Hematopoiesis and bone interact in various developmental and pathological processes. Neurogenic heterotopic ossifications (NHO) are the formation of ectopic hematopoietic bones in peri-articular muscles that develop following severe lesions of the central nervous system such as traumatic cerebral or spinal injuries or strokes. This review will focus on the hematopoietic facet of NHO. The characterization of NHO demonstrates the presence of hematopoietic marrow in which quiescent hematopoietic stem cells (HSC) are maintained by a functional stromal microenvironment, thus documenting that NHOs are neo-formed ectopic HSC niches. Similarly to adult bone marrow, the NHO permissive environment supports HSC maintenance, proliferation and differentiation through bidirectional signaling with mesenchymal stromal cells and endothelial cells, involving cell adhesion molecules, membrane-bound growth factors, hormones, and secreted matrix proteins. The participation of the nervous system, macrophages and inflammatory cytokines including oncostatin M and transforming growth factor (TGF)-β in this process, reveals how neural circuitry fine-tunes the inflammatory response to generate hematopoietic bones in injured muscles. The localization of NHOs in the peri-articular muscle environment also suggests a role of muscle mesenchymal cells and bone metabolism in development of hematopoiesis in adults. Little is known about the establishment of bone marrow niches and the regulation of HSC cycling during fetal development. Similarities between NHO and development of fetal bones make NHOs an interesting model to study the establishment of bone marrow hematopoiesis during development. Conversely, identification of stage-specific factors that specify HSC developmental state during fetal bone development will give more mechanistic insights into NHO. Heterotopic ossification (HO) is an abnormal development of bone tissue within soft tissue. HO can be hereditary such as Fibrodysplasia Ossificans Progressiva (FOP) or acquired following traumatic injuries and burns . Among aACVR1 gene encoding a type I BMP receptor  . The patIt is currently admitted that NHOs are the result of an endochondral ossification process although intramembranous ossification has also been suggested . Foley eThe development of heterotopic bones in muscles after severe CNS trauma raises interesting stem cell biology questions particularly regarding the cells-of-origin of NHO. Adult skeletal muscles contain two major types of progenitor cells participating in muscle regeneration. Myogenic satellite cells (SCs) are CD56 expressing stem cells located between the basal lamina and myofiber plasma membrane. To regenerate damaged myofibers, activated SCs proliferate, differentiate into myoblasts and fuse to form multinucleated myofibers with the support of macrophages, endothelial cells (ECs), fibroblasts and pericytes  or FAPs (via a Prrx1 gene enhancer transgene) are specifically labeled, we find that following SCI, NHO are derived from Prrx1 expressing FAPs, not from Pax7 expressing SCs  and central (SCI) neurologic lesions have an effect on FAPs, inducing STAT3 activation, high IL-6 secretory activity and abnormal proliferation . FurtherThe presence of ectopic hematopoietic bones developing in muscles following CNS injuries is puzzling for the hematologist since, in adults, hematopoiesis is physiologically restricted to the BM of skeletal bones.During fetal development, blood formation occurs in discrete anatomical extraembryonic and intraembryonic niches, generating different hematopoietic cell (HC) types . First HSchofield first used the term “niche” to describe a putative HSC-specific environment in the BM that “preserved the reconstituting ability of stem cells” . SuccessWithin these niches, HSCs are maintained quiescent by a complex molecular interplay between cells from mesenchymal origin, ECs, neuronal cells and HSC progenies, such as megakaryocytes and macrophages. Diffusible factors including inflammatory cytokines and extra-cellular matrix components perfect this molecular network, subtly controlling the fate of HSCs .Apart from stromal cells, macrophages are essential to HSC regulation within niches. They are the most abundant HCs in the dorsal aorta when the number of intra-aortic hematopoietic cluster peaks, and are suggested to promote definitive HSC formation from the dorsal aorta hemogenic endothelium through pro-inflammatory signaling cascades . Among tIn the context of NHO, it is noteworthy to integrate the role of the nervous system as an important regulator of bone remodeling and hematopoiesis homeostasis. Since the discovery of skeleton innervation by Besides its role in energy homeostasis, leptin plays a major role in neuroendocrine regulation and bone metabolism. The expression of leptin receptor on adult MSCs, osteoblasts and chondrocytes, suggests direct effects on bone growth and metabolism. Leptin can also indirectly modulate bone formation through effectors downstream of the hypothalamus such as estrogen, cortisol, IGF-1 and parathyroid hormone, and through activation of local adrenergic signaling at the osteoblast level via β2 adrenergic receptors (AR) . SensoryAs reported above, HSCs are mainly located in perivascular areas of the adult BM, comprising both sinusoidal and arteriolar blood vessels. The arteriolar structures are highly innervated by SNS fibers. The neuroreticular complex formed by SNS nerves and perivascular MSCs has been reported to be a central regulator of HSC quiescence within BM niches  mice that lack osteoblasts and osteolineage cells, the vasculature within the nascent bones and bone marrow can sustain multilineage proliferative progenitors but not long-term HSCs. As a result, wild-type HSC transplanted in Osx embryos engraft the liver but not the nascent BM. Therefore, interactions with osteoblasts within fetal bone regulate HSC quiescence and homing ability (Cxcl12 or Kitl gene from Osx+ osteoprogenitors has more effect on hematopoietic progenitors than on proper HSCs (Lepr+ MSCs (that form osteoprogenitors) for HSCs to be maintained (In Osterix-null (Osx ability . In the per HSCs . In contintained . These rUnderstanding the development of hematopoiesis in an adult osteogenic muscle environment as observed in NHO could help gain further insights on the role of bone forming cells in this process. Identification of stage-specific factors that orientate HSC developmental state during fetal bone development must be harnessed to gain more mechanistic insights into NHO development. Similarly, understanding the cellular origin of NHO, the role of inflammation and muscle environment might contribute to a better understanding of the impact of specific niche components on fetal BM HSC properties.In the recent few years, knowledge about NHO pathogenesis has been considerably improved as accredited by the rapidly increasing number of publications in the field. These progresses were mainly due to the development of more suitable animal models and to the availability of patient samples thanks to well organized cohorts. The current review focusing on the hematopoietic features of NHO ossifications, attempts to recapitulate how a favorable environment for the development of bone with HSC niches can develop in adult muscles following central neurological lesions. It emphasizes the role of a persistent inflamed muscle environment driving FAPs to an osteogenic fate initiating the development of ossification followed by the establishment of a mature hematopoietic bone tissue.However, there are still numerous questions in respect to the molecular mechanisms underlying this complex and multifactorial pathological process. Among those, the potential differences between normal endochondral ossification and neurogenic HO in terms of signaling events, cell type involvement and environment remains unanswered. Likewise, how an inflamed adult muscle environment becomes pro-osteogenic and thereafter hematopoietic, and what is the influence of altered nervous and neuroendocrine systems as well as hypoxia in this process? Does the neoformation of hematopoietic bones in muscles mimic what happens during development and can we learn from NHO for a better identification of stage-specific factors that specify HSC developmental state during fetal bone development? Is the impaired mobility of patients a trigger in the development of NHO and does an early and adequate mobilization of patients can avoid or at least reduce its evolution?Gathering surgeons, clinicians, specialists in physical medicine/rehabilitation and researchers within a European/International consortium would be a provocative initiative for developing translational collaborative projects to better understand NHO pathogenesis and, armed with this knowledge, enable the identification of new targets to treat and if possible prevent NHO development. Moreover, such knowledge may also provide new insights for cell therapy needs and for improving treatment of blood and bone disorders.DG, FT, EO, KA, JG, H-WT, MS, J-PL, M-CL, and SB wrote the manuscript. DG, EO, M-CL, and SB prepared the figures. All authors revised the manuscript and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Family caregivers often manage complex medical/nursing tasks (MNTs) for older adults returning home after a hospitalization. The purpose of this qualitative study was to describe caregivers’ experiences leveraging diverse resources to manage MNTs for older adults receiving post-acute home health care services (HHC). In-depth telephone interviews were conducted with 20 caregivers of older adults who received HHC following hospitalization. Interviews were digitally audio-recorded, transcribed, and analyzed using directed content analysis. The Theory of Dependent-Care informed the analytical framework. We organized codes using three theoretical constructs related to managing older adults’ MNT care needs (“tasks related to the other”), accessing existing social/environmental resources (“tasks related to the situation of care”), and working with the healthcare system (“tasks related to the system of care”). Caregivers’ descriptions of MNTs included the complexity and socioemotional impact of assisting in these tasks . When needed, caregivers’ accessed social  and environmental  resources to help address the older adults’ care needs. Caregivers also identified challenges and strategies for navigating and coordinating care and services within HHC and the larger healthcare system. Caregivers assisting with complex MNTs in the post-acute HHC setting need additional training and support. HHC providers can actively engage caregivers by tailoring training and support strategies, assessing social and environmental contexts and resources, and facilitating caregivers’ navigation of the healthcare system. Future research could elucidate social and environmental factors associated with successful collaborative relationships among providers, older adults and their caregivers in the post-acute HHC setting.


