In retrospect, the yet to be resolved refractory nature of adult cardiomyocytes with respect to cell cycle progression and cell division necessitates the need for an innovative approach to promote adult cardiomyogenesis.Cardiomyocyte loss followed by scar formation is the leading cause of heart failure upon pathological injury, chronic or acute stress, and aging. Despite decades of investigation, therapeutic development to enhance cardiomyocyte turnover and restore the structural and functional integrity of the heart has been limited due in part to the inherent lack of proliferative capacity within adult cardiomyocytes. A therapeutic solution to the conundrum of post-mitotic cardiomyocytes has long been sought after, leading to a range of pre-clinical interventional approaches including (but not limited to) overexpression of cell cycle proteins, induction of systemic hypoxemia, as well as transcriptional and hormonal regulation. The consensus outcome reveals dedifferentiation rather than proliferation potential of adult mammalian cardiomyocytes based upon phenotypic changes such as (1) loss of myofibrillar structure; (2) expression of stem cell markers; and (3) exhibition of immature metabolic functions. In an effort to illustrate the myocardial therapeutic significance of PR, Chen et al., demonstrated that short-term myocardial introduction of OSKM reprograms cardiomyocytes to a fetal phenotype evidenced by (1) transcriptome resembling neonatal and embryonic developmental stages; (2) expression of α-SMA; and (3) morphological rearrangement and cell cycle re-entry in vitro. Regardless of the time of induction, in vivo OSKM expression promoted structural recovery of the heart following myocardial infarction; however, functional results varied among induction regimens.Cellular reprogramming via the four pluripotency factors, OCT4, SOX2, KLF4, and MYC (OSKM), is a promising approach to epigenetically remodel somatic cells of various lineages into an induced pluripotent stem cell state. Partial reprogramming (PR) via the transient introduction of OSKM reverses age-associated phenotypes and promotes the regenerative potential of adult tissues such as skeletal muscle. From cardiomyocyte-specific overexpression of cyclins to transdifferentiation of fibroblasts into myocytes, to differentiating induced pluripotent stem cells (iPSCs) into cardiomyocytes, time and again, the results indicate that such approaches are unlikely to translate directly into clinically relevant therapies. And yet, each new insight into cardiomyocyte biology increases the knowledge base necessary to design better informed regenerative therapies. The current findings by Chen et al. reveal a threshold of cardiomyocyte dedifferentiation in adult mice, after which cardiac function declines and cardiac tumors form, in contrast to lower vertebrates and neonatal mammals, which tolerate greater cardiac plasticity.Driving cell cycle progression to achieve true proliferation in adult mammalian cardiomyocytes represents a longstanding goal in the ongoing effort to repair damaged myocardiumet al. highlight the challenge of associating clinically relevant cardiac repair with endogenous cardiomyocyte cell cycle progression. All of the partial reprogramming regimens result in reduced scar size in infarcted hearts, and post-injury therapeutic treatment yields the most 5-Ethynyl-2′-deoxyuridine (EdU) + cardiomyocytes. However, the best functional outcomes are observed in the pre-injury treatment group, whereas no functional improvement is observed in the post-injury therapeutic treatment cohort. Salvage, cell cycle progression, and function appear disconnected in this repair model.Creating pre-clinical models of cardiac repair that reflect clinically therapeutic scenarios remains an ongoing challenge in cardiac research. Differentiation of cardiac progenitor cells, iPSCs, or reprogrammed cardiomyocytes into functional, mature myocytes remains a major roadblock for translational applications. Experimental treatments that coincide with myocardial injury tend to represent cardioprotective salvage models rather than therapies that replace damaged myocardium post-injury. Functional outcomes may be improved; however, cardiac patients are unlikely to receive regenerative treatment at the time of a cardiac event. Interestingly, the infarction injury results presented by Chen . Reagents that track cell cycle in real-time, such as various transgenic fluorescence ubiquitination cell cycle indicator reporter animal models, can provide dynamic readouts of cell cycle status in vitro and in vivo. Perhaps the most convincing data demonstrating cardiomyocyte proliferation in the current publication are live imaging videos tracking tagged cells going through karyo and cytokinesis. Of course, the next crucial step in the regenerative process is to convert these dedifferentiated reprogrammed proliferating cardiomyocytes into functional adult cells that contribute to cardiac function. Whether comparable division and re-differentiation occur in damaged reprogrammed hearts remains to be demonstrated.Identifying true cardiomyocyte replication represents another point of contention among researchers. Mature cardiomyocytes are generally post-mitotic; however, their nuclei can undergo changes that appear to reflect proliferation, such as DNA synthesis in response to stress, binucleation or karyokinesis without cytokinesis, or increases in ploidy during aging. Measures of cell cycle re-entry such as EdU, phospho histone H3, even aurora B kinase, are insufficient to definitively prove full cardiomyocyte cellular division–8. Reprogrammed cardiomyocytes in an adult heart are not equivalent to developing cardiomyocytes maturing in concert with associated systemic postnatal hormonal changes. Studies have shown that the paracrine, metabolic and structural milieu of an adult mammalian heart favor cellular hypertrophy or senescence over cardiomyocyte proliferation. The myocardial environment in most heart disease patients is probably even less conducive to proliferation and repair, underscoring the challenge of transforming reprogrammed cells into new functional new myocytes. Nonetheless, while the gap between basic research findings and clinically relevant cardiac therapies remains unbridged, cumulative research findings are essential to successful development of those therapies.Systemic context plays a crucial role in myocardial regenerative potential. Metabolic and paracrine factors, and the state of the extracellular matrix all have an enormous impact on cardiomyocyte cell cycle activityet al., represent substantial translational hurdles. How can cardiomyocyte reprogramming be administered safely and titrated to avoid the deleterious effects observed in over-reprogrammed hearts? Would this be possible given the enormous variability among human cardiac patients? Perhaps the real takeaway lesson from this and similar studies investigating cardiomyocyte proliferation lies in understanding what makes an adult cardiomyocyte healthy and capable of cell cycle re-entry to the point of replication. From a preventative medicine point of view, a more realistic approach may be to identify lifestyles and habits that support the more youthful and proliferative cardiomyocyte phenotypes identified in partial reprogramming models. Transcriptomic and proteomic profiling studies comparing youthful and diseased or senescent cardiac phenotypes may provide therapeutically relevant targets for suppressing senescence-associated secretory phenotype, inflammation, or oxidative stress in a time and a dose-dependent way to encourage myocardial healing. Evaluating signaling pathways associated with youthful or proliferative phenotypes could also reveal safer, more reliable targets. Ultimately, combinatorial therapies incorporating multiple restorative strategies probably hold the most promise for improving cardiac patient outcomes.Many questions about cardiomyocyte proliferation remain unanswered from the basic and clinical perspectives, perhaps the most important being: can adult human cardiomyocytes be coaxed to divide in response to injury on a therapeutically relevant level, and is it possible to quantify this proliferation in recipient human patients? Experiments performed in young adult mice in no way reflect the systemic profile of human heart patients, many of whom are elderly or have underlying comorbidities such as hypertension, diabetes, or other metabolic dysregulation. Timing and dosage of a hypothetical reprogramming therapy, in light of the results presented by Chen In summary, the holy grail of physically mending damaged human hearts remains elusive. Considerable time, resources, and effort have gone toward understanding myocardial injury, repair, aging, and possible regeneration in vertebrate animal models. Approaches including cell therapy, tissue engineering, and driving adult mammalian cardiomyocytes to proliferate in response to damage as documented in neonatal hearts, or adult fish and reptile systems, have yielded valuable new insights into cardiac biology. Moreover, although a marketable therapy to repair pathologically challenged human hearts has not yet materialized, this goal has inspired incredible scientific creativity and a deeper understanding of cardiac cellular and molecular biology. Put another way, research findings cannot be valued solely on their immediate translational relevance, or unduly influenced by increasing pressure to produce therapies and cures. However, clinically driven studies that build on collective basic and translational research findings bring cardiac medicine closer to curing or even preventing heart disease altogether.


The COVID-19 pandemic posed new challenges for caregivers. This study examines the prevalence of pandemic care challenges  and their associations with caregiver mental health and interpersonal well-being in a nationally representative sample of 311 caregivers who participated in the June 2020 National Poll on Healthy Aging. We consider seven care challenges and supports as key predictors of caregiver mental health  and interpersonal well-being  in bivariate tests and ordinary least squares regressions. Each care challenge/support was endorsed by between 13-23% of caregivers. Difficulty getting needed medical care was the most predictive challenge associated with increased caregiver stress, depressive symptoms, and worsened interpersonal well-being. All care challenges predicted an increase in caregiver stress. Effective caregiver tools and supports must consider changing policies and care needs, especially during a pandemic.


Self-reported cognitive difficulties are common in older adults and may be an early indicator of future cognitive decline or dementia. In past retrospective reports, cognitive difficulties have been linked with differences in social engagement or social relationships among older adults. However, little is known about how self-reported cognitive difficulties in daily life, such as memory lapses, relate to older adults’ daily social experiences. This study examined how self-reported cognitive difficulties were related to older adults’ daily social interactions and loneliness. Data were drawn from 312 community-dwelling older adults (aged 70 to 90 years) who reported their social interactions and loneliness throughout the day (five times) as well as cognitive difficulties  at the end of each day for 14 days. Multilevel models revealed that participants reported fewer memory lapses on days when they reported more frequent interactions with family members (p=.041). Higher levels of disruptions to daily activities caused by cognitive difficulties, in turn, predicted higher levels of loneliness the next day (p=.006), but not changes in social interactions the next day. At the between-person level, more memory lapses in daily life were associated with less frequent social interactions with friends, but more frequent unpleasant social interactions and higher levels of loneliness on average. These results suggest that older adults’ self-reported cognitive difficulties were dynamically associated with their social interactions and loneliness at the daily level and played an important role in older adults’ social life and well-being.


