUs, the reliability of telemedicine technology, as well as faster door-to-groin puncture times for patients requiring thrombectomy . ResultsPrehospital triage of patients with suspected LVO to EVT centers is now recommended. The Mission Lifeline: Stroke EMS Triage Algorithm provides a framework that includes neurological examination-based prehospital stroke severity tools. Decisions regarding which severity to tool to use can likely be based on ease of use as prospective comparative studies did not demonstrate meaningful performance differences. Standard score cutpoints of many of these tools favor specificity over sensitivity, which will lead to many missed LVO strokes. Sensitivity should be prioritized, and CPSS ≥ 2 provides similar performance compared to other sensitive stroke severity tool cutpoints but would not require significant training to implement. Several LVO stroke diagnostic devices have published peer-review initial studies, but each device will require prehospital validation before becoming available for use. Mobile stroke units improve patient outcomes and, when available, can perform vessel imaging on scene to diagnose or rule out LVO stroke. Cost-effectiveness analyses are planned. Ongoing improvements in prehospital LVO triage will likely require tailoring the diagnostic approach to the needs of each region.


Termites are a prototypical example of the ‘extended phenotype’ given their ability to shape their environments by constructing complex nesting structures and cultivating fungus gardens. Such engineered structures provide termites with stable, protected habitats, and nutritious food sources, respectively. Recent studies have suggested that these termite-engineered structures harbour Actinobacteria-dominated microbial communities. In this review, we describe the composition, activities, and consequences of microbial communities associated with termite mounds, other nests, and fungus gardens. Culture-dependent and culture-independent studies indicate that these structures each harbour specialized microbial communities distinct from those in termite guts and surrounding soils. Termites select microbial communities in these structures through various means: opportunistic recruitment from surrounding soils; controlling physicochemical properties of nesting structures; excreting hydrogen, methane, and other gases as bacterial energy sources; and pretreating lignocellulose to facilitate fungal cultivation in gardens. These engineered communities potentially benefit termites by producing antimicrobial compounds, facilitating lignocellulose digestion, and enhancing energetic efficiency of the termite ‘metaorganism’. Moreover, mound-associated communities have been shown to be globally significant in controlling emissions of methane and enhancing agricultural fertility. Altogether, these considerations suggest that the microbiomes selected by some animals extend much beyond their bodies, providing a new dimension to the ‘extended phenotype’. This review discusses how and why termites select for beneficial microbial communities by constructing mounds, nests, and fungal gardens, and explores the ecological and biogeochemical impacts of these termite-engineered communities. Mounds contain complex networks of internal chambers that facilitate gas exchange, harbour the colony, and allow food storage or fungiculture , instead cultivates bacterial combs as a food source  to chemically analyze the degree of pretreatment of lignin and polysaccharides during the fungus garden maturation in O. formosanus laboratory colonies; this revealed that the fungus-comb microbiome contributes to significant polysaccharide and lignin cleavage, leaving the mature comb enriched in more digestible cellulosic oligomers that are eventually ingested by termite host  or, primarily in the case of fungus-farming termite combs and subterranean C. formosanus opportunistically recruits potentially defensive Streptomyces from surrounding soils and provides favourable nutrients for their proliferation , all of which is rapidly consumed to subatmospheric levels by mound communities  and Methylocystis methanotrophs, which appear to be kinetically adapted to elevated methane concentrations (Chiri et al. In addition to providing multifaceted benefits to termites, the microbial communities associated with termite nesting structures offer a range of ecosystem services Fig. . Of thesTermite-associated bacteria also enhance soil fertility, especially in savanna and dryland regions, by mediating various supporting services. Termite nest and mound soils promote growth of a wide range of plants both in natural environments and agricultural settings Watson . It was With respect to provisioning services, termite nesting communities are also relevant for understanding and tackling the antimicrobials arm race. Hundreds of novel natural products have been identified from termite nests, especially combs of fungus-farming termites, often with potent antibacterial or antifungal properties (Sujada et al. Increasing evidence suggests that the microbial communities residing within termite nesting structures engage in symbiotic relationships with termites. The microorganisms benefit from a relatively stable and selective habitat, high nutrient availability, and pathogen exclusion mechanisms. The microorganisms recruited to termite nesting structures likely span the spectrum of commensals to mutualists, though the majority appear to benefit termites by mediating antimicrobial production, lignocellulose digestion, and nutrient recycling. Yet in other respects, mound-associated bacteria are atypical of classical symbionts: they are generalist bacteria that can adopt both free-living and mound-associated lifestyles; are opportunistically recruited and sustained through normal nest-building and digestive activities of termites; and exhibit strong geographic variations in community composition even within species. However, strong arguments have been presented that animals can dependably acquire microbial symbionts if potential symbionts are widely distributed and promiscuous associations can form (Moran and Sloan