Research demonstrates reciprocal relationships between personality and depression as well as the important role interpersonal conflicts play, but rarely explores these risk factors in older adults. This study aimed to examine relationships of personality traits, processes, and the impact of emotional involvement and distress during an interpersonal conflict on depression in older adults. The study also investigated whether emotional involvement or interpersonal distress moderate the relationship between personality pathology and depression. Depressed middle and older adult inpatients  completed self-reports and interview-based assessments regarding personality traits , interpersonal problems (IIP-25), and depression (GDS). Narrative responses regarding an interpersonal conflict were obtained and rated for contamination themes as well as emotional involvement and distress. Overall, findings indicated that living with others predicted higher depression (p= .046) and was related to higher neuroticism and interpersonal problems. Personality traits (Neuroticism)  and processes  , as well as higher levels of emotional distress  and involvement  in an interpersonal conflict were also tied to depression in bivariate but not multivariate analyses. The moderating effects of emotional involvement or distress on the relationship between personality and depression were not supported. Depressed older inpatients who live with others appear at higher risk of depression. Personality traits and processes may be more distal risk factors for depression. Findings are discussed in relation to stress generation as well as clinical implications targeting emotional regulation.


Dear Editor th, they confirmed that they had identified a new coronavirus, which is a family of microRNA respiratory viruses including the common cold, and viruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). This new virus was temporarily named “2019-nCoV”. Wuhan city is a major international transport hub. This report to World Health Organization (WHO), raised global public health concern because this is the third coronavirus –associated acute respiratory illness outbreak. On 31 December 2019, Chinese authorities reported the increase in incidence of severe pneumonia in Wuhan city, Hubei province of China. One week later, on January 7Currently, up to the date of submitting this letter, 4593 cases of 2019-nCoV infections have been confirmed globally, both in China  and outside of China (56 confirmed in 14 countries.). WHO risk assessment of 2019-nCoV infection is Very High in China and High in other countries  or severe pneumonia, Acute Respiratory Distress Syndrome (ARDS), sepsis and septic shock. Patients with pre-existing medical comorbidities develop a more severe disease and have higher mortality rates compared to patients who do not have any comorbidity.Clinical care of patients with suspected 2019-nCoV should focus on early recognition, immediate isolation (separation), implementation of appropriate infection prevention and control (IPC) measures and provision optimized supportive care. At the triage of an Emergency room, early recognition of suspected patients allows for timely initiation of IPC. 2019-nCoV should be considered as a possible etiology of influenza like illness (ILI) under certain situations according to case definitions of WHO  or non-invasive ventilation (NIV) should be used in selected patients with hypoxemic respiratory failure. Hypoxemic respiratory failure due to ARDS among these patients commonly results from intrapulmonary ventilation-perfusion mismatch or shunt and usually requires mechanical ventilation. Thus, rapid sequence intubation should be performed using airborne precautions. Implementation of mechanical ventilation using lower tidal volumes (4-8 ml/kg predicted body weight) and higher positive end-expiratory pressure (PEEP) is suggested. Patients with SARI should be treated cautiously with intravenous fluids when there is no evidence of shock, because aggressive fluid resuscitation may worsen oxygenation. For resuscitation of septic shock in adults, at least 30 ml/kg of isotonic crystalloid should be infused in the first 3 hours of shock identification and in children rapid bolus of 20 ml/kg as loading dose and up to 40-60 ml/kg of isotonic crystalloid infusion in the first hour of shock identification is needed. Vasopressor should be administered when shock persists during or after fluid resuscitation. If signs of poor perfusion persist despite reaching mean arterial pressure (MAP) target (i.e. >65 mmHg) with fluids and vasopressor, consider administering an inotrope such as dobutamine. Empiric antimicrobials should be initiated within one hour of identification of sepsis to treat all likely pathogens causing SARI. Empiric antibiotic treatment should be based on the clinical diagnosis of severe pneumonia or sepsis, local epidemiology and susceptibility data as well as treatment guidelines. If influenza is also a concern and there is a local circulation of influenza virus, a neuraminidase inhibitor should be adjoined to empiric therapy. Empiric antibiotic therapy should be de-escalated on the basis of microbiology results and clinical judgment. Systemic corticosteroids should not be routinely adding to therapy unless indicated for another reason. Collection of clinical specimens for laboratory diagnosis is suggested in early outbreak period and after that it is only advised for investigational purposes. If laboratory diagnosis is considered, serology is recommended only when RT-PCR is not available. Otherwise, HCW should collect specimens from both the upper respiratory tract and lower respiratory tract for testing 2019-nCoV via RT-PCR  should be developed and implemented in the emergency departments, as the frontline of treating human infections of 2019-nCov in the hospitals.


Increased systolic blood pressure (SBP), pulse pressure and carotid-femoral pulse wave velocity (cfPWV) are strong predictors of cardiovascular events. The aorta and carotids are both elastic arteries susceptible to arterial stiffening and its deleterious complications. The relative importance of ascending aortic and carotid stiffness on central arterial stiffness remains unclear.Our aim was to study the relationship of local arterial stiffness in the carotid and ascending aorta to central arterial stiffness assessed by cfPWV and peripheral BP.We studied 22 healthy subjects . Central arterial stiffness was determined using carotid and femoral tonometry and transit surface distances (cfPWV). Distensibility of the ascending aorta was calculated as the ratio of its transverse area change on MRI to the central pulse pressure from radial tonometry arterial waveforms using a transfer function. Carotid distensibility was calculated as the ratio of transverse area change by sonography to carotid pulse pressure by tonometry. Local stiffness indexes of carotid and aorta were calculated from distensibility by the reverse Moens-Korteweg equation. Peripheral SBP and pulse pressure were averages of 6 brachial measurements. Linear regression was used to study correlations between aortic and carotid stiffness and cfPWVAortic stiffness has a significantly stronger correlation than carotid stiffness with: age , peripheral SBP , pulse pressure , and cfPWV . In multivariate analysis with simultaneous adjustment for age, body mass index, SBP, pulse pressure, aortic stiffness and carotid stiffness, aortic stiffness is the strongest independent determinant of cfPWV (p = 0.013), SBP (p = 0.005) and pulse pressure (p = 0.01).Stiffness of the ascending aorta is a stronger predictor of cfPWV and peripheral SBP and pulse pressure than carotid stiffness among healthy individuals. This is consistent with heterogenous age-related stiffening of large arteries.


This study reviews the existing literature on psychiatric interventions for individuals affected by the COVID-19 epidemic. My article cumulates previous research on how extreme stressors associated with COVID-19 may aggravate or cause psychiatric problems. The unpredictability of the COVID-19 epidemic progression may result in significant psychological pressure on vulnerable populations. Persons with psychiatric illnesses may experience worsening symptoms or may develop an altered mental state related to an increased suicide risk. The inspected findings prove that psychological intervention measures for patients affected by the epidemic should be designed and personalized adequately. Preventive measures seek to decrease infection rates and cut down the risk of the public healthcare system to eventually be overburdened. Throughout the COVID-19 crisis, people with psychiatric illnesses may confront a decrease in mental health services. As limitations in the current review, by focusing only on articles published in journals indexed in Web of Science, Scopus, and ProQuest, I inevitably disregarded other valuable sources. Subsequent research directions should clarify the effectiveness of online mental health services in providing remote psychiatric interventions to individuals affected by the COVID-19 epidemic. COVID-19 has placed a significant strain on health systems on a large scale . There mAdequate conformity to spatial distancing in addition to home confinement, self-isolation, and quarantine may have the repercussion of social disconnection with adverse effects for psychological wellbeing . The manOn The COVID-19 epidemic has generated extreme stressors that may aggravate or cause psychiatric problems, affecting the brain or generating immune reactions. Emotional responses comprise intense psychosocial distress and insecurity. Such patients need timely, precise information concerning approaches for diminishing risk.COVID-19 pandemic-related, compulsory self-isolation, home confinement, and quarantine are related to poor psychological and physical health . Taking On Infectious disease outbreaks such as COVID-19 bring about mental health conditions as individuals’ emotional reactions tend to comprise extreme fear and confusion, while their anxious responses may lead to socially disruptive behaviors. Symptoms such as anxiety, nervousness, and insomnia may occur in COVID-19 infected patients with psychiatric disorders.The level of risk of COVID-19 spread among persons having a severe mental illness may be more significant than that in the general population, as a consequence of constant unhealthy behaviors and standards of living . IndividAs On People with mental health disorders may be more considerably affected by the emotional reactions generated by the COVID-19 epidemic. Affected individuals are exposed to mental health disorders and suicidal ideation and behavior, resulting in pervasive emotional distress and heightened risk for psychiatric disorders. Social relationships are pivotal in suicide prevention.The swift spread of COVID-19 and important death rate may aggravate the risk of mental health issues and intensify current psychiatric symptoms, damaging their proper functioning and cognition to a greater extent . The conThe author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Long-term care residents with and without cognitive impairment may experience undertreatment of persistent pain . Certified nursing assistants (CNAs) are important sources of information about resident pain as they provide the majority of residents’ hands-on care. Therefore, assessing the accuracy of CNAs’ pain assessments and potential influencing factors may provide insight regarding the undertreatment of pain. Informed by prior research, this study examined resident pain catastrophizing and cognitive status as predictors of CNAs’ pain assessment accuracy. CNA empathy was examined as a moderating variable. Analyses confirmed a relationship between pain catastrophizing and CNA pain rating accuracy , reflecting lower accuracy of ratings for residents higher in catastrophizing. Hypotheses predicting a relationship between resident cognitive status and CNA pain rating accuracy and moderating effects of empathy were disconfirmed. Challenges of conducting research in long-term care are discussed.