ABSTRACT IMPACT: This study provides insights on how to replicate a successful initiative for preventing unintended teen pregnancy. OBJECTIVES/GOALS: Reducing unintended teen pregnancy is a national health priority, and a recommended strategy is to increase awareness and availability of long-acting reversible contraception (LARC). The Rochester LARC Initiative did this, and teen LARC use rose from 4% to 24%. The goal of this study is to determine key elements for replicating the intervention. METHODS/STUDY POPULATION: Our initiative used an innovative approach we call ‘community detailing’ to deliver education about LARC to adults working with teens. We analyzed the intervention goals, design components, implementation strategies, and public health outcomes. Our analysis was informed by the CDC model for Promoting Science-Based Approaches to Teen Pregnancy Prevention Using Getting to Outcomes (PSBA-GTO), Diffusion of Innovations, and RE-AIM framework for implementation outcomes. We compared our model with characteristics of LARC-promotion efforts, as well as successful health education campaigns. We tabulated the components of our intervention across theoretical domains, aiming to determine essential elements of effective design, adaptation, and dissemination & implementation. RESULTS/ANTICIPATED RESULTS: The initiative incorporated multiple components common to successful health education programs: measurable behavior-change outcomes; formative research before roll-out; tailored communications for different audiences; speakers who were credible, knowledgeable and skilled communicators; content that was new to recipients and essential for decreasing barriers to desired behaviors. It included elements of successful LARC promotion/teen pregnancy prevention programs, such as organizing information by effectiveness of methods and using youth-empowering messaging. It differed from other successful programs by offering discussions to adults who work with teens in both medical and community settings. This analysis also highlights unintended positive ripple effects. DISCUSSION/SIGNIFICANCE OF FINDINGS: These results establish how community detailing is effective for disseminating actionable information about the safety, efficacy and availability of LARC. These insights could inform other prevention initiatives. An anticipated practical product of this study will be a user-friendly manual for replicating the LARC Initiative in other locations.


Drug-induced myocarditis is a rare, but underrecognized complication of clozapine therapy for schizophrenia. We present a case of clozapine-induced myocarditis with recovery of cardiac function after drug cessation and summarize the literature to highlight the variable presentation of this condition. A 29-year-old man presented from a psychiatric hospital with 2 days of sudden onset, progressive chest pain, and troponin elevation after recently initiating clozapine therapy.The patient had a history of alcohol abuse and treatment-resistant schizoaffective disorder with multiple suicide attempts. After intentional ingestion of acetaminophen and lithium, he was involuntarily hospitalized for intensive treatment, including initiation of clozapine therapy.The differential diagnosis included acute coronary syndrome, myopericarditis from viral or drug-induced etiology, pulmonary embolism, and pneumonia. The patient first noted substernal chest pain worse with deep inspiration 8 days after clozapine initiation. Symptoms worsened over the following two days. Electrocardiogram (EKG) demonstrated ST elevations most prominent in V2-V3 . Serum lChest pain persisted, and he was transferred to the cardiology service. Cardiovascular exam was notable for tachycardia without murmurs or rubs. He had no peripheral edema or elevated jugular venous pressure. Lungs were clear. Cardiac magnetic resonance (CMR) imaging showed global hypokinesis with a left ventricular (LV) ejection fraction (EF) of 45% Figure  and subtMyocarditis was suspected based on a clinical syndrome of chest pain and elevated troponin in the setting of a known causative medication and low pretest probability for coronary artery disease. CMR confirmed the diagnosis by the updated Lake Louise Criteria . This caClozapine-induced myocarditis (CIM) is a drug-related myocarditis with variable presentation ranging from mild symptoms to fulminant myocarditis. The mechanism of toxicity to cardiomyocytes is unclear. In animal models, clozapine induces serum catecholamine excess that causes cardiac inflammation and myocyte apoptosis through tumor necrosis factor-alpha-mediated pathways . At autoThe true incidence of CIM is difficult to ascertain due to underdiagnosis of subclinical or mild presentations and may be underrecognized; thus, a high index of suspicion is required . ShortneCardiovascular complications resulting from antipsychotic medications are not limited to myocarditis. Patients with schizophrenia treated with antipsychotics are at higher risk of sudden unexplained death than the general population . CardiovWhen CIM is suspected, cardiology consultation should be obtained with inpatient monitoring for arrhythmia and heart failure. Aside from drug withdrawal, no specific treatment for CIM has been identified. Patients with LV systolic dysfunction warrant guideline-directed medical therapy (GDMT) in the absence of contraindications. Close cardiology follow-up and repeat echocardiography after clozapine cessation and initiation of GDMT should be individualized.Intriguingly, published literature reports cases of clozapine reinitiation in patients with severe schizophrenia refractory to alternate antipsychotics despite prior drug withdrawal due to CIM. Rechallenge with clozapine can be successfully achieved with intensive monitoring with swift discontinuation of the drug for any sign of myocardial injury . In one The patient was not reinitiated on clozapine and instead was treated with lithium and electroconvulsive therapy. Repeat echocardiography 2 weeks later demonstrated recovery of LV function Figure .Patients with schizoaffective disorders treated with antipsychotics are at higher risk for sudden unexplained death. CIM is a rare but likely an underrecognized complication of clozapine therapy and a mechanism of sudden cardiac death. Treating psychiatrists and consulting cardiologists must maintain high index of suspicion for CIM with withdrawal of clozapine in the acute setting to reduce poor outcomes. In the long term, care must be patient-centered with consideration of underlying psychiatric and cardiovascular disease severity.To recognize the clinical presentation of drug-induced myocarditis, associated with the use of clozapineTo illustrate the role of noninvasive testing in diagnosis of clozapine-induced myocarditisTo understand the importance of a multidisciplinary approach involving both psychiatry and cardiology specialists in managing clozapine-induced myocarditis


Visual representation of the community in materialsPositive FramingStatistics and graphs should be minimalAppropriate reading level and minimizing jargonABSTRACT IMPACT: Advanced spatial analysis techniques are used to target a community education intervention for Immigrant and African American women to increase breast cancer screening. OBJECTIVES/GOALS: We are addressing breast cancer screening disparities through the development of the COmmuNity kNowlEdge to aCtion Toolkit (CONNECT). CONNECT implements a mixed-methods approach using GIScience, community education, and social media to mitigate the impact of breast cancer screening disparities for Immigrant African and African American women. METHODS/STUDY POPULATION: We used advanced spatial analysis techniques, Spatially Adaptive Filters (SAF) to reveal mammography screening rates below the state level. SAF create screening maps of This new information allows lay health educators to identify and engage their communities in the Breast Cancer Champions program. We transformed and curated existing cancer educational material into culturally relevant educational training for lay health educators. Lay health educators participate in educational trainings and receive stipends for conducting formal and informal breast cancer education and screening events. RESULTS/ANTICIPATED RESULTS: We have identified four principles for designing culturally relevant education materials.Due to COVID-19, our breast cancer champions are engaging with their community in socially responsible ways . Our social media campaign, which began in October has already attracted over 1000 followers. DISCUSSION/SIGNIFICANCE OF FINDINGS: Despite the disruption of COVID-19, our project continues reduce breast cancer screening disparities. We have developed and created culturally appropriate materials and are currently training Champions. By incorporating an online presence into our community outreach, we are increasing the ways we connect with our community.


The local vascular inflammation is not only caused by SARS-CoV-2 infection but also accelerated by gut dysbiosis-caused systemic inflammation and decreased anti-inflammatory mechanisms.On the other hand, brain pathological changes could further increase gut dysbiosis. It has been well demonstrated that the gut-brain axis has bidirectional effects.An appreciation of the role of intestinal dysbiosis in the cytokine storm in COVID-19 neurological comorbidity has therapeutic implications. Modulation of gut dysbiosis to improve gut microbiota could be achieved by various approaches such as probiotics, prebiotics, faecal microbiome transplantation and dietary modification.Data sharing is not applicable to this article as no new data were created or analysed.The authors report no competing interests.


