Live imaging of nitric oxide release in vascular endothelial cells in response to mechanical stimuli on an organ chip

Background

Nitric oxide (NO), released from vascular endothelial cells in response to mechanical stimuli, regulates cardiac contractility and are also involved in the prevention of the development of cardiac hypertrophy.

Purpose

To establish an experimental system for live observation of NO release in response to mechanical stimuli on an organ chip.

Methods

Organ chips, which we used for the development of a heart-on-a-chip in the previous study [1], were used.

We seeded 300,000 human umbilical vein endothelial cells on a stretchable elastic membrane coated with Matrigel of a chip channel. Shear stress was applied to the cells by increasing flow rate of a peristaltic pump connected to the chip channel (Figure 1A). Pressure stimulus was applied by hydrostatic pressure. Stretch stimulus was applied by suction to the side ports of a chip using an electric syringe pump (Figure 1B). Cells were stained with 10 μM 4,5-diaminofluorescein diacetate for fluorescent live NO imaging.

Results

Monolayers of the endothelial cells formed intercellular junctions confirmed by CD31 staining (Figure 1C, yellow). Apparent permeability, which was measured by Texas red dye (MW 3000), was maintained at a low level of ∼3x10–6 cm/s until day 30, suggested the formation of robust intercellular junction.

When the endothelial cells were subjected to a pressure stimulus of 60 mmHg for 60 s, NO release was observed that lasted for >2 minutes (Figure 2A). A peak value of 1.46±1.08 (mean ± standard deviation) times the baseline was observed 271 s after the beginning of the pressure stimulus (n=251 cells). When the cells were subjected to a 1% stretch for 60 s, a peak value of 1.29±0.33 times the baseline was observed 105 s after the beginning of the stretch stimulus (Figure 2B). A shear stress of 0.01 dyn/cm2 hardly increased NO release (1.20±0.27 times the baseline, Figure 2C).

Conclusion

The system for live NO imaging in vascular endothelial cells in response to mechanical stimuli was established using organ-on-a-chip. The heart-on-a-chip with endothelial cells will be useful in elucidating the effects of mechanical stimulus such as hypertension on the contractile function and the remodeling of the heart.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Impact of metabolic syndrome and its components on clinical severity and long-term prognosis in patients with premature myocardial infarction

Background

Metabolic syndrome (MetS) is involved in the occurrence, development and prognosis of cardiovascular diseases, especially acute myocardial infarction (AMI). In recent years, the trend of AMI at a younger age has gradually attracted people's attention. Relevant studies have confirmed that MetS affects the prognosis of people aged ≥45 with AMI. However, there is still a lack of research on MetS in people with premature myocardial infarction (PMI).

Purpose

To explore the impact of MetS and its components on clinical severity and long-term prognosis in PMI patients.

Methods

772 Patients with AMI who aged ≤45 years old from 2015 to 2020 in a hospital were enrolled. The patients were divided into MetS group (n=417) and non-MetS group (n=355) according to the criteria proposed by NCEP ATP III in 2005 (Any 3 of the following 5): 1) Hypertension: BP ≥130/85 mmHg or consistent hypertensive patients undergoing treatment; 2) Hypertriglyceridemia: fasting plasma triglyceride ≥1.7 mmol/L; 3) Fasting HDL-C <1.0 mmol/L in men and <1.3 mmol/L in women. 4) Hyperglycemia: fasting blood glucose level ≥6.1 mmol/L or known diabetic patients undergoing treatment; 5) Central obesity: BMI ≥28.0 kg/m2