Objective: Using the stress-coping theory, the aims of the present study were to test what levels of caregiving intensity  posed the most negative influence on caregiver burden as well as how social support moderated such associations among dementia caregivers. Methods: Data from the baseline assessment of the Resources for Enhancing Alzheimer’s Caregiver Health (REACH II) (N = 637) were used. Caregiver burden , caregiving intensity (caregiving hours), and social support  were the main measurements. Separate multivariate regression models were conducted with Stata 16. Results: The results showed that the relationships between caregiving hours and caregiver burden were nonlinear after controlling all of the socio-demographic variables. Further analyses showed that when caregiving hours reached 13.50 hours per day, the levels of burden were the highest. In addition, received social support, satisfaction with social support, and social network significantly moderated the relationship between caregiving hours and caregiver burden among dementia caregivers when they were examined separately. However, only social network played a significant moderator role when examining the four social support indicators simultaneously. Discussion and conclusion: These findings suggest the need for programs and practices on educating caregivers regarding how to identify, approach, and gain social support/s, especially in how to broaden the caregivers’ social network while caring for a family member with dementia.


Carefully maintained and precisely inherited chromosomal DNA provides long-term genetic stability, but eukaryotic cells facing environmental challenges can benefit from the accumulation of less stable DNA species. Circular DNA molecules lacking centromeres segregate randomly or asymmetrically during cell division, following non-Mendelian inheritance patterns that result in high copy number instability and massive heterogeneity across populations. Such circular DNA species, variously known as extrachromosomal circular DNA (eccDNA), microDNA, double minutes or extrachromosomal DNA (ecDNA), are becoming recognised as a major source of the genetic variation exploited by cancer cells and pathogenic eukaryotes to acquire drug resistance. In budding yeast, circular DNA molecules derived from the ribosomal DNA (ERCs) have been long known to accumulate with age, but it is now clear that aged yeast also accumulate other high-copy protein-coding circular DNAs acquired through both random and environmentally-stimulated recombination processes. Here, we argue that accumulation of circular DNA provides a reservoir of heterogeneous genetic material that can allow rapid adaptation of aged cells to environmental insults, but avoids the negative fitness impacts on normal growth of unsolicited gene amplification in the young population. E. coli and asexual yeasts reveal that strains with high mutation rates outperform those with low mutation rates, showing that mutation provides an adaptive advantage  to several megabases   are highly focused in aged cells and are suggested to drive premature ageing and shortened lifespan , and is instead generated from chromosomal DNA at such a high rate that simple asymmetric retention of the newly generated copies in the mother cell is sufficient for CUP1 accumulation , the most transcribed protein-coding gene in muscle tissue, is also the largest producer of circular DNA per gene (Moller et al. Excitingly we have observed that the rate of copy number variation events including circular DNA formation is not completely random, which may improve this cost–benefit balance for aged cells (Hull et al. By itself, an adaptive phenotype in an individual aged cell is of little use if the causal circular DNA is selfishly retained in the mother cell, as would be the case if asymmetric segregation is maintained, and we must consider how circular DNA accumulation is translated into a heritable advantage. First, once circular DNA has accumulated, segregation can be relaxed under stress allowing circles with replication origins to propagate at high copy number in the population Fig. , step 5aThe idea that a sub-population trades short-term growth for adaptive capacity is formalised in bet-hedging (concisely reviewed in (Levy et al.


The primary impact of ventilation and ventilatory efforts on left ventricular (LV) function in left ventricular dysfunction relate to how changes in intrathoracic pressure (ITP) alter the pressure gradients for venous return into the chest and LV ejection out of the chest. Spontaneous inspiratory efforts by decreasing ITP increase both of these pressure gradients increasing venous blood flow and impeding LV ejection resulting in increased intrathoracic blood volume. In severe heart failure states when lung compliance is reduced, or airway resistance is increased these negative swings in ITP can be exacerbated leading to LV failure and acute cardiogenic pulmonary edema. By merely reversing these negative swings in ITP by the use of non-invasive continuous positive airway pressure (CPAP), these profoundly detrimental forces can be immediately reversed, and cardiovascular stability can be restored in moments. This forms the clinical rationale for the immediate use of CPAP for the treatment of acute cardiogenic pulmonary edema. Increasing ITP during positive pressure ventilation decreases the pressure gradients for venous return and LV ejection decreasing intrathoracic blood volume. In a hypovolemic patient even with LV dysfunction this can result in hypotension due to inadequate LV preload. Minor increases in ITP as occur using pressure-limited positive-pressure ventilation primarily reverse the increased LV afterload of negative swings in ITP and if fluid overload was already present, minimally alter cardiac output. The effect of changes in lung volume on LV function are related primarily to its effects on right ventricular (RV) function through changes in pulmonary vascular resistance and overdistention (hyperinflation). In acute lung injury with alveolar collapse, positive pressure ventilation may reduce pulmonary vascular resistance if alveolar recruitment predominates. Hyperinflation, however, impedes diastolic filling while simultaneously increasing pulmonary vascular resistance. Thus, increasing lung volume can reduce RV afterload by reversing hypoxic pulmonary vasoconstriction or increase afterload by overdistention. Hyperinflation can also impede RV filling. All of these processes can be readily identified at the bedside using echocardiography. Understanding the hemodynamic coupling of the heart and lungs plays a significant role in managing patients in the critical care setting. The basic heart-lung physiology has been discovered earlier in the collection of papers. Understanding diastolic and systolic left heart failure is of upmost importance when treating patients with a variety of other common medical conditions such as sleep apnea, ARDS and COPD as these conditions are deeply intertwined. These interactions are magnified in the setting of decreased left ventricular (LV) function. Here we seek to explain how clinical presentations affect the left ventricle and how management of these conditions can have a profound effect on LV function. For simplistic sake, the forces that cause clinically relevant heart-lung interactions are illustrated in There are multiple aspects of cardiopulmonary physiology that affect patients with heart failure. Lung volume and hyperinflation affect autonomic tone and pulmonary vascular resistance. In 1966 de Burgh Daly et al. showed that the correlation between systemic vascular resistance and ventilation was secondary to reflexes from intrapulmonary receptors altered by changes in lung volume. Lung inflation by either negative or positive intrathoracic pressure (ITP), in the setting of blocked carotid sinus and aortic arch baroreceptors, led to an immediate decrease in systemic vasomotor tone . FurtherHere we will discuss the importance of heart-lung interactions in various clinical scenarios including acute cardiogenic pulmonary edema (ACPE), ventilatory weaning, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and acute respiratory distress syndrome (ARDS).Left heart failure can be characterized by systolic dysfunction, diastolic dysfunction, or both. In developed countries, systolic ventricular failure is most commonly associated with ischemia  and hypertension, which also contributes to diastolic dysfunction. In other parts of the world, Chagas disease and rheumatic heart disease are more prevalent causes. Understanding heart lung interactions is essential for the management of all left heart failure patients. Negative intrathoracic pressure leads to increased LV transmural pressure increasing LV afterload. In patients with left heart failure, negative swings in intrathoracic pressure can markedly decrease LV ejection leading to rapid increases in LV filling pressure and secondary (hydrostatic) pulmonary edema. The spontaneous breathing efforts also represent a metabolic stress on the body. During periods of increased work of breathing, spontaneous ventilation increases oxygen demand of respiratory muscles as well as of the myocardium and may induce circulatory insufficiency and visceral organ ischemia .Based on these principles the primary treatment of acute cardiogenic pulmonary edema should be the immediate abolishment of negative swings in ITP. While hypovolemic patients may decrease their cardiac output when positive pressure ventilation is initiated due to the decrease in preload (moving leftward on the ventricular function curve), these effects are minimized if continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) are used in patients with acute heart failure, because the spontaneous inspiratory efforts remain but the negative swings in ITP are markedly