Bladder cancer is a heterogeneous disease that is composed of epithelia with varying transcriptional, mutational and lineage signatures. The epithelia of bladder tumors can also undergo pronounced changes in transcriptional and phenotypical qualities in response to progression, treatment related stresses and cues from the tumor microenvironment (TME). We hypothesize that changes in epithelial tumor heterogeneity (EpTH) occur due to the evolving content of epithelial subpopulations through both Darwinian and Lamarckian-like natural selection processes. We further conjecture that lineage-defined subpopulations can change through nongenomic and genomic cellular mechanisms that include cellular plasticity and acquired driver mutations, respectively. We propose that such processes are dynamic and contribute towards clinical treatment challenges including progression to drug resistance. In this article, we assess mechanisms that may support dynamic tumor heterogeneity with the overall goal of emphasizing the application of these concepts to the clinical setting.Acquired therapeutic resistance remains a major challenge in cancer management and associates with poor oncological outcomes in most solid tumor types. A major contributor is tumor heterogeneity (TH) which can be influenced by the stromal; immune and epithelial tumor compartments. We hypothesize that heterogeneity in tumor epithelial subpopulations—whether de novo or newly acquired—closely regulate the clinical course of bladder cancer. Changes in these subpopulations impact the tumor microenvironment including the extent of immune cell infiltration and response to immunotherapeutics. Mechanisms driving epithelial tumor heterogeneity (EpTH) can be broadly categorized as mutational and non-mutational. Mechanisms regulating lineage plasticity; acquired cellular mutations and changes in lineage-defined subpopulations regulate stress responses to clinical therapies. If tumor heterogeneity is a dynamic process; an increased understanding of how EpTH is regulated is critical in order for clinical therapies to be more sustained and durable. In this review and analysis, we assess the importance and regulatory mechanisms governing EpTH in bladder cancer and the impact on treatment response. Tumor heterogeneity (TH) has been referred to as the “Rosetta Stone” of cancer progression and therapeutic response ,2. The iWithin a single tumor, TH encompass both the tumor microenvironment, including stromal and immune cells, as well as the cell autonomous epithelial compartment. TH is also regulated by acellular components such as stromal and connective tissues. Together, such elements form a plastic tumor milieu which can change dynamically during tumor progression and in response to therapeutic challenges.When considered on a patient population scale, TH is typically extensive and contributes towards the complexity of understanding for when and how often to administer a drug for optimal clinical response. In some instances, drugs that are considered beneficial on a population scale can induce adverse disease progression on certain tumor types, thus highlighting the need for assigning tumor-specific treatments.While bladder cancer presents as a mutational disease, genetic changes continue to occur in pretreated tumor progression and in response to therapy. Thus, the mutational landscape not only has implications for immune cell infiltration but contributes towards the pool of cells capable of clonal expansion, treatment resistant disease and metastasis. Growing evidence supports that lineage transdifferentiation is an important mechanism for cancer cells to adapt to the stress of therapy ,10 incluRecently, single-cell technologies have greatly leveraged our ability to understand the remarkable transcriptional diversity present in bladder cancers. Such technologies provide opportunities to understand the evolutionary changes in tumor cell composition commencing from pretreated primary tumors through to post-treatment, resistant metastasis. We will address the importance of single-cell technologies to increase our understanding of EpTH both with respect to bulk changes in subpopulations as well as single-cell changes in cellular identity (lineage transformation). Improved single-cell techniques will provide the sensitivity and spatial information needed to address critical questions of whether EpTH can be experimentally manipulated to enhance treatment and reduce lethal phenotypes including bladder cancers with neuroendocrine-like (NE-like) signatures. While such processes have proven to be reversible under certain experimental conditions ,13, the As the importance of TH and relevance for tumor progression encompass a large body of information, our discussion and analysis will focus on the tumor epithelial compartment.Clinical bladder cancer typically presents with substantial pathological heterogeneity and a high mutational burden . MultiplIn an effort to reconcile previously published MIBC classification schemes, large-scale studies conducted by Kamoun et al. analysed 1750 transcriptomic profiles from 18 datasets and have identified a consensus molecular classification of MIBC that includes six molecular subtypes: luminal papillary (LumP), luminal nonspecified (LumNS), luminal unstable (LumU), stroma-rich, basal/squamous (BaSq) and NE-like .In this instance, consensus classifiers were associated with distinct mRNA signatures which strongly associated with clinical outcome and overall survival . The utiStrikingly, only approximately 30% to 40% of residual bladder tumors following NAC or immunotherapy were of the same lineage subtype as the pretreatment tumors ,24. In aMolecular analysis using bulk RNA seq data has increased our understanding of TH and the potential clinical utility in selecting patients for different systemic treatment . HoweverThe use of single transcriptomic technologies such as single-cell RNA sequencing (scRNA-seq), single-cell DNA seq (scDNA-seq) and spatial sequencing (sp-seq) in research will prove superior for defining clinically viable information, over bulk molecular analysis, by allowing the ability to study TH and to characterize rare cell epithelial subpopulations ,29. HoweIntratumoral molecular and genetic heterogeneity have been associated with poor prognosis in multiple cancers including lung cancer, head and neck cancers and chronic lymphocytic leukemia ,30,31,32Together, these findings demonstrate significant intratumoral heterogeneity in bladder cancer and suggest that categorical molecular subtyping may not be adequate for optimal therapeutic outcomes.Mechanisms promoting Intra-EpTH in pretreated bladder tumors can be broadly divided into mutational and nonmutational. Mutational mechanisms induce heterogeneity in genomic DNA which in turn can translate to phenotypic heterogeneity. Nonmutational mechanisms of heterogeneity induce phenotypic variability without any genetic modifications . The prePretreated urothelial carcinoma is characterized by a high mutational burden that contributes to TH. With a median of 8.1 mutations per mega base pair, bladder cancer ranked 11th in terms of mutational burden when compared with 166 other cancer types . PhylogeMultiple genetic driver mutations are associated with bladder cancer carcinogenesis and progression . Cells wDrivers of bladder cancers with high mutational burden remain poorly understood. Although DNA replication occurs with high fidelity, occasional transcriptional errors still occur even in the absence of mutagens, thereby introducing de novo genetic mutations. This stochastic mutational process is involved in tumorigenesis and disease progression . ExposurThe apolipoprotein B mRNA-editing enzyme catalytic polypeptide-like (APOBEC) can induce tumoral genetic heterogeneity leading to an APOBEC mutational signature present in urothelial cancers and other solid tumors . Using wThe genetic heterogeneity in tumor epithelial plays a significant role in disease progression and development of drug resistance largely due to either de novo or acquired therapy-resistant clones . High inAlthough mutational burden has been associated with response to immune checkpoint inhibitors (ICI), recent evidence suggests that tumors with high Intra-TH have decreased response to ICI. Using a preclinical melanoma mouse model, investigators evaluated the association of total mutational burden and intra-TH with respect to antitumor immunity . They shAs opposed to mutational mechanisms where variability in cellular DNA is the source of heterogeneity, nonmutational drivers of tumoral heterogeneity do not involve modification in the cellular genetic code. Embryological development is an example of nonmutational process of changing heterogeneity where cells with the same DNA code differentiate into multiple cellular phenotypes. Different from genetic heterogeneity, tumor cells contributing toward nonmutational heterogeneity can be highly plastic and have important contributions towards tumor development ,58.At a baseline or pretreatment setting, fluctuating cellular transcription constitutes a source of cellular heterogeneity. Upon the exposure to drugs, cells meeting a threshold of resistance-related gene expression will survive and be selected for ,60. For Cellular plasticity represents the capacity of cells to adopt different phenotypes and switch between different lineage identities . TogetheIn bladder cancer, cellular plasticity has been observed by Yang et al. using single-cell sequencing to demonstrate that nonstem cells, in urothelial cancers, can acquire stem-like properties and develop self-renewal capabilities . CellulaEMT is a tightly regulated process involved in embryonal development and in tissue healing and represents the most studied example of cellular plasticity . EMT shoThe formation of epithelia with neuroendocrine qualities constitutes another lineage occurring frequently during therapeutic stress  Figure B. For exTaken together, this suggests that plasticity is important in the evolution of bladder cancer. We conjuncture that plasticity represents a clinically important resistance mechanism as cells switch from a treatment-sensitive lineage to treatment-resistant lineages in order to accommodate the stress of therapy.While mounting evidence supports that lineage plasticity is a bona fide mechanism for cancer cells to adapt to therapy, less is understood as to whether plasticity can be reversed in a controlled manner. Due to its important role in tumor progression and aggressiveness, EMT represents an attractive target for the development of targeted therapies. Multiple pathways regulating EMT are being investigated as potential treatment targets with clinical trials investigating drugs capable of targeting EMT being conducted in solid tumors such as breast cancer, lung cancer and colorectal cancer ,97. InteIn response to drug exposure, a subpopulation of cancer cells termed drug-tolerant persisters (DTPs) will acquire a poorly differentiated phenotype and enter a dormant, slow-cycling and drug tolerant state  Figure C. DTPs cAlthough tolerant cells may pre-exist in the tumor, it has been shown that some cells become DTPs through EMT and phenotype plasticity following drug exposure ,102,103.In basal-like breast cancer cell lines, exposure to MEK and PI3K/mTOR inhibitor resulted in development of DTPs through epithelial plasticity driven by therapeutic challenge . In EGFRTumor heterogeneity is a dynamic process that serves an important role in tumor progression and response to therapies. Changes in TH through clinical evolution are likely a consequence of both changing proportions of lineage defined subpopulations as well as processes of cellular plasticity. Understanding how clinically approved therapies regulate these processes on a temporal scale will help define therapies. Adaptive therapy is an example of a novel treatment approach that incorporates these concepts and aims to maintain a population of treatment-sensitive cells to prevent the expansion of treatment-resistant cell populations B.Using mouse models of breast cancer, Enriquez-Navas et al. showed that low doses of paclitaxel are effective in controlling tumor volume and preventing unopposed proliferation of treatment-resistant cell populations . AdaptivA better understanding of cancer cell heterogeneity and plasticity will allow clinicians to consider tumor heterogeneity in a dynamic and adaptive fashion, rather than in a static manner in the elaboration of new treatment approach.Tumor heterogeneity and cellular plasticity are hypothesized to play important roles in the evolution and management of bladder cancer. The limitations of homogenous and static classifications of urothelial cancer need to be acknowledged. The heterogeneous and dynamic nature of this disease should be emphasized paving the way for further research on specific mechanisms regulating the dynamics of tumor subpopulations and cellular plasticity.


Dislocation of inferior vena cava filter (IVCF) is a rare complication with potential IVC perforation and other life-threatening risks requiring early diagnosis and in-time retrieval. Most of dislocation IVCF in the past have been shelved or removed by open surgery. It is very difficult to retrieve the filters by interventional technology.Here we report a 49-year-old man suffering from dislocation of IVCF implanted due to deep vein thrombosis (DVT) in the right femoral vein. Successful retrieval of the IVCF using double sheaths docking technique was done soon after confirmation of the dislocation. Importance of monitoring and early detection of dislocation of IVCF should be emphasized to avoid further complications.The double vascular sheaths docking technique can be considered as a preferential option in difficult operative situation. DVT in lower extremities occurs under conditions of venous endothelial damage, blood hypercoagulation, and stasis. The main risks of DVT include early fatal pulmonary embolism (PE) and late pulmonary hypertension. For patients with anticoagulation contraindications and recurrent DVT, IVCF should be implanted to prevent fatal PE. Furthermore, monitoring on IVCF status is critical to guarantee its’ thrombus capture effect and reduce filter-derived complications.IVCF-derived adverse events have been reported as placement issues 45.1%), IVC penetration (29.9%) and IVC filter fracture (27.1%) [%, IVC peWe report an insidious case of IVCF leg dislocation, potentially leading to perforation of the vena cava. Double sheaths docking technology was used to successfully retrieved the IVCF, verifying the importance of timely handling of IVCF migration.A 49-year-old man with DVT in right femoral vein following ruptured cerebral aneurysm underwent retrievable IVCF  implantation to prevent fatal PE. Pharmoco-mechanical thrombectomy was performed with angiojet system . During the surgery, a leg of the filter was found to be dislocated Fig. A, which IVCF is an absolutely therapeutic choice for avoiding fatal PE when conventional anticoagulation is contraindicated or deemed ineffective . A retriThis case revealed filter leg dislocation and axial migration of the filter. The dislocated filter leg may not only causes perforation of the inferior vena cava, resulting in retroperitoneal hematoma , and cauDislocation of the IVCF is a rare and serious complication, calling for our sufficient attention. Monitoring on IVCF status is critical to guarantee its’ thrombus capture effect and reduce filter-derived complications. The double vascular sheaths docking technique can be considered as a superior method.