diminished or abolished. Thus, CPAP and BiPAP selectively reduce LV afterload shifting the ventricular function curve upward in patients with acute heart failure without decreasing venous return. Numerous clinical trials have shown the immediate beneficial cardiovascular effects of initiating CPAP or BiPAP. These findings were reinforced by a meta-analysis by Weng et al. showing less need for endotracheal intubation and a trend toward reduced mortality when non-invasive ventilation is initiated on patients presenting with acute cardiogenic pulmonary edema . UnfortuPatients subjected to hyperinflation and increased juxtacardiac pressure will experience a drop in biventricular volumes. Furthermore, some of these effects, including decreased vasomotor tone, may be affected by induction of anesthesia during initiation of mechanical ventilation. Lung inflation with volumes less than 10 mL per kilogram of body weight leads to vagal tone withdrawal and, consequently, an increase in heart rate. This is known as respiratory sinus arrhythmia. On the other hand, lung hyperinflation with volumes greater than 15 mL per kilogram of body weight leads to vagal tone activation and sympathetic tone withdrawal. In such cases, patients exhibit a decrease in blood pressure secondary to vasodilation from a decrease in systemic vasomotor tone. Many patients with LV failure are also hypervolemic owing to increased antidiuretic hormone activation. Thus, in volume overloaded patients with heart failure, initiation of mechanical ventilation and some degree of lung hyperinflation will decrease preload, cause vasodilation and, thereby, decrease intrathoracic blood volume. In those settings, the slight decrease in LV afterload may augment LV ejection keeping cardiac output constant despite a sustained increase in ITP. These are the reasons why patients with LV failure usually tolerate intubation and positive-pressure ventilation well without secondary post-intubation hypotension .Weaning patients from positive pressure ventilation results in several processes occurring simultaneously. First, respirations change from positive swings in ITP to negative swings in ITP. This must increase venous return and LV afterload. The combined effects of these two processes lead to an increase in intrathoracic blood volume. Second, metabolic demand increases as respiratory muscles resume their normal activity. Patients with increased work of breathing during weaning will experience sympathetic hyperactivation and catecholamine surge leading to increased heart rate and hypertension, which in turn will increase myocardial oxygen demand. If the work of breathing is excessive or LV functional reserve is too limited, then the patient will fail weaning. Weaning failure will manifest as acute cardiovascular collapse, hypotension, tachycardia, and even acute cardiogenic pulmonary edema. These hemodynamic changes can be ameliorated by restricting fluids, having the patients slightly hypovolemic and treating bronchospasm prior to extubation. Optimizing bronchodilation, avoiding volume overload and controlling afterload prior to weaning trials will facilitate liberation from mechanical ventilation .Patients with COPD can also have LV failure. Both COPD and obesity are associated with terminal airway collapse with increased shunt. COPD patients are more likely to experience hyperinflation owning to the increased airway resistance combined with increased lung compliance. These patients experience limitations in expiratory flow secondary to airway collapse. Both hyperinflation and dynamic hyperinflation can increase pulmonary vascular resistance and compress the heart within the cardiac fossa. The combined effects can worsen RV dysfunction by minimizing RV end-diastolic volume (EDV) while simultaneously increasing RV afterload. Patients with LV failure need a higher LV filling pressure and EDV to sustain LV stroke volume. Since hyperinflation compresses the heart, LV end-diastolic volume also decreases, and thus cardiac output often decreases during acute exacerbations of COPD in patients with LV dysfunction .Commonly, patients with LV failure develop RV failure. In such cases, increases in transpulmonary pressure secondary to lung hyperinflation lead to increased RV afterload and decreased RV ejection and RV stroke volume leading to systemic hypotension. In these circumstances, patients may experience acute cor pulmonale and RV ischemia. COPD exacerbations can cause hypoxemia, hypercapnia and increased sympathetic tone. Passive increases in pulmonary artery pressure due to increased LV filling pressure rarely cause enough increases in pulmonary artery pressure to result in acute RV failure. These three mechanisms increase pulmonary vasomotor tone. Patients with COPD may also have chronic pulmonary hypertension leading to RV hypertrophy. Increasing RV afterload increases RV end-systolic volume and, by extension, RV EDV. Clinically, these patients may present with increased jugular venous distension during spontaneous inspiration (Kussmaul’s sign) and the shift in the intraventricular septum will decrease LV end diastolic compliance leading to decreased cardiac output  Mooney . LimitataCO2 beyond the apneic threshold. Furthermore, episodes of hypoxia and waking from sleep lead to sympathetic activation, which further increases LV afterload and contributes to an increase in myocardial oxygen demand. Patients with OSA have intermittent hypoxemia and formation of free radicals and inflammatory molecules that lead to vascular remodeling. The negative swings in ITP during OSA lead to a combined increase in LV afterload and systemic hypoxemia. Thus, at the time that LV wall stress is increasing, myocardial oxygen delivery is being compromised. Over months, these repetitive OSA events lead to the development of congestive heart failure and a downward shift in the ventricular function curve. Acutely, the negative swings in ITP, hypoxia, and sympathetic surge lead to increased LV afterload and reactive systemic hypertension leading to increased myocardial metabolic demand. Chronically, these factors worsen LV hypertrophy, which in turn affects LV diastolic function. OSA has been associated with LV remodeling and increased incidence of cardiovascular disease . Nocturnal CPAP or BiPAP have been shown to improve outcomes in patients with disordered sleep. Specifically, OSA patients with heart failure demonstrate improvement in daytime off-CPAP LV function if the CPAP treatment abolishes the obstructive breathing patterns .Noncardiogenic pulmonary edema or ARDS is characterized by decreased lung volumes secondary to alveolar collapse and pulmonary congestion, increased dead space ventilation, hypoxemia and increased work of breathing. Often hypoxemia is not responsive to non-invasive ventilation and intubation with positive end-expiratory pressure (PEEP) is required to sustain gas exchange and minimize receptive alveolar collapse at end-expiration. The resultant higher mean and end-inspiratory airway pressure often further increase dead space ventilation. Dead space ventilation along with hypoxic pulmonary vasoconstriction secondary to alveolar collapse lead to increased pulmonary vascular resistance. This must impede RV ejection and increase RV EDV, which in turn decreases LV diastolic compliance by the process of ventricular interdependence. Indeed, Jardin et al. demonstrated many years ago that when ARDS patients were given high levels of PEEP their LV stroke volume decreased despite a high pulmonary artery occlusion pressure, used as a surrogate of LV EDV. However, when these same patients were fluid resuscitated to restore their LV EDV to their pre-PEEP levels, LV stroke volume also returned to its pre-PEEP value even though PEEP was still being used. This seminal work clearly demonstrated that lung hyperinflation and high levels of PEEP impair LV filling by decreasing LV diastolic compliance through the process of ventricular interdependence and increased juxtacardiac ITP. These points are described elsewhere in this series in greater detail .2 and optimal cardiac output for a given blood volume. Titrating PEEP based on RV systolic function and lung compliance is an important technique to monitor for developing RV failure and preventing PEEP too low that would worsen alveolar collapse and hypoxia or PEEP too high that would worsen PVR and RV afterload and, consequently, worsen LV diastolic filling  and overdistention (increasing resistance). This elusive “sweet spot” mean airway pressure that balances these two opposing effects is often equated to the point where PEEP maximizes lung compliance. Clinical studies suggest that the highest PEEP associated with the best value of lung compliance is also associated with better RV systolic function as measured using transesophageal echocardiography, least dead space ventilation, assessed as end-tidal CO filling .aCO2 levels are all predictive of the development of cor pulmonale in ARDS. Clearly, all these effects are predictable based on the above logic. Driving pressure is a surrogate of lung stress due to its effect on hyperinflation and pulmonary vascular resistance. Likewise, higher PaCO2 levels are indicative of increased dead space and lead to pulmonary vasoconstriction and increased pulmonary vascular resistance. Mitigating these factors is critical to avoid right heart failure, RV dilation and, consequently, poor LV diastolic filling and low output heart failure (Other investigators looked at variables that are prominent in patients with ARDS that develop cor pulmonale. These investigators concluded that pneumonia being the etiology of ARDS, driving pressure, worsening P:F ratio and rising P failure .Heart-lung interactions play a crucial role in understanding and managing patients with left heart failure under most conditions independent of ventilatory mode.


Behavioural supersensitivity may be a result of increased glutamate sensitivity of D2-MSN and reduced sensitivity to dopamine. We propose that clozapine may address behavioural supersensitivity by modulating glutamate activity which may partially explain its unique effectiveness in the setting of treatment resistant schizophrenia. The mainstay of schizophrenia treatment is chronic antipsychotic medication to prevent relapse of a psychotic episode. These antidopaminergic drugs reduce D2 dopamine receptor-mediated transmission. It has been proposed that relapse rates following antipsychotic discontinuation may be due to withdrawal phenomenon rather than due to illness recurrence . The leai intracellular signalling, behavioural supersensitivity was reversed [Kruyer et al. studied the mechanism of antipsychotic-induced behavioural supersensitivity and did not find any change in D2-receptor expression or function in mice administered chronic haloperidol, in the ventral striatum, dorsal striatum or midbrain and concluded neither D2-receptor expression nor the hypothesized increased function of the receptor could explain behavioral supersensitivity . Insteadreversed .Based on the above, Kruyer et al. propose D2-medium spiny neurons hyperexcitation in the nucleus accumbens core underpins neuropathology during chronic antipsychotic treatment, antipsychotic discontinuation and behavioural supersensitivity, such that chronic antipsychotic treatment possibly reduces modulatory dopaminergic input making D2-medium spiny neurons hyperexcitable to incoming excitatory transmission from glutamate . BehavioAntipsychotic-induced behavioural supersensitivity is postulated to reduce the efficacy of antipsychotic medication leading to increasing antipsychotic doses, tolerance and treatment resistance. It has also been possibly linked to the development of tardive dyskinesia which is a motor disorder known to be caused by prolonged antipsychotic exposure . A recenClozapine is a unique medication acting upon multiple receptors , and is 14and may also potentiate glutamate transmission by regulating glutamate transport [It has been hypothesised that clozapine may specifically modulate brain glutamate and that this effect could contribute to its unique efficacy for patients with treatment-resistant schizophrenia , 15. Gluransport . Tanahasransport  also demransport . Clozapiransport . In an aransport  and thisransport . Glutamaransport . Deficitransport .However, despite the evidence for glutamatergic dysfunction in schizophrenia, specific pharmacological strategies have so far been largely unsuccessful . These aThere is indirect evidence to support that the efficacy of clozapine in refractory schizophrenia may be related to its modulatory effect on glutamate activity –30. HoweThe efficacy of clozapine in reversal of tardive dyskinesia can provide indirect links to understand this mechanism further. Antipsychotic-induced behavioral supersensitivity has been considered a possible aetiological factor for the development of both treatment resistant schizophrenia and tardive dyskinesia . Meta-anKruyer et al., show antipsychotic-induced behavioural supersensitivity may be a consequence of hyperexcitation of D2 medium spiny neuron in the nucleus accumbens core, due to enhanced glutamatergic transmission . TherefoKruyer et al., have suggested the potential role of deep brain stimulation and transcranial magnetic stimulation, in reducing and preventing excitatory plasticity in D2 medium spiny neuron . HoweverUnderstanding the mechanistic basis for antipsychotic-induced behavioural supersensitivity may lead to better prevention efforts (reducing both antipsychotic dose and usage) as well as facilitate targeted treatments for supersensitivity psychosis and tardive dyskinesia. Future research should specifically investigate clozapine’s role in antipsychotic-induced behavioural supersensitivity  and the mechanism by which clozapine (and other therapeutic approaches) may modulate glutamate-induced excitability specifically within the striatum and the nucleus accumbens. Future controlled trials should be conducted studying the effect of clozapine, electroconvulsive therapy, deep brain stimulation, transcranial magnetic stimulation and other glutamate modulating compounds for the treatment of supersensitivity psychosis with concomitant assessment of glutamate activity within the striatum and nucleus accumbens. These studies may also help identify biomarkers for treatment resistant schizophrenia and possible predictors of clozapine response.The aetiology of treatment resistant schizophrenia is likely complex and treatments that just target either dopamine or glutamate transmission are less likely to be successful . There i


IntroductionIn 2019, the Centers for Medicare & Medicaid Services (CMS) combined all autologous breast flap procedures under one billing code, effective from December 31, 2024. This change will result in equal insurance reimbursement rates for popular flap options, such as transverse rectus abdominis muscle (TRAM) and deep inferior epigastric perforator (DIEP) flaps, which were previously billed separately using S-codes based on complexity.MethodsThis study aimed to analyze insurance code changes for autologous breast reconstruction flap procedures. Data were collected from the American Society of Plastic Surgeons' annual plastic surgery statistics reports, including specific insurance codes and case volumes from 2007 to 2020. A comprehensive analysis was conducted to assess recent trends in flap utilization rates, documenting any modifications or additions to the existing codes and their implementation years.ResultsThe study analyzed billing codes and case volumes for autologous breast reconstruction procedures, with a focus on the DIEP flap and other alternatives. Non-autologous breast reconstruction procedures showed consistently higher case volumes compared to autologous procedures from 2007 to 2020. Notably, the popularity of the DIEP flap surpassed that of other flap options after 2011.ConclusionThe removal of S-codes for autologous breast reconstruction by CMS and the subsequent potential decrease in insurance coverage for the DIEP flap may lead to a decrease in its utilization and a shift toward more invasive options, like the TRAM flap. This change could result in financial burdens for patients and widen socioeconomic disparities in breast reconstruction, limiting access to preferred reconstructive methods and impacting patient autonomy and overall well-being. In 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a protocol to combine all autologous breast flap procedures under a single billing code, 193464 [Currently, most plastic surgeons receive reimbursement from insurance companies for specific flap reconstruction procedures with S-codes, such as S2068 for DIEP flap surgery, S2066 for the superior gluteal artery perforator (SGAP) flap surgery, and S2067 for stacked flap surgery, where multiple flaps are stacked on top of one another to accommodate for lack of flap volume with a single flap . This diData collectionThe primary objective of this study was to comprehensively analyze insurance code changes concerning flap procedures for autologous breast reconstruction. To achieve this, we employed a meticulous data collection approach that involved gathering relevant information from multiple reliable sources.Sources of dataWe collected the necessary data from the annual plastic surgery statistics reports, which are published by the esteemed American Society of Plastic Surgeons . These rInsurance code identificationTo ensure a robust analysis, we first identified and compiled a comprehensive list of specific insurance codes associated with autologous breast reconstruction flap procedures . This liCase volume recordsThe case volume data for the autologous flap procedures were meticulously gathered from the annual plastic surgery statistics report . These cData analysisAfter obtaining the insurance codes and corresponding case volumes, we performed a detailed analysis to assess the impact of insurance code changes on the utilization of the DIEP flap procedure. First, we identified instances of insurance code changes related to the DIEP flap procedure by comparing the codes recorded in consecutive annual plastic surgery reports. Any modifications or additions to the existing codes were noted, and the corresponding years of implementation were documented. To examine the effect of code changes on the utilization of the DIEP flap, we compared the case volumes before and after each identified code change. This allowed us to assess any fluctuations in procedure frequency and identify potential trends related to insurance code modifications.Billing codes assessed through the annual plastic surgery statistics reportThe analysis focused on the insurance codes and case volumes associated with the DIEP flap procedure and other autologous flap alternatives, as obtained from the CMS . Table 1Case volume of autologous and non-autologous breast reconstructionNon-autologous breast reconstruction procedures had a higher case volume  compared to autologous breast reconstruction procedures 168,652 cases) , "stacked" flaps, DIEP, and superficial inferior epigastric artery (SIEA) flaps. The findings are summarized in Table In 2021, the CMS discontinued S-codes for autologous breast reconstruction, making the 193464 billing code the sole source of insurance reimbursement for reconstructive breast procedures. In anticipation of these changes, several insurance companies have pre-emptively ceased coverage for the DIEP flap under S2068; other insurance companies are expected to follow [With the removal of appropriate additional reimbursement for the DIEP flap procedure, there is concern that breast reconstruction surgeons will decrease their DIEP flap case volume and potentially revert to utilizing more invasive autologous options, such as the TRAM flap ,7. WhileThere has been an increase in the frequency of DIEP flaps performed following the introduction of S-codes . This trWithout the additional reimbursement provided by S-codes, there is fear that surgeons cannot cover the DIEP procedure costs . For theFurthermore, these insurance changes may broaden the socioeconomic disparities in breast reconstruction . PatientSociodemographic factors currently represent disparities in autologous breast reconstruction and implant-based reconstruction ,20. PatiImplant-based reconstruction is another standard method for breast reconstruction. Some individuals prefer autologous tissue options due to their more natural feel and appearance. Additionally, increased reports and awareness of breast implant illness (BII) and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has decreased interest in implant-based reconstructive options . The decLimitationsDespite the rigorous data collection and analysis, certain limitations must be acknowledged. The reliance on aggregated case volume data from annual reports might have introduced sampling bias, and the lack of individual patient data limited our ability to explore patient-specific factors. Additionally, the focus on a specific time frame (2007 to 2020) and the potential variability in insurance coding practices should be considered when interpreting the results. Nonetheless, our research serves as a foundation for further exploration and underscores the importance of monitoring insurance code updates in the realm of plastic surgery practices.Limiting access to alternative autologous reconstructive options for those recently afflicted by a life-threatening breast cancer diagnosis revokes patient autonomy and heightens socioeconomic health disparities. Introducing and popularizing the DIEP flap was a productive step forward in the field of breast reconstruction. In recent years, the usage and popularity of the DIEP flap have skyrocketed; however, recent changes in reimbursement can potentially result in an inflection point in the number of cases performed in the future. Limiting access to this option only to those who can pay out-of-pocket may dramatically impact our patients' physical, mental, and overall well-being.