OBJECTIVES/GOALS: Clinical trials are the gold standard for developing evidence-based medicine. However, 20% of pediatric randomized clinical trials are discontinued and about 30% of completed trials go unpublished.  Although patient recruitment is the most cited barrier to completing clinical trials, trials funded by academia are more likely discontinued compared to those funded by industry. This study is an attempt to gain additional insights into clinical trials in academic pediatrics. METHODS/STUDY POPULATION: Junior pediatrics faculty (Instructors and Assistant Professors) were recruited to participate in an online survey through RedCAP. The physicians were asked if they had prior experiences with clinical trials and whether they have interest in participating in clinical trials. Those interested were asked three additional questions: what role they were interested in, barriers to participating and interventions they thought would educate them about participating in clinical trials. RESULTS/ANTICIPATED RESULTS: Ninety two (92) out of 119 (77%) junior pediatrics faculty completed the survey. Twenty (20) pediatric subspecialties were represented and respondents were on various academic pathways. A third of the respondents (35%) had previously participated in clinical trials. A majority of the faculty respondents  are on the clinical educator pathway. The 13 respondents who were not interested in clinical trials indicated their preference for patient care, education and quality improvement. Of those interested in clinical trials, the top three preferred roles were site co-investigator (68%), help designing future protocol (47%) and site principal investigator (44%). Other than time, the top barriers to participation were a lack of awareness of what it takes to lead or engage in clinical trials (53%) and a lack of training on clinical trials (45%). Mentoring from an experienced clinical trialist emerged as the top preferred intervention (78%). DISCUSSION/SIGNIFICANCE OF IMPACT: Although limited to one institution, the findings of this study provide insights into pediatric faculty interest in clinical trials. If academic pediatricians are provided with mentoring, there could be an uptick in completed and published clinical trials involving pediatric populations.


Through leveraging the known advantages of musical engagement and socialization, choir interventions are known to facilitate psychological and cognitive benefits for persons with dementia (PwD). Surprisingly, no research has explored whether social singing may also confer neurological advantages. In this study, we employed functional near infrared spectroscopy (fNIRS) to investigate the cortical correlates of both social and solo singing in PwD (n=13). Paired-sample t-tests were used to evaluate within-person differences in frontal cortical activation between the social vs solo singing. Results showed significant activation differences in three frontal channels, with social singing requiring comparatively less frontocortical activation. These findings indicate potential neural benefits of social singing – with less frontal activation being a proxy for greater reliance on intact proceduralized systems – and serve to highlight the utility of fNIRS in better understanding the neural correlates underlying the benefits of social singing interventions for PwD.


In 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs). Compared to physicians, NPs were required to complete 16 additional hours of training on controlled substance prescribing before a buprenorphine waiver application. As this differential additional education mandate was seen as a potential barrier, we evaluated the impact of this requirement on both NP waiver acquisition and prescribing of controlled substances, comparing NPs who obtained waivers to those who had not.Through 2016–2018 Oregon Prescription Drug Monitoring Program and linked NP licensure data, we identified factors associated with waiver acquisition at baseline (2016) and evaluated changes in controlled substance prescribing before (2016) and after waiver acquisition (2018). Using chi-square and Mann-Whitney U testing, we calculated and described controlled substance prescribing types, rates, and patient level quantities including co-prescribing of benzodiazepines and opioids by NPs. Multivariable linear regression compared prescribing by waivered and non-waivered NPs for significant changes in non-buprenorphine controlled substance prescribing.Waivered NPs were more likely to have a psychiatric certification, have prior disciplinary action, and have generally higher levels of non-buprenorphine controlled substance prescribing than their non-waivered counterparts. While there was a significant increase in opioid prescriptions per patient among waivered NPs, following CARA implementation, co-prescribing of benzodiazepines and opioids significantly declined among waivered NPs relative to non-waivered NPs.Although educational requirements were rescinded in 2021 for most applicants, enhanced opioid prescribing training should be incorporated into professional educational offerings regardless of regulatory mandate. We recommended continued focus on education regarding avoidance of high risk prescribing such as co-prescribing of opioids and benzodiazepines. NPs who acquire waivers may take on higher risk patients already using opioids, and these findings may represent transitions in practice and patient setting. United States federal law and regulation expanded access to buprenorphine for treatment of opioid use disorder (OUD). In 2016 Congress passed the Comprehensive Addiction and Recovery Act (CARA) which extended prescriptive authority for office-based treatment with buprenorphine to nurse practitioners (NPs) for up to 30 patients beginning in 2017 . StudiesUnlike physician assistants, who are required to practice with a supervising physician, NPs have autonomous practice in many states. As of December 2021, 24 states and the District of Columbia confer full scope of practice to NPs without a requirement for physician involvement in prescribing decisions . States NPs are granted full prescriptive authority for scheduled drugs in the state of Oregon, which was among states with the largest increase in NP prescribing of buprenorphine, particularly in very rural areas after implementation . NPs in In late 2020, the Trump administration promulgated rule changes to remove the DEA waiver requirement for physicians who prescribe buprenorphine to fewer than 30 patients . AlthougThe effect of these additional educational requirements on non-buprenorphine controlled substance prescribing has not been evaluated. It is critical to examine how and if expanded educational requirements impacted prescribing of controlled substances overall. While OUD is the target of buprenorphine therapy, prescribers authorized to provide it are not restricted from continued prescribing of opioids or other controlled substances such as benzodiazepines which can create risk for patients, and a history of substance abuse diagnosis is associated with high dose benzodiazepine prescribing by primary care providers .Characteristics of NPs who prescribe buprenorphine and where they practice likely differ from those who prescribe controlled substances generally. County level variables which facilitate buprenorphine prescribing include treatment capacity, overdose rate, and percentage of male non-Hispanic white population . PrescriThe objectives of this study were: 1) to describe characteristics of NPs who obtained a waiver in Oregon to prescribe buprenorphine (waivered) compared to those who did not (non-waivered) and 2) to evaluate changes in non-buprenorphine controlled substance prescribing following CARA implementation between waivered and non-waivered NPs. We hypothesize that increased educational components for waivered NPs would change controlled substance prescribing as measured by key variables associated with patient use and dispensing patterns.n = 396,385) prescriptions. This dataset includes information on drug name, strength, quantity dispensed, days’ supply, date dispensed, and prescriber. NP characteristics were determined through a Drug Enforcement Agency (DEA) number linked demographic and licensure database from the Oregon Board of Nursing. The Board of Nursing licensure database contains demographic and practice information such as age, NP specialty certifications, licensure date, and prior professional disciplinary action.We excluded all non-NP prescribers from this study as well as any prescriptions for buprenorphine products . We included all NPs with one or more prescriptions for either an opioid or benzodiazepine prescription dispensed by a pharmacy and entered into the Oregon Prescription Drug Monitoring Program (PDMP) database from January 1, 2016 to December 31, 2018  and licensure time was categorized into five-year increments by the Oregon Health Authority prior to data release. For professional certification, we identified if NPs had a psychiatric or mental health specialty certification. DEA waiver-status was provided by Oregon’s PDMP program.Our first objective was to identify factors associated with NP waiver acquisition. We compared demographic and licensure characteristics between NP who ultimately received an waiver and those who did not. We also used PDMP dispensing data to compare controlled substance prescribing patterns between these two groups of NPs using 2016 (pre-CARA) as the baseline year. For each NP, we calculated the number of unique patients to whom they prescribed opioid analgesics, the average number of opioid prescriptions they prescribed to each patient, the number of patients to whom they prescribed long-term opioid therapy, and the number of patients who received at least one opioid prescription at or above 90 morphine milligram equivalents (MME) per day . We consP-values less than 0.05 were considered statistically significant. All analyses were performed using Stata/SE 15.1 .Our second objective was to evaluate changes in controlled substance prescribing among waivered NPs relative to those who were not. Using the prescribing metrics described above, we used multivariable linear regression to compare changes in prescribing patterns in 2018 relative to 2016 (prior to CARA waiver acquisition) across groups. In each regression model, the dependent variable was operationalized as the within NP difference in each prescribing metric; independent variables included waiver status, age, years in practice, psychiatric specialty, prior discipline, and the prescribing metric at baseline (2016). p < 0.001) and have had prior discipline  than non-waivered NPs.Of the 3321 NPs identified in the Board of Nursing licensure data, 187 were identified as acquiring a wavier by the Oregon Health Authority. Demographic and prescribing characteristics for these NPs are summarized in Table p < 0.001). Prior to waiver acquisition, waivered NPs wrote significantly more opioid prescriptions per patient than non-waivered NPs  and had more patients with long-term opioid therapy . NPs who became waivered also prescribed benzodiazepines to more patients  and with higher intensity  than those who did not. Waivered NPs co-prescribed opioids and benzodiazepines to more patients than those who were not .Of the NPs included, 1450 had one or more controlled substance prescription in Oregon’s PDMP in 2016. At baseline (2016 pre-CARA), waivered NPs were more likely to have prescribed controlled substances than non-waivered NPs , initial waiver acquisition required additional training above and beyond that which was required by physicians. Although continuing education can improve performance, its link to patient outcomes is tenuous . While tHowever, additional support is needed to engage other healthcare professionals who might facilitate or limit buprenorphine access. For example, a recent study found 20% of pharmacies limited buprenorphine access for patients with OUD . InclusiOur results found that waivered NPs significantly changed their practice regarding the high-risk co-prescribing of benzodiazepines and opioids as compared to non-waivered NPs. Given the removal of the educational mandate to become a waivered prescriber, consideration should be given to multiple methods of continued support and interprofessional education regarding not only safer provision of controlled substances but also effective ongoing treatment of substance use disorders.