Spatial transcriptomics technologies developed in recent years can provide various information including tissue heterogeneity, which is fundamental in biological and medical research, and have been making significant breakthroughs. Single-cell RNA sequencing (scRNA-seq) cannot provide spatial information, while spatial transcriptomics technologies allow gene expression information to be obtained from intact tissue sections in the original physiological context at a spatial resolution. Various biological insights can be generated into tissue architecture and further the elucidation of the interaction between cells and the microenvironment. Thus, we can gain a general understanding of histogenesis processes and disease pathogenesis, etc. Furthermore, in silico methods involving the widely distributed R and Python packages for data analysis play essential roles in deriving indispensable bioinformation and eliminating technological limitations. In this review, we summarize available technologies of spatial transcriptomics, probe into several applications, discuss the computational strategies and raise future perspectives, highlighting the developmental potential. Human organs and systems are comprised of distinct cell subpopulations whose physiological processes and functions are deeply correlated with their spatial distributions and cellular interactions. To gain a deeper understanding of tissue architecture as well as heterogeneity and to subsequently obtain biological insights into intercellular communication and microenvironment, it is crucial to decipher the disparities among tissue regions and cells in their original spatial context. Previously developed single-cell RNA sequencing (scRNA-seq)  has provAlthough current cutting-edge spatial transcriptomics techniques are confronted with some drawbacks such as relatively low resolution and comparatively insufficient sequencing depth , they arSpatial transcriptomics technologies have been continuously making significant progress. Multiple technologies have emerged in recent years, and their applications and advantages and disadvantages are comprehensively reviewed. In this article, we summarize the landscapes of available spatial transcriptomics technologies, present the employment of spatial techniques in extensive fields of biomedical research and focus on the status quo of computational strategies of data analysis.Since the initial spatial transcriptomics workflow was established in 2016 , this fiLaser capture microdissection (LCM)  is a micJunker and colleagues  devised In summary, microdissection-based methods provide a competent approach to obtaining regions of interest from tissue samples with high sensitivity. These techniques enable focused research into the microanatomical structures and gene expression information of specific regions. However, Geo-seq, which integrates LCM and scRNA-seq (Smart2-seq), offers only a ten-cell resolution due to the limitations of microdissection-based techniques. During the laser-capturing and tissue segregation procedures of LCM, the quality of RNA molecules and the intactness of obtained cells may not be fully maintained. Additionally, microdissection is time-consuming and labor-intensive, limiting the throughput and the capacity to handle large tissue samples. Despite these shortcomings, microdissection-based technologies can still provide robust methods for gene expression profiling.In situ hybridization is a strategy that enables the visualization of RNA molecules within their original context via probes complementary to the objective transcripts rather than extracting them from tissue sections. An early iteration of in situ hybridization technique termed single-molecule fluorescent in situ hybridization (smFISH)  is compeTo overcome the drawbacks of accumulating errors, Chen and colleagues  devised in-situ-hybridization-based techniques allow for the visualization of RNA molecules within their original tissue context by hybridizing probes with complementary targets. This enables the detection of target genes for biological validation of bioinformatic analysis results and the study of gene expression patterns. However, the nature of FISH methods imposes an intrinsic limitation on throughput. Additionally, specific probes must be synthesized before the hybridization process, necessitating the use of ready-made kits to overcome this challenge [Overall, hallenge .In situ sequencing (ISS) method developed by Ke and colleagues  enables To examine transcripts without prior knowledge of tissue, Lee and colleagues  devised in-situ-sequencing-based methods enable spatial-level gene expression analysis and avoid the bias introduced by transcript extraction. However, these techniques still face challenges. For example, prior knowledge of the tissue may be required to design specific padlock probes, and read length may be limited. Additionally, in situ sequencing may not be feasible for unconventional or rare cell types and genes. Potential applications of these methods include studying gene expression regulation within tissues or cells and localizing gene variants.In contrast to traditional sequencing methods that separate cells from their spatial context, Ståhl and colleagues  proposedImprovement of the resolution of spatial barcoding strategies has been continuously pursued. In 2019, Rodriques and colleagues  developeSlide-seq, HDST and Seq-Scope introduced above can provide much higher and even subcellular resolutions, generating more refined spatial distribution information. The approaches to improving the resolutions of Slide-seq and HDST are similar, involving bead arrays with 10-μm- and 2-μm-diameter beads, respectively , 45. It Overall, spatial-barcoding-based techniques allow for the simultaneous acquisition of gene expression and spatial location information. However, selecting the appropriate resolution requires careful consideration. Low resolution may obscure the intrinsic tissue structure and require further decomposition analysis to gain comprehensive insights, while high resolution may introduce those aforementioned challenges. Additionally, capture efficiency may be relatively low. Despite these limitations, spatial-barcoding-based techniques are widely used to study tissue architecture, tumor heterogeneity, the tumor microenvironment, etc.Spatial transcriptomics technologies are potent tools for studying the intricate structure, the dynamics of tissue and organ systems and inherent mechanisms within their original context. These technologies can provide valuable biological insights by revealing tissue architecture, developmental patterns and diseases, among which tumor biology may be one of the most extensive applications of spatial transcriptomics. Primary application scenarios of implementing spatial transcriptomics techniques are presented Fig.  and seveDecoding intercellular interaction and identifying cell subpopulations are of fundamental significance in delineating tissue architecture and defining structural components through the establishment of a transcriptome atlas of a specific tissue or organ, thus facilitating the perception of tissue dynamics. Hildebrandt and colleagues  managed Furthermore, spatial transcriptomics technologies are generally utilized in developmental biology to reveal spatiotemporal gene expression patterns and uncover tissue morphogenesis throughout the entire development course or multiple pivotal stages. Asp and colleagues  profiledBeyond the above insights about tissue architecture and development, spatial transcriptomics techniques have a robust capacity for clarifying disease microenvironments and pathogenesis. Boyd and colleagues  combinedA substantial part of disease research is the study of tumor biology which could be the most extensive application of spatial transcriptomics. Significant challenges in devising tumor treatment procedures are induced by tumor heterogeneity. Moncada and colleagues  utilizedTo comprehensively interrogate the tissue sections, bioinformatic analyses have to be performed to unravel the intertwined and multiplexed bioinformation and minimize the impact of current technological limitations and subsequently derive biological significance more accurately from raw spatial transcriptomics data. These bioinformatics analyses range from spatially-variable genes identification and clustering analysis to gene imputation, etc., which can be handily effectuated through a substantial number of computational strategies devised in recent years. Herein, circumstantial comparisons of algorithms and usages among the existing R or Python packages are presented Table .Table 4CDistinguishing cell types and subpopulations is a fundamental task in the bioinformatic analysis of spatial transcriptomics data. This can be resolved with the help of clustering analysis where spatially-variable genes can be discovered and data dimensions can be reduced through approaches such as principal component analysis (PCA), t-distributed stochastic neighbour embedding (t-SNE) and uniform manifold approximation and projection (UMAP). These methods calculate similarity among barcode spots and define clusters within a tissue. A robust clustering procedure is provided by a widely-distributed R package Seurat , on whicWithin a certain tissue, some genes exhibit conspicuous spatially-variable expression whereas some other genes such as housekeeping genes are expressed equally among the cells. The specific pattern in which the expressions of genes spatially vary can convey indispensable bioinformatic insights into identifying cell types and subpopulations and corresponding spatial information and underlying spatial functions. Some program packages perform outstandingly in identifying spatially-variable genes. Svensson and colleagues  describeA common issue in spatial transcriptomics technology is that a single barcode-capturing spot may be overlaid by multiple cells. Thus, the detected expression is an aggregation of a heterogeneous set of cells within the spot, which may impact the efficiency and accuracy of identifying cell subpopulations and delineating tissue atlas. For example, 10 × Genomics Visium offers a resolution of 55 μm meaning the diameter of each capturing spot is 55 μm which is several-fold larger than a typical tissue cell. The spatial decomposition process through various deconvolution algorithms can address this discrepancy, which is to disentangle the mixture of mRNAs and subsequently predict the proportions of each cell type in one capturing spot. A spatial decomposition method devised by Ma and colleagues  is termeGene imputation refers to the task of inferring lost gene expression information or “dropouts” caused by factors such as low protocol sensitivity, mitigating errors during gene measurement and facilitating deconvolution. Biancalani and colleagues  introducThe aforementioned strategies, including spatial decomposition and gene imputation, have demonstrated considerable efficacy in enhancing the resolution of spatial transcriptomics data and compensating for lost gene expression information. Nevertheless, certain limitations persist. These approaches are based on computational models for predicting cell locations and gene information and therefore, their predictions may be subject to error, potentially resulting in imprecise and spurious results. Further investigation and refinement are necessary to more effectively leverage these technologies and derive more reliable biological insights.Cellular interaction operated within the microenvironment where cells are adjacent to each other can convey significant perceptions into tissue dynamics and the way the communication networks change when experiencing conditions such as disease. A Graph Convolutional Neural networks for Genes (GCNG) method was introduced to infer extracellular interactions from gene expression by depicting a cellular relationship graph transformed from spatial transcriptomics data and subsequently encoding gene expressions, and the graph is then convolved with expression information . Cang anCopy number variation (CNV) refers to the increase or decrease in the copy number due to gene segment rearrangements. Typically, CNVs involve segments longer than 1000 base pairs and are mainly manifested as submicroscopic deletions or duplications. CNVs are a common form of genetic variation in the human genome, with 5% ~ 10% of the genome affected by CNVs, which is much higher than other forms of genetic variation. Ascertaining the transition from benign to malignant tissue forms the foundation for improving early cancer diagnosis, as genomic instability in histologically benign tissue can signal an early event in cancer evolution. Furthermore, the spatial distribution and activity of CNVs can impact phenotype, making mapping their spatial distribution valuable for comprehending, diagnosing, and treating diseases. Previously, gene expression was utilized to infer CNVs in individual cells, successfully identifying regions of chromosomal gain and loss . EricksoGene expression within a tissue is influenced by the spatial position of cells in the tissue microenvironment. Spatial transcriptomic data can provide valuable insights