Spinal cord injury (SCI) leads to irreversible functional impairment caused by neuronal loss and the disruption of neuronal connections across the injury site. While several experimental strategies have been used to minimize tissue damage and to enhance axonal growth and regeneration, the corticospinal projection, which is the most important voluntary motor system in humans, remains largely refractory to regenerative therapeutic interventions. To date, one of the most promising pre-clinical therapeutic strategies has been neural stem cell (NSC) therapy for SCI. Over the last decade we have found that host axons regenerate into spinal NSC grafts placed into sites of SCI. These regenerating axons form synapses with the graft, and the graft in turn extends very large numbers of new axons from the injury site over long distances into the distal spinal cord. Here we discuss the pathophysiology of SCI that makes the spinal cord refractory to spontaneous regeneration, the most recent findings of neural stem cell therapy for SCI, how it has impacted motor systems including the corticospinal tract and the implications for sensory feedback. Traumatic spinal cord injury is most commonly caused by compression, laceration and contusions which lead to severe impairment of motor/sensory function below the level of injury . The magThe initial traumatic event that may comprise fractures and/or dislocation of the vertebral column results in disruption of the vasculature, neurogenic shock and alterations in ion and neurotransmitter release. Ultimately this will set the stage for the secondary phase of injury ,5,6,7 inThe lack of repair following spinal cord injury is due to both cell intrinsic factors and the extrinsic injury environment . NeuronsWhile the first traumatic damage leads to immediate and often serious impairment of neurological function, the secondary phase usually dictates the full magnitude of injury. Inflammatory cells and resident glia including astrocytes and oligodendrocyte progenitor cells become reactive at the lesion that culminates in a permanently remodeled tissue ,26,27 F. As a heAnother main component that limits axonal growth is the physical barrier formed at the lesion site. SCI usually results in a breakdown of the blood spinal cord barrier (BSCB) and vascular permeability . FollowiIn efforts to increase axonal regeneration and recovery of function, experimental approaches targeting the environment at the injury site such as inhibiting molecules associated with scar and myelin debris ,31,44 haOne strategy to restore functional connectivity between severed spinal cord segments is the transplantation of neural progenitor cells (NPCs). NPCs have high therapeutic potential for reconstruction of the injured spinal cord tissue, since they can proliferate and differentiate into neurons and glia ,53. In aA major issue in these earlier techniques was a lack of retention of neural tissue within the injured spinal cord parenchyma that resulted in poor cell survival and failure of axonal growth. Later studies successfully overcame this issue by providing a more appropriate source or substrate for axonal growth. An experimental model using a peripheral nerve inserted into the lesion in the CNS showed extensive growth of axons from transplanted neurons along the “neuron-free conduits” . Later, Although experimental studies in the 1980s showed a gradual improvement of cell survival, integration and axonal growth, there was no evidence of functional improvements. Only in the 1990s did intraspinal fetal grafts placed into the site of SCI in adult and newborn rats show some improvements in functional outcomes ,58,64. TThe concept of neuronal relays is applicable when new neural circuits support and establish new connections across the site of injury. Specifically, descending host motor axons that project into stem cell grafts ,69,70 esAs previously discussed, SCI usually results in a large lesion area that damages not only the central gray matter, but also the surrounding white matter axon tracts that connect the brain with the rest of the body. Although damage of local spinal cord gray matter neurons primarily affects local segmental functions, disruption of white matter axon tracts is the major cause of neurological deficits below the level of injury ,78. UnliNeural stem/progenitor cell transplants have the potential to reconnect damaged axons since transplant-derived neurons can function as neuronal relays for disrupted pathways. First, transplant-derived neurons can serve as new neuronal targets attracting injured host axons that regenerate into and innervate the graft. A typical example is the robust regeneration of corticospinal (CST) axons into neural progenitor cell grafts . Second,In order to successfully generate neuronal relays by transplanted neural stem/progenitor cells in the injured spinal cord, a continuous transplant that completely fills the lesion site is needed. Excellent tissue integration with the surrounding host parenchyma and direct contact of transplants with the host tissue are additional pre-requisites for the ingrowth and outgrowth of axons . Large aAs an alternative approach, neural stem/progenitor (NSC/NPC) cells have been transplanted into remaining spared portions of the spinal cord, rostral and caudal to the lesion epicenter rather than in the lesion epicenter itself ,84. MostIn order to function as neuronal relays, a large proportion of transplanted NSC/NPC must differentiate into neurons that can reconnect injured circuits. Freshly dissociated rodent embryonic spinal cord-derived neural stem/progenitor cells usually differentiate into ~30% neurons and ~50% glia when embedded in a growth factor cocktail containing fibrin matrix within 7 weeks after transplantation . In contFor the formation of neuronal relays, propriospinal neurons and interneurons might be ideal as these neurons serve as natural “relays” in the intact spinal cord . In precIn general, transplant-derived neurons share many similarities with developing neurons. This includes a high intrinsic growth capacity allowing for axon extension into surrounding areas and remote regions. Transplanted neural stem/progenitor cells supported by fibrin-containing growth factors survive and differentiate into healthy neurons that can robustly extend their axons into host white matter over very long distances to innervate host gray matter. As many as 29,000 axons were shown to emerge from rat NPC grafts in caudal direction  in the rat . Graft-dThe traditional source of neural stem/progenitor cells from the developing CNS contains various stages of NSCs and progenitor cells. Fetal CNS tissue, such as brain and spinal cord, can either be directly transplanted without prior dissociation , dissociAn alternative means to generate neural stem cells or neural progenitor cells is the use of pluripotent stem cells including embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs). ESCs are derived from the inner cell mass of the early blastocyst and have unlimited proliferative potential, therefore providing an unlimited resource of stem cells. In addition, ESCs are able to differentiate into a variety of cell types including neural cells . iPSCs hIn order to replace lost neurons and glia and to generate functional neuronal relays for CNS repair, pluripotent stem cells need to be induced to differentiate into neural cell lineages, especially to neural stem/progenitor cells or even early-stage neurons through a process called neural induction and differentiation. Early studies used a method of embryoid body (EB) formation and manual selection of neural rosettes after spontaneous differentiation or neural induction using growth factors or co-culture with PA6 stromal cells. Recent studies have focused on manipulation of specific signaling pathways such as inhibition of BMP, TGF beta  and WNT pathways by proteins and/or small molecules for neural induction. In addition, the early stage neuroectoderm can be patterned by different morphogens to produce distinct rostro-caudal, dorsoventral and mediolateral neurodevelopmental lineages ,93.Interestingly, in caudal spinal neurodevelopment, neural progenitors are derived from transient neuro-mesodermal progenitors that are capable of generating both spinal cord neural and mesodermal progenitors . This prAdditional studies with human ESC- or iPSC-derived neural stem/progenitor cells in animal models of SCI are needed to support the safety, feasibility and potency of these cells for clinical translation.An alternative approach and short-cut is direct conversion of somatic cells into induced neural stem cells (iNSCs) ,96. InteDescending motor tracts represent key elements to voluntary motor control in humans. One such pathway, the corticospinal tract (CST), commands its voluntary motor control not due to its connections with the motor cortex, but its immediate and direct access to spinal and motor interneurons within the spinal cord . In humaTo address this, we and others have used neural progenitor cell transplantation into a lesion cavity to provide a fortuitous substrate for axon regeneration and reinnervation ,104,110.This concept of neural relays was further supported when rhesus monkeys with a cervical spinal cord injury received a human caudal neural progenitor cell graft and showed CST axons growing into the graft for up to 500 µm . Other aInterestingly, more modern techniques have revealed the molecular signature of the adult corticospinal neuron as it regenerates after injury. Surprisingly, translational profiling indicated that during an early time after injury, CST neurons reverse back towards an immature developmental state and take on a gene expression profile similar to embryonic day 18 CST neurons . This prOne might ask if this strategy is feasible to establish the primordial circuits of the CST required for appropriate interneuron and motoneuron innervation within the spinal cord, leading to restored cortico-motor circuits for precise motor control. In the developing CST circuit in infant rhesus monkeys, CST fibers terminate within the intermediate zone of the spinal grey and no CST fibers innervate the motoneuron pools of the ventral horn . During Given that modern tools of neuroscience have unveiled that adult regenerating CST neurons regress back towards an embryonic fate while undergoing active regeneration, one can hypothesize that activation of this intrinsic developmental program can be harnessed to drive new CST circuit formation, and that in combination with training-induced adaptation, projections towards the appropriate targets within the spinal cord can be achieved.Most studies examining NSC-mediated behavioral improvements and formation of novel circuits have focused on descending motor systems, whereas restoration of sensory function from levels below a site of SCI has not received the same attention. Without doubt, there is a good rationale to focus on motor systems and specifically CST axons, one of the most important pathways for fine motor control. However, without any sensory feedback, precise supraspinal motor control will be difficult to achieve. Besides the important role of sensory feedback in motor control, regaining sensory function in areas below the lesion site could prevent or reduce some of the worst secondary complications from spinal cord injury including life threatening autonomic dysreflexia, detrusor sphincter dyssynergia that can lead to kidney failure, and pressure skin lesions, one of the leading secondary complications after SCI. In addition, pain at or below a site of SCI is highly prevalent in the SCI population, particularly in patients with incomplete injuries, severely impairing the quality of life ,122. ThuAscending sensory projections include the dorsal column system, which is mainly responsible for fine discriminative touch and conscious proprioception. It is the only system with direct long primary sensory neuron projections from ipsilateral DRGs to dorsal column nuclei (Nucleus gracilis/Nucleus cuneatus) and one of the most investigated systems in spinal cord regeneration. It has long been appreciated that the intrinsic regenerative capacity of these neurons can be enhanced by lesions of their peripheral axons ,124. TheEvidence for synaptic connections between sensory axons and different types of NSC graft-derived neurons also comes from several more recent studies. In mice with dissociated E13 fetal NPC grafts in lesions at level C4, retrograde transganglionic labeling of DRG neurons was observed as low at the upper lumbar spinal cord . As the These data raise the question whether sensory innervation of graft-derived neurons is a random process or whether formation of synapses between sensory axon and graft-derived neurons is more selective and specific. In studies examining sensory axon regeneration into syngeneic E14 rat NPC suspension grafts in a dorsal column lesion, neurons expressing dorsal horn markers  were not only clustered but also aligned in laminae-like patterns similar to the mature spinal cord . This unTaken together, the studies described above strongly suggest that mouse, rat and human NSC grafts are innervated by host sensory projections and therefore fulfill the first major prerequisite for functional sensory relays. There is also ample evidence for the second prerequisite, namely that primary sensory axons extending into NSC grafts form functional synapses, and that there is at least a preference if not some specificity in the graft-derived neuron population that receives sensory input. Regarding the third requirement for a sensory relay, namely innervation of relevant host sensory target nuclei by graft-derived axons, information is sparser, although NSC graft-derived axons extend into rostral direction in virtually every study. In immunodeficient rats with hiPSC-derived NSC grafts to C5 lateral hemisections, GFP-labeled graft-derived axons were found in dorsal column nuclei, medulla and midbrain and cerebellum, all sensory target nuclei . WhetherAt level and below level pain after spinal cord injury is highly prevalent, in particular in SCI patients with incomplete injuries. An area of potential concern is the possibility that NSC transplantation worsens or induces pain symptoms either by inappropriate new connections or by influencing the pain circuitry in the surrounding host spinal cord. Most studies have not reported any potential sensory adverse effects of NSC grafts but specific functional tests that can detect nociceptive sensitization were not always conducted. On the contrary, using stem cells differentiated towards inhibitory lineages, amelioration of pain-like behaviors has been reported. While SCI-related neuropathic pain has many underlying mechanisms, spinal disinhibition (loss of inhibitory activity) resulting in hyperactivity of the pain circuitry plays an important role in the pathophysiology of pain. Thus, a localized increase in inhibitory neuronal activity or innervation by transplants of inhibitory interneurons could be an effective means of modulating pain.Inhibitory neuronal progenitors obtained from the medial ganglionic eminence have been the focus of one set of studies. In animal models of peripheral neuropathies, grafting embryonic MGE-derived precursors into the lumbar spinal cord profoundly reduced pain-like behavior . TranssyDespite the detrimental outcomes after SCI, there is no effective treatment to restore functional connectivity of the injured spinal cord. One promising strategy is to reconstruct the lesion site with neural stem/progenitor cell grafts (NSC/NPC) as transplanted cells can differentiate into neurons that may re-connect disrupted spinal neural circuitry. Recent studies from our and other groups support the concept of neuronal relay formation by transplant-derived neurons.First, embryonic and pluripotent stem cell-derived NPCs can be transplanted into a lesion cavity and differentiate into neurons and glia. These developmentally early stage grafts integrate with the host tissue without generating a glial “scar” between host and graft , where gSecond, recent work not only demonstrates successful regeneration of both descending supraspinal motor axons and ascending sensory axons into NSC/NPC transplants, but also the formation of functional synaptic connections. Corticospinal optogenetic stimulation in the motor cortex showed a clear calcium response in graft-derived neurons in the spinal cord, indicative of action potentials initiated by host motor circuitry . TranssyThird, host axons growing into these NSC/NPC grafts within the lesion cavity appear to have at least some specificity. Regenerating motor circuits extended their axons into the graft and formed synapses with premotor interneurons and motor neurons, avoiding sensory interneuron clusters within the graft . In turnFourth, NSC/NPC grafts support functional improvements after injury. NSC/NPCs with spinal identity placed into clinically relevant models of SCI resulted in functional improvement in hindlimb ,110 and Although the above studies support the role of NSC/NPC grafts as a potential therapeutic intervention for SCI, meaningful functional improvements in the clinic will likely require additional advances. While a large proportion of corticospinal axons penetrate into NSC/NPC grafts in the lesion site, most of these axons are located within the first 1 mm of the rostral host/graft interface. Intensive rehabilitation can strengthen and even reshape newly formed circuitry to promote functional outcomes after injury as rehabilitation can strengthen synapses , lead toFinally, potential adverse effects associated with NSC/NPC transplantation need to be addressed before clinical translation, including possible over-growth or tumor formation and transplant-induced pain. Consistent and reproducible protocols for the production of a sufficiently large number of cells under defined conditions have to be generated. Potency assays and cellular characterization with minimum acceptance criteria need to be established, and in vivo dose–response curves for efficacy and toxicity have to be completed. Parallel progress in the generation and transplantation of neuronal subpopulations most relevant for the formation of neuronal relays may further enhance the formation and efficacy of novel neuronal circuits. Thus, additional preclinical studies are warranted to support and improve the safety and efficacy of NSC/NPC therapy. Progress over the next years is likely to advance neural stem cells for the generation of neuronal relays in SCI towards clinical trials.