into tissue regions, as they contain information on spatial position matrices, HE region staining of sections, and relative distances between individual cells, which can be used to delineate spatial regions. MULTILAYER is an algorithm that utilizes agglomerative clustering and community detection methods for graphical partitioning, enabling digital imaging of spatial transcriptomic analysis . This alSpatial trajectory analysis is an analytical method frequently employed in spatial transcriptomics to uncover dynamic cellular evolution and differentiation processes. This approach infers evolutionary trajectories and differentiation relationships between cells by analyzing their spatial positions and gene expression levels within tissue sections. The stLearn package can visualize spatial trajectories in tissue slices and infer biological processes from transcriptional state gradients across tissues . SimilarBoth spatial transcriptomics and scRNA-seq are effective methods for obtaining biological insights into tissues and diseases. However, each method has its limitations. By integrating spatial transcriptomics and scRNA-seq data, these methods can complement each other to provide comprehensive biological information. For instance, RCTD generates spatial decomposition by assigning cell types to spatial transcriptomics spots , whereasMethods for analyzing spatial transcriptomics data are generally similar and can be divided into data preprocessing and downstream analysis. Data preprocessing typically involves quality control and normalization to improve data quality for downstream analysis and obtain more reliable biological information. For spatial-barcoding-based methods, quality control aims to remove low-quality spots and genes from spatial transcriptomics data. Quality control parameters can be adjusted based on tissue type, research requirements, and other factors. These parameters may include removing spots with fewer than a certain number of transcripts, removing genes expressed in fewer than a certain number of spots, and removing spots with a high proportion of mitochondrial genes. Normalization accounts for the difference in sequencing depth among different spots. Since differences among spots in spatial transcriptomics data can be relatively large, effective normalization is essential.After preprocessing, downstream analysis can be performed. The data should first undergo dimensionality reduction and clustering analysis to distinguish spots with different features. Biological information can then be interpreted through these clusters in subsequent analysis. Algorithms such as PCA, t-SNE, and UMAP can be used for this purpose and are available in many data analysis packages. Next, gene expression patterns in the data can be analyzed, including differential expression analysis and spatially variable gene analysis, which can be performed using packages such as Seurat and SpatialDE, respectively. Additionally, cell information from tissue slices can be annotated onto spatial transcriptomics data. Since the sequencing unit  of some spatial transcriptomics technologies may contain more than one cell, spatial decomposition can infer the proportion of various cells in each sequencing unit based on the data to obtain cell locations in the spatial context. This step can be achieved using packages with deconvolution algorithms such as RCTD and cell2location. Gene imputation can also predict the positions of low-expressed or missing genes in space due to possible dropout using packages like Tangram. Furthermore, personalized analysis can be conducted based on research objectives. For instance, packages such as Giotto can be used to analyze the communication between cells or spatial regions, including receptor-ligand interactions. SpatialInferCNV can perform copy number variation analysis at the spatial level, while stLearn and SPATA can be used for spatial trajectory analysis and MULTILAYER for spatial region identification. These analytical methods and packages provide excellent visualization during data analysis, facilitating step-by-step comprehension of current analytical outcomes to guide subsequent analysis. Moreover, it is essential to integrate spatial transcriptomics data with scRNA-seq data and other omics data to obtain a more comprehensive understanding of biological information.Explosive advances in spatial transcriptomics technologies have been made in recent years to expand our understanding of miscellaneous tissues and organs. However, current spatial transcriptomics methods are confronted with some challenges of low resolution, sensitivity, throughput, etc., hindering our precise perception of normal and abnormal tissues, which calls for further innovations in technologies to overcome these deficiencies. Given that each technology bears its biological strengths, we envision the integration across these technologies which complement each other in the drawbacks before a novel and robust technology is launched. With future technology revolutions, intercellular signaling could be resolved at higher and even single-cell resolution. In addition, larger-scale tissue specimens may be investigated to allow for depicting organ-level tissue topography, enabling a more holistic and consecutive interpretation of tissue structures, which latently poses challenges for accelerating bioinformatic analysis with higher efficiency and accuracy and more powerful information processing capacity. Beyond the prospective advancement in refining and optimizing current protocols of spatial transcriptomics, we also envisage the integration with multi-omics including epigenomics, proteomics, and metabolomics to shed light on the intrinsic convoluted mechanisms of cellular interactions and disease and better probe into tumor progression and growth course. In addition to advances in spatial transcriptomics technologies, innovations in data analysis strategies are also anticipated. As deep learning technology continues to progress, its application in spatial transcriptomics data analysis is expected to become more widespread. In the future, more deep-learning-based methods may be developed to process and analyze spatial transcriptomics data to improve data resolution and interpretation reliability. Furthermore, as data scale and complexity increase, visualization and interactive analysis will become important tools for spatial transcriptomics data analysis. Future spatial transcriptomics data analysis methods will need to integrate visualization and interactive analysis technologies to better understand and interpret data.Since some spatial transcriptomics techniques, especially some widespread spatial-barcoding-based techniques, are not capable of offering single-cell resolution at the spatial level and scRNA-seq cannot reflect the spatial distribution of each cell, we envision a more organic and efficient alignment of single-cell datasets and corresponding spatial information. The alignment can be achieved by mapping single cells to spatial data, where each cell is matched with a spatial location in an ideal condition. Nevertheless, current methods for integration cannot generate precise matching due to technological limitations, which calls for further breakthroughs in the effectiveness and efficiency of data integration algorithms. By integrating both datasets, we can decipher potential intercellular communication pathways, including ligand-receptor interactions and juxtacrine and paracrine signaling. This may provide insights into previously unclear physiological and disease mechanisms and help discern more refined classifications of certain diseases, facilitating precise and individualized medical treatment. Additionally, publicly-available datasets can be interrogated retrospectively with the integration of spatial transcriptomics and scRNA-seq data to obtain novel biological cues which may be concealed in the raw data before.Moreover, we anticipate the translational medicine research into the clinical significance of spatial transcriptomics, particularly with the compatibility of the 10 × Genomics Visium platform with FFPE tissue blocks allowing retrospective analysis into previously opaque tissue specimens to glean more sufficient information on clinical diagnostics and prognostics as well as therapeutic methods and targets. For example, research into human DLPFC distinguished the layer-enriched genes that may be associated with schizophrenia and autism spectrum disorder, implicating the potential of neuropsychiatric disorders progression in those bearing the risk gene expression . In tumo


The clinical spectrum of atrial fibrillation means that a patient-individualized approach is required to ensure optimal treatment. Cardiac computed tomography can accurately delineate atrial structure and function and could contribute to a personalized care pathway for atrial fibrillation patients. The imaging modality offers excellent spatial resolution and has been utilised in pre-, peri- and post-procedural care for patients with atrial fibrillation. Advances in temporal resolution, acquisition times and analysis techniques suggest potential expanding roles for cardiac computed tomography in the future management of patients with atrial fibrillation. The aim of the current review is to discuss the use of cardiac computed tomography in atrial fibrillation in pre-, peri- and post-procedural settings. Potential future applications of cardiac computed tomography including atrial wall thickness assessment and epicardial fat volume quantification are discussed together with emerging analysis techniques including computational modelling and machine learning with attention paid to how these developments may contribute to a personalized approach to atrial fibrillation management. Atrial fibrillation is conventionally classified according to a single domain - the temporal pattern of the arrhythmia. Whilst the use of classification systems has increased our understanding of atrial fibrillation to some extent, such an approach can overlook the importance of the interplay of factors related to the patient, their symptom severity, risk factors and the atrial electrophysiological substrate underpinning atrial fibrillation. Given these interactions, the management of atrial fibrillation necessitates the delivery of a coordinated patient-individualized care pathway to ensure optimal treatment. Whilst more research to explore the patient-specific pathophysiological basis of atrial fibrillation is necessary, the principles of patient-individualized care have been encapsulated in the 4S-AF scheme which aims to provide a structured, pathophysiology-based characterisation of a patient's atrial fibrillation comprising four domains - stroke risk, symptom severity, severity of atrial fibrillation burden and substrate severity.Within this framework, computed tomography may provide useful information to guide atrial fibrillation management by enabling assessment of cardiac structure and function. Advances in computed tomography temporal and spatial resolution have strengthened its utility in the field of electrophysiology.This review will discuss the current state-of-the-art for computed tomography in atrial fibrillation management together with potential future applications that form part of ongoing research .Fig. 1Th22.1In atrial fibrillation, cardiac computed tomography has been used prior to direct current cardioversion, radiofrequency catheter ablation and left atrial appendage closure to investigate for contraindications, delineate anatomy and guide procedures.In the context of atrial fibrillation ablation procedures, pre-procedural atrial imaging can define patient-specific atrial anatomy.Prior to percutaneous left atrial appendage occlusion, pre-procedural imaging is utilised to guide left atrial appendage occluder device selection and sizing, and to facilitate procedure planning.2.2In patients with sub-therapeutic anticoagulation (missed anticoagulant doses or short duration of therapy), investigation for left atrial appendage thrombi prior to direct current cardioversion or atrial instrumentation is required.,Computed tomography can be used to differentiate between left atrial appendage thrombus and slow blood flow by comparing early arterial and delayed phase images.2.32) score. In a recent simulation study by Qureshi et al., it has been demonstrated that left atrial appendage morphology may affect coagulation dynamics in blood flow during sinus rhythm and atrial fibrillation, and subsequent risk of thrombus formation.Cardiac computed tomography can be used to accurately characterize left atrial appendage morphology . Left at2.4Prior to radiofrequency catheter ablation of the pulmonary veins in atrial fibrillation, an awareness of a patient's left atrial and pulmonary vein anatomy can enable accurate targeting and planning through the measurement of ostial diameter, characterization of variants in pulmonary vein anatomy such as accessory pulmonary veins or common pulmonary vein ostia, and the identification of anomalies such as anomalous pulmonary venous return, pulmonary vein occlusion or the presence of a persistent left superior vena cava.Variations in pulmonary