The continuing COVID-19 pandemic has necessitated changes to research protocols and approaches to mitigate health risks to both study participants and researchers. This is particularly true of studies exploring the biopsychosocial well-being and personal perspectives of older adults and those at elevated risk of COVID-19 complications. While videoconferencing platforms have enabled remote work and social activities, reliance on them may potentially exclude some individuals . Persons living with dementia (PLWD) may experience difficulties navigating videoconferencing systems and building rapport with interviewers, though the inclusion of PLWD in research is necessary to ensuring their equitable representation. This presentation disseminates promising practices and lessons learned from a longitudinal study conducting remote interviews on sensitive topics with PLWD and their care partners (CP). Findings are drawn from a case study of the Better Together Dementia Care Study, an 18-month longitudinal study of PLWD (N=8) and their CPs (N=13), which implemented remote interviewing in Summer 2020 to gather data on the quality-of-life, resilience, relationship quality, adverse childhood experiences, mistreatment, and health status of PLWD. Researchers were able to interview most enrolled PLWD (n=7) via videoconferencing. Paper surveys were mailed to phone-interviewed participants, enabling them to view questions and answer choices in concordance with verbal queries. Researchers also tested a protocol asking CPs to leave the room while PLWD answered questions on sensitive topics. Findings support the use of remote interviewing with PLWD and provide insights to guide replication of these approaches.