vein anatomy are common and can be easily assessed with computed tomography.2.5Pulmonary vein stenosis is a recognized complication of atrial fibrillation ablation close to or within the pulmonary vein ostia. Symptoms typically take weeks to months to manifest and include shortness of breath, dry cough and, in some instances, chest pain.2.6Injury to extra-cardiac structures is a recognized, but fortunately rare, complication of atrial fibrillation ablation. The esophagus lies adjacent to the posterior wall of the left atrium leaving it vulnerable to injury during radiofrequency catheter ablation.Methods to reduce risk of atrio-esophageal fistula formation such as active esophageal coolingThe proximity of the right and left phrenic nerves with the right superior pulmonary vein and left atrial appendage roof respectively also leaves these structures vulnerable to injury during ablation.3Advances in computed tomography image acquisition and analysis provide the opportunity for its role in atrial fibrillation assessment to expand. Techniques including computational modelling, artificial intelligence-based imaging, atrial wall thickness assessment and epicardial adipose tissue characterisation may enable an individualized precision-cardiology approach to atrial fibrillation management. This section summarizes these approaches and suggests areas where future research developments using computed tomography may address knowledge gaps in the management of atrial fibrillation.3.1The ability of cardiac computed tomography to accurately delineate atrial structure can enable the acquisition of complex three-dimensional human atrial geometry which can form the basis of computational organ-level atrial models .45 TheseComputational models could be used to characterize an individual's substrate severity and lead to personalized atrial fibrillation ablation therapy. Hwang et al. used cardiac computed tomography to create atrial models which could be used to compare different ablation strategies for atrial fibrillation.ClinicalTrials.gov, #NCT05057507) study will aim to use computational modelling to define patient-specific mechanisms of atrial fibrillation.Computational modelling for personalized atrial fibrillation procedure planning is an area of active research, offering the potential to better understand arrhythmia pathophysiology and improve clinical arrythmia prevention, risk stratification and treatment.Future research developments using computational models will require three-dimensional anatomical geometry and cardiac computed tomography is therefore likely to play a role in the generation of these models. A key advantage of cardiac computed tomography in this setting is the high spatial resolution of image acquisition which enables accurate anatomical assessment of wall thickness and left atrial appendage morphology. Previous studies using magnetic resonance imaging to evaluate the role of computational modelling in atrial fibrillation therapy have been unable to include variations in left atrial wall thickness or appendage morphology.3.2Machine learning is likely to be beneficial for personalized atrial fibrillation care in the future.Improved image quality with machine learning-based reconstruction algorithms may improve the ability to assess thin structures such as the atrial wall.The ability of cardiac computed tomography to characterise atrial structure may prove to be of prognostic importance as structural parameters such as left atrial volume3.3Changes in the structure and electrical behavior of the left atrium are associated with conditions which predispose to atrial fibrillation, although it is also recognized that these changes may occur in response to atrial fibrillation itself.Furthermore, we have developed reference values for left atrial wall thickness measurements on computed tomography, measured left atrial wall thickness at two locations (roof and floor) using computed tomography in 100 persistent atrial fibrillation patients., measured thickness around the pulmonary vein antra in patients undergoing repeat ablation procedures and found that antral wall thickness was higher in areas of pulmonary vein reconnection., found no association between left atrial wall thickness measurements and pulmonary vein isolation success rates.Studies have also been performed to examine for an association between left atrial wall thickness measurements and atrial fibrillation ablation success rates. Zuo et al.The use of computed tomography to assess atrial wall thickness and provide non-invasive substrate determination may enable us to identify areas where the risk of recurrence is potentially higher and personalize therapy to improve outcomes. The utility of computed tomography-derived left atrial wall thickness in guiding catheter ablation approach has been demonstrated by Teres et al., who found that personalized ablation approaches adapted to left atrial wall thickness allowed pulmonary vein isolation with lower radiofrequency delivery, fluoroscopy, and procedure times.3.4Cardiac computed tomography enables a three-dimensional assessment of the volume, thickness, and attenuation of the epicardial adipose tissue C.71 Some,Several studies have shown that patients with atrial fibrillation have increased epicardial adipose tissue thickness, mass and volume compared with patients without atrial fibrillation . A meta-,,,Recently, assessment of the pericoronary adipose tissue attenuation has gained attention due to its association with subsequent cardiac events.Notably these studies have considered only single-plane analysis or peri-atrial fat attenuation limited to the posterior left atrium. Furthermore, cut-off values to accurately define abnormal epicardial adipose tissue attenuation have not been defined and vary between research studies. Further mechanistic studies are therefore needed to study the role of global peri-atrial fat and fat attenuation in atrial fibrillation pathogenesis.In a study by Zhang et al., it has been shown that the radiomic characteristics of epicardial adipose tissue may improve the identification of patients who have atrial fibrillation compared to quantification of epicardial adipose tissue volume.At present it is unknown whether changes in epicardial adipose tissue are a cause or consequence of atrial fibrillation. Epicardial adipose tissue, which contains ganglionated plexi, actively secretes cytokines and adipokines which may lead to inflammation and atrial remodelling. The secretion of pro-fibrotic factors by epicardial adipose tissue may contribute to atrial myocardial fibrosis and this may act as a substrate for atrial fibrillation.4Cardiac computed tomography can provide important anatomical information for patients with atrial fibrillation and has been used in the pre-, peri- and post-procedural stages of management. New techniques such as computational modelling and machine learning are improving our understanding of the development of atrial fibrillation and responses to therapy. In the future information such as atrial structure, atrial wall thickness, and epicardial adipose tissue from computed tomography may be used to provide a personalized approach for the management or prevention of atrial fibrillation.MCW has given talks sponsored by Canon Medical Systems, Siemens Healthineers and Novartis. SN receives research funding from Siemens for computed tomography image analysis. SEW has consulting agreements with EPD/Phillips, GSK and Biosense Webster.


Most mental disorders, when examined individually, are associated with an increased risk of cardiometabolic complications. However, these associations might be attributed to a general liability toward psychopathology or confounded by unmeasured familial factors.To examine whether the associations between psychiatric diagnoses and increased risk of cardiometabolic complications are attributable to a general liability toward psychopathology, or confounded by unmeasured familial factors.We conducted a cohort study in Sweden and identified all individuals and their siblings born in Sweden 1955-1962 with follow-up through 2013. After excluding individuals who died or emigrated before 1987, the final sample consisted 672 823 individuals. We extracted ICD-coded diagnoses (recorded 1973-1987) for ten psychiatric conditions and criminal convictions when participants were aged 18-25 years, and ICD-coded diagnoses (recorded 1987-2013) for five cardiometabolic complications  when the participants were 51-58 years old. Logistic regression models were used to estimate the bivariate associations between psychiatric conditions or criminal convictions and cardiometabolic complications in individuals. A general factor model was used to identify general, internalizing, externalizing, and psychotic factors based on the psychiatric conditions and criminal convictions. We then regressed the cardiometabolic complications on the latent general factor and three uncorrelated specific factors within a structural equation modeling framework in individuals and across sibling pairs.Each psychiatric conditions significantly increased the risk of cardiometabolic complications; however, most of these associations were attributable to the general factor of psychopathology, rather than to specific psychiatric conditions. There were no or only small associations between individuals’ general psychopathology and their siblings’ cardiometabolic complications, suggesting that the associations were not attributable to genetic or environmental confounding factors shared within families. The same pattern was evident for the specific internalizing and psychotic factors.Individuals with mental disorders in early life had an increased long term risk of cardiometabolic complications, which appeared attributable to a general liability toward psychopathology. Sibling analyses suggested that the elevated risk could not be attributed to confounds shared within families.This highlights the importance of transdiagnostic and lifestyle based interventions to reduce the risk of cardiometabolic complications, particularly in patients with several mental disorders.None Declared


Transcranial magnetic stimulation (TMS) is a non-invasive FDA-approved therapy for major depressive disorder (MDD), specifically for treatment-resistant depression (TRD). Though offering promise for those with TRD, its effectiveness is less than one in two patients . Limits on efficacy may be due to individual patient variability, but to date, there are no established biomarkers or measures of target engagement that can predict efficacy. Additionally, TMS efficacy is typically not assessed until a six-week treatment ends, precluding interim re-evaluations of the treatment. Here, we report results using a closed-loop phase-locked repetitive TMS (rTMS) treatment that synchronizes the delivery of rTMS based on the timing of the pulses relative to a patient's individual electroencephalographic (EEG) prefrontal alpha oscillation indexed by functional magnetic resonance imaging (fMRI). Among responders, synchronized rTMS produces two systematic changes in brain dynamics: a reduction in global cortical excitability and enhanced phase entrainment of cortical dynamics. These effects predict clinical outcomes in the synchronized treatment group but not in an active-treatment unsynchronized control group. The systematic decrease in excitability and increase in entrainment correlated with treatment efficacy at the endpoint and intermediate weeks during the synchronized treatment. Specifically, we show that weekly biomarker tracking enables efficacy prediction and dynamic adjustments through a treatment course, improving the overall response rates. This innovative approach advances the prospects of individualized medicine in MDD and holds potential for application in other neuropsychiatric disorders.


BMC Cardiovascular Disorders invites authors to submit articles investigating what drives and affects Cerebrovascular disorders to improve patient care.Cerebrovascular disorders pose a global health concern. Advances in basic and clinical research, including induced pluripotent stem cell models and multi-omic approaches, have improved our understanding and management of these disorders. However, gaps in our knowledge remain.  BMC Cardiovascular Disorders welcomes submissions to its new “Cerebrovascular Disorders” collection to help further our understanding of such conditions and open new avenues for risk stratification and therapeutic intervention.Cerebrovascular disorders comprise a range of distinct pathologies, including ischaemic and haemorrhagic stroke, transient ischaemic attack, and other intracranial vascular disorders , and significantly increase the risk of vascular dementia. Cerebrovascular disorders represent a significant medical and economic challenge anticipated to rise due to the increasing age of the global population . The pasHDAC9 large-vessel stroke risk to screen for histone deacetylase (HDAC) small molecule inhibitors ) We look forward to the “Cerebrovascular Disorders” article collection bringing together basic and clinical research to develop our understanding of what drives and affects such conditions to improve patient care.