Similar to humans and laboratory animals, reproductive aging is observed in wild species-from small invertebrates to large mammals. Aging issues are also prevalent in rare and endangered species under human care as their life expectancy is longer than in the wild. The objectives of this review are to (1) present conserved as well as distinctive traits of reproductive aging in different wild animal species (2) highlight the value of comparative studies to address aging issues in conservation breeding as well as in human reproductive medicine, and (3) suggest next steps forward in that research area. From social insects to mega-vertebrates, reproductive aging studies as well as observations in the wild or in breeding centers often remain at the physiological or organismal scale (senescence) rather than at the germ cell level. Overall, multiple traits are conserved across very different species (depletion of the ovarian reserve or no decline in testicular functions), but unique features also exist . There is a broad consensus about the need to fill research gaps because many cellular and molecular processes during reproductive aging remain undescribed. More research in male aging is particularly needed across all species. Furthermore, studies on reproductive aging of target species in their natural habitat (sentinel species) are crucial to define more accurate reproductive indicators relevant to other species, including humans, sharing the same environment. Wild species can significantly contribute to our general knowledge of a crucial phenomenon and provide new approaches to extend the reproductive lifespan. Reproductive aging is a process involving a combination of multiple intrinsic and extrinsic factors affecting the whole organism and more directly the reproductive organs as well as the quality of germ cells. Reproductive aging in human and laboratory animals has been studied for decades at the physiological, hormonal, cellular, and molecular levels. As gamete quality declines more rapidly in women than in men, reproductive aging leads to infertility, increased miscarriages, and birth defects . The menCaenorhabditis elegans and Drosophila melanogaster has conserved properties in the process of mammalian ovarian aging  during aging are associated with declining reproductive performance. This can be used as a predictor of fertility longevity in cattle; however, it still remains largely unexplored in sheep and other farm species . DomestiCoturnix japonica) males demonstrated that similar to mammals, plasma androgen levels decline gradually, being accompanied by a loss of reproductive behavior . For instance, aging in the drosophila model still remains understudied in males. However, recent reports have shown that, not only sperm, but also seminal fluid are both qualitatively and quantitatively affected by age with each component making distinct contributions to declining reproductive performance in older males . Studiesbehavior . Interesbehavior .Antechinus sp.) to negligible reproductive senescence   . Even th glaber) . This isThe objectives of this review are to (1) present conserved as well as distinctive traits of reproductive aging in different wild animal species (2) highlight the value of comparative studies to address aging issues in conservation breeding as well as in human reproductive medicine, and (3) suggest next steps forward in research.The study of reproductive senescence in free-ranging populations is invaluable as it allows to better understand fundamental aspects, such as mate choice, sperm competition, or environmental impact. Furthermore, short- and long-lived wild species exhibit unique characteristics that inform our understanding of aging processes. An overview of the impact of aging on reproductive traits (including some observed in humans) in selected wild mammalian species (from rodents to non-human primates) is presented in Meles meles), there is strong evidence for a gradual decline in sex-steroid levels with age in both sexes, which is even followed by over 2 years of post-reproductive life (Acinonyx jubatus) after the age of 9, which is even older than the average life expectancy (In carnivores like the European badger (ive life . Interespectancy .Cervus elaphus) stags show a faster decline in annual breeding success than females that went through successive gestations and lactations (Canis rufus), reproductive aging in males also is observed while there is no evidence for reproductive aging in wild female wolves , there is no consequence of early life reproduction; however, for a given number of offspring, females that weaned more sons than daughters experience earlier senescence (In bighorn sheep (nescence . OffspriPan troglodytes), females with high number of years spent gestating and lactating during their reproductive lives have a delayed ovulatory attrition (Papio sp.) also suggested that reproductive senescence occurs later in females than males , calf survival decreases with maternal age because of less maternal investment , although reproduction does not entirely cease until the age of 65 year old, females have a relatively long post-reproductive life     or the f glaber) .Castor fiber), earlier breeding opportunities lead to earlier senescence through resource-dependent mechanisms , chimpanzees (Pan troglodytes), and chamois (Rupicapra rupicapra). Notably, some species rather show an increase in fertility as they age   . As seenconomus) . Lastly,An overview of the knowledge about the impact of aging on reproductive traits (including some observed in humans) in selected wild non-mammalian species  is presented in Somniosus microcephalus), reptiles , and some birds   .Gryllus campestris) investing more in early reproduction may senesce faster and die younger (Setophaga caerulescens) older males tend to have longer sperm cells, which may be advantageous in post-copulatory sexual selection  (Leucopsar rothschildi)   or birdsschildi) .Zoo animal populations represent an ideal model to study reproductive aging process since lifespan is frequently longer than in the wild, so repeated observations under controlled conditions are possible. Reproductive aging also represents a major issue in conservation breeding, especially for genetically valuable individuals that are too often not reproducing .Heterocephalus glaber) colonies has generated intriguing data. Unusually large ovarian reserve in naked-mole rat provides one mechanism to account for this species’ protracted fertility. However, whether germ cell nests in adult ovaries contribute to the long reproductive lifespan remains to be determined (Research on naked mole rat (termined .Mustela nigripes), has revealed that even modest aging decreases sperm production and libido while abnormal sperm number increases (Arctictis binturong) show that males of advanced ages still produce good quality semen  and cheetahs (Acinonyx jubatus)  . As repojubatus) .Ailuropoda melanoleuca) cub by artificial insemination with frozen-thawed semen in one of the oldest females in captivity . A good illustration is the recent birth of a giant panda (aptivity . While aAcinonyx jubatus), uterine environment in aging females is the real issue while oocyte quality is not affected (in vitro fertilization (IVF) on oocytes from old donors and transfer the resulting embryos into young recipient females  that quickly dies after the breeding season (As highlighted in g season . Except Acinonyx jubatus), nothing is known about the influence of aging in gamete quality (success of fertilization and early embryo development) or uterine environment  reported above could suggest some research areas or questions in humans, for instance:•Understanding rapid vs. absence of decline in fertility.•Exploring sustained oocyte quality in felids (and other species having induced ovulations).•Examining the influence of parental age on offspring reproductive health .•Characterizing the impact of allostatic load  known for very long lifespan.•Using the systems biology approach to better understand and mitigate reproductive aging.Regarding mitigations and treatments, expanding reproductive life could be achieved through, hormonal treatments  also are crucial to define more accurate reproductive metrics that are relevant to species, including humans, sharing the same habitats. We must keep building bridges between the ecology of senescence and areas of research in reproductive science. Repeated observations in zoo animals also will remain invaluable sources of information to decipher the mystery of reproductive aging.In sum, wild species can potentially contribute to the general knowledge of a crucial phenomenon. Comparative models will help to understand the fundamental mechanisms underlying reproductive aging and then develop new approaches to extend the length and the quality of reproductive lifespan, which will ultimately impact overall health.PC and MA contributed equally to the preparation and the writing of the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


ABSTRACT IMPACT: This study aims to advance the understanding of the biological mechanisms associated with feeding disturbances in infants born to diabetic mothers through non-invasive salivary gene expression analyses and body composition measurements at birth. OBJECTIVES/GOALS: To determine if non-invasive salivary gene expression analyses and body composition measurements at birth could elucidate biological mechanisms associated with aberrant feeding behaviors and disrupted metabolic profiles commonly seen in infants born to diabetic mothers. METHODS/STUDY POPULATION: This prospective cohort study enrolls subjects born at ≥35 weeks’ gestation without a history of intrauterine growth restriction or major congenital anomalies. The diabetic cohort is defined as infants born to mothers with gestational diabetes or type 2 diabetes. The primary outcome is salivary expression of the hunger signaling genes, AMPK and NPY2R. Secondary outcomes include infant body composition measurements, obtained by skinfold measurement and/or air displacement plethysmography, and salivary expression of the adipokines, leptin, ghrelin, and adiponectin. Multiple logistic regression will be used to determine which factors are associated with AMPK and NPY2R expression. RESULTS/ANTICIPATED RESULTS: We propose that poor oral intake seen in infants of diabetic mothers may be due to alterations in the expression of hunger signaling genes  resulting in a diminished feeding drive in these large for gestational age infants. In addition, infant adiposity and the expression of genes involved in the adipoinsular axis will be inversely proportional to feeding volume intake. Namely, increased neonatal fat mass will be associated with increased expression of leptin and decreased expression of ghrelin and adiponectin. DISCUSSION/SIGNIFICANCE OF FINDINGS: Infants of diabetic mothers are at higher risk of poor oral feeding in the newborn period. This study aims to elucidate the link between neonatal body composition, adipoinsular axis, and hunger signaling to explain this unique feeding phenotype.


Hematopoietic cells and their microvesicles have recently emerged as novel markers of cardiovascular risk. The crosstalk between these vesicles and endothelial dysfunction or vascular damage is a field of continuous progress. Additionally, thromboinflammation represents an emerging concept in cardiovascular diseases. In hypertension, the role of signaling pathways in hypertension remains also under investigation. Realizing the unmet needs of increased awareness of treating physicians and active researchers in this complex setting, we launched our Special Issue on “Molecular Advances in Hypertension and Blood”. Our issue has addressed both sides of the coin by publishing four articles that are summarized in this editorial. Firstly, we published an experimental study providing evidence that certain molecular pathways may be involved in myocardial remodeling in the settings of arterial hypertension and chronic kidney disease. Secondly, an in vitro study revealed a novel immune-modulatory effect of Ticagrelor, which is widely used in patients with hypertension and cardiovascular disease. Thirdly, another translational study assessed endothelial injury and pro-coagulant activity using circulating microvesicles in survivors of allogeneic hematopoietic cell transplantation, compared to a control population matched for traditional cardiovascular risk factors. Lastly, a review article delineated the role of Toll-like receptors in the pathogenesis of essential hypertension.Hematopoietic cells and their microvesicles have recently emerged as novel markers of cardiovascular risk ,2,3. TheAll articles submitted to us for this Special Issue underwent a rigorous peer review process. Ultimately, four articles were published. Three of these articles detail original research into (i) signaling pathways in arterial hypertension and chronic kidney disease, (ii) evidence suggesting a novel immune-modulatory effect of Ticagrelor, and (iii) endothelial injury and pro-coagulant activity in survivors of allogeneic hematopoietic cell transplantation. This Special Issue also includes one review that discusses the role of Toll-like receptors in essential hypertension. These four articles are discussed below.(i) Bodganova and colleagues aimed to delineate the pathophysiology of myocardial remodeling in arterial hypertension and chronic kidney disease. The authors induced early chronic kidney disease in spontaneously hypertensive rats and compared myocardial remodeling with controls. Chronic kidney disease in these rats was associated with increased FGF23 and decreased renal a-Klotho, along with increased systolic blood pressure, myocardial mass index, cardiomyocyte diameter and myocardial fibrosis. Myocardial remodeling was correlated with increased expression of calcineurin/NFAT and β-catenin. TRPC6 protein levels and mRNA expression were also elevated. Therefore, the authors concluded that Wnt/β-catenin and TRPC6/calcineurin/NFAT signaling pathways may be involved in myocardial remodeling of arterial hypertension and chronic kidney disease, potentially mediated by the FGF23 and α-Klotho axis [(ii) Mitsios and colleagues investigated the effects of Ticagrelor on inorganic polyphosphates released by thrombin-activated platelets and stent-induced neutrophil extracellular traps (NETs) in ST elevation myocardial infarction (STEMI). The authors stimulated neutrophils from healthy individuals and patients receiving Ticagrelor to produce NETs, and further incubated them with plasma from the infarct-related artery of STEMI patients. Then, they assessed the effects of Ticagrelor on NETs and tissue factor loading. Ticagrelor attenuated NETs induced by inorganic polyphosphates and inhibited stent-induced NET release. Considering the clinical need for novel antithrombotic strategies targeting inflammation, their findings highlighted an important and novel immune-modulatory effect of Ticagrelor .(iii) Gavriilaki and colleagues studied 45 survivors of allogeneic hematopoietic cell transplantation  without established cardiovascular disease and 45 control individuals matched for traditional cardiovascular risk factors. Circulating microvesicles (MVs) of different cellular origins (platelet and erythrocyte) were increased in alloHCT compared to controls. Endothelial MVs were increased only in recipients of a myeloablative conditioning. These results suggested that endothelial dysfunction and increased thrombotic risk in alloHCT survivors, independently of traditional cardiovascular risk factors .(iv) Lazaridis and colleagues reviewed the role of Toll-like receptors into essential hypertension considering that subclinical inflammation has been implicated in the pathogenesis of the disease. Toll-like receptors have emerged as novel effectors in the inflammatory background, which is evident from the very early stages of hypertension. This review has highlighted the contribution of innate immunity in the pathogenesis of hypertension and clarified the role of TLR signaling in promoting inflammation and hypertensive vascular damage .Taking into account the multi-disciplinary character of this Special Issue, we hope that it will inspire researchers and clinicians to continue their explorations into novel advances in blood and hypertension.


Upper motor neuron (UMN) is a term traditionally used for the corticospinal or pyramidal tract neuron synapsing with the lower motor neuron (LMN) in the anterior horns of the spinal cord. The upper motor neuron controls resting muscle tone and helps initiate voluntary movement of the musculoskeletal system by pathways which are not completely understood. Dysfunction of the upper motor neuron causes the classical clinical signs of spasticity, weakness, brisk tendon reflexes and extensor plantar response, which are associated with clinically well-recognised, inherited and acquired disorders of the nervous system. Understanding the pathophysiology of motor system dysfunction in neurological disease has helped promote a greater understanding of the motor system and its complex cortical connections. This review will focus on the pathophysiology underlying progressive dysfunction of the UMN in amyotrophic lateral sclerosis and three other related adult-onset, progressive neurological disorders with prominent UMN signs, namely, primary lateral sclerosis, hereditary spastic paraplegia and primary progressive multiple sclerosis, to help promote better understanding of the human motor system and, by extension, related cortical systems. Upper motor neuron (UMN) is the term traditionally used for motor neurons within the central nervous system proximal to the spinal motor neuron. Dysfunction of the upper motor neuron in neurological diseases manifests with well-recognised clinical features, including (i) increased muscle tone at rest and in response to passive velocity-dependent muscle stretch , (ii) pyDysfunction of upper motor neurons is well recognised in several inherited and acquired neurological diseases. Inherited disease with prominent clinical features of UMN dysfunction include hereditary spastic paraplegia, leukodystrophies, such as Alexander’s and Krabbe disease, and craniovertebral junction anomaly. Acquired disease of the central nervous system with prominent features of UMN dysfunction include neurodegenerative disorders such as amyotrophic lateral sclerosis (ALS) and primary lateral sclerosis (PLS), inflammatory disorders such as primary progressive multiple sclerosis (PPMS) and paraneoplastic encephalitis, chronic infection with human T lymphotrophic virus-1 (HTLV)-1 and syphilis, cerebrovascular events such as ischemic and haemorrhagic stroke or cerebral palsy and rare spinal cord ischemia due to vascular malformation.The pathophysiology of neurological diseases where UMN dysfunction predominates may yield novel insights into the complexity and division of function of the pathways that subserve motor control ,4, incluAmyotrophic lateral sclerosis is a rapidly progressive neurodegenerative disorder of the human nervous system, exhibiting prominent features of upper motor neuron dysfunction . The terAmyotrophic lateral sclerosis is characterised by preferential patterns of muscle wasting and weakness. Specifically, the split hand , split hClinical UMN signs are variably manifest in ALS phenotypes. The extensor plantar response is evident in approximately half of ALS patients , while bDespite varying ALS phenotypes , the hisThe initial utility of imaging in neurological disease of the brain and spinal cord was for structural assessment of tissue, which was clinically difficult to visualise. Brain and spinal cord imaging in ALS diagnosis was used for exclusion of other disorders with characteristic imaging features . Though Reconstructing fibre pathways using tractography, detecting metabolite markers of neuronal integrity or cell turn-over using magnetic resonance spectroscopy (MRS), assessing cortical networks using resting-state functional MRI (R-fMRI) techniques and assessing grey matter perfusion with arterial spin labelling (ASL) are newer technologies being developed to assess functional changes in the upper motor neuron in disease  which maThe technique of electrical stimulation of the motor cortex to record motor evoked potentials in target upper limb muscles was developed  in the eA consistently reported neurophysiological abnormality in ALS, is the phenomenon of cortical hyper excitability thought to result from a loss of inhibitory pathways mediated via GABA-A receptors ,39,40. HA receptors and enhanced by glutamatergic and noradrenergic pathways [Several other neurophysiological measures also provide insights into upper motor neuron pathology in ALS. The motor-evoked potential (MEP) amplitude reflects a summation of complex corticospinal volleys  and the pathways . An incrpathways ,47 earlyCentral motor conduction time (CMCT) represents the time from stimulation of the motor cortex to the arrival of the corticospinal volley at the spinal motor neuron . CMCT isB receptors in the latter part [Cortical silent period (CSP) designates the interruption in EMG generated by voluntary motor activity in a target muscle following stimulation of the contralateral motor cortex. CSP is mediated by spinal mechanisms in its early part and cortical inhibitory mechanisms acting via GABAter part . Reductiter part ,39,53 anThe motor threshold (MT) reflects the ease of stimulation of the corticomotor neuron and reflects the density of projection of corticomotorneurons on the spinal motor neuron ,54. MT iPrimary Lateral Sclerosis (PLS) is an adult-onset, sporadic, slowly progressive neurodegenerative disorder of the upper motor neuron. The term is attributed to Charcot , who desDemographically, PLS is a non-familial disorder with slight male preponderance, low incidence ,61 and sHistopathology in PLS has been obtained in a few clinically well-defined cases , showingNeuroimaging in PLS has been limited and is usually undertaken in PLS as a subset of ALS cohorts. No clear diagnostic neuroimaging markers have been identified in PLS. MRI changes reported in PLS have included (i) atrophy specifically of the precentral gyrus , (ii) reCortical neurophysiology studies using transcranial magnetic stimulation reveal motor cortex inexcitability in PLS  with inaHereditary spastic paraplegia (HSP) is a genetically diverse group of inherited disorders resulting in length-dependent dysfunction primarily of the corticospinal axons, though other spinal tracts such as the posterior columns may also be involved. They are now understood to be a family of genetic disorders causing dysfunction primarily of extremely long corticomotor axons due to a variety of genetic mutations, affecting pathways involved in the maintenance of axonal health and integrity . The inhHereditary spastic paraplegia (HSP) has been categorised based on genetic inheritance into autosomal dominant, autosomal recessive or X-linked  primary Histopathology in HSP is limited due to the relatively normal lifespan of patients with pure HSP . NeuropaNeuroimaging in HSP was initially a tool to exclude mimic causes of spastic paraplegia. Atrophy of the spinal cord without anteroposterior flattening measured most often at the cervical cord level is the most reported finding in pure and complicated forms of HSP . StudiesCortical changes were not noted in a group of patients with the autosomal dominant (AD) genetic HSP when using the transcranial magnetic stimulation technique to probe motor cortex hyperexcitability  with motPrimary progressive multiple sclerosis (PPMS) has been studied under the category of inflammatory disorders of the central nervous system. PPMS is clinically an insidious-onset slowly progressive pure upper motor neuron disorder presenting with gait dysfunction . FeatureInterestingly, a case report of a patient with a clinical diagnosis of PPMS and a family history of Pelezaeus–Merzbacher disease revealed a point mutation in the proteolipid protein1 (PLP-1) gene . PLP-1 cThe role of inflammatory cells causing pathological changes in the cerebral cortex and spinal cord in PPMS has been well described , with B Along with the wider subject of multiple sclerosis, PPMS has been extensively studied using neuroimaging modalities, and current diagnostic criteria require the presence of typical brain or spinal cord lesions for the diagnosis of PPMS . The lesCortical excitability using transcranial magnetic stimulation technique  did reveThis review summarises the salient features of four adult-onset neurological diseases with progressive and prominent upper motor neuron signs, with emerging key differences in their pathophysiological mechanisms. An improved understanding of the upper motor neuron has been promoted by studies exploring the pathophysiology of these disorders.Amyotrophic lateral sclerosis (ALS) is now recognized as a TDP-43 proteinopathy . HoweverPrimary lateral sclerosis (PLS) is also thought to be a TDP-43 proteinopathy , though Hereditary spastic paraplegia (HSP) is emerging as a disorder of a heterogenous family of genes which code for proteins involved in axonal transport, resulting in a length-dependent motor disorder affecting primarily the lower limbs ,77. OthePrimary progressive multiple sclerosis (PPMS) is increasingly being recognized as a neurodegenerative disorder, with neuroinflammation being the pathogenetic mechanism for neurodegeneration ,95. Nota


The spinal cord (SC) is a complex structure containing several neuronal circuits related with motor function of the upper and lower limbs, operating under the influence of higher centres. Central nervous diseases can change the responses of the spinal motor circuits leading to its dysfunction. Over the last decade, there has been a growing interest in the study of trans-spinal direct current stimulation (tsDCS) as a potential therapeutic tool to modulate spinal circuits through the application of electric currents delivered non-invasively . ComputaA literature narrative review was carried out through Pubmed database and manual search, considering the following selection criteria: research papers published in journals with impact factor in the areas of neuroscience, neurophysiology and biomedical engineering from 2008 to 2018; use of keywords related with the topic ; written in English. A qualitative analysis was performed over the literature selected considering the following items: electrode montage; tsDCS protocol; methods for assessing motor responses; observed changes; computational results; induced electric field (EF) distribution.Discussion and conclusions: Literature review indicates that experimental findings mainly depend on electrode polarity and position over the SC. tsDCS is a tool amenable to modulate motor circuits excitability in the spinal cord. This intervention can have clinical implications in the treatment of conditions like spasticity. However, future studies should consider EF magnitude and its orientation relative to spinal neurons. We propose that future clinical protocols should be guided by computational modelling to increase the chances of consistent positive results [Published studies showed different neuromodulation effects on the motor responses of the lower limb. Whereas some studies reported a reduction of spinal motoneurons excitability using anodal tsDCS, others described higher motor unit recruitment with cathodal stimulation T10–T12), suggesting modulation of Ia-motoneuron (MN) synapse. Other authors failed to replicate a modulatory effect applying tsDCS . Modelli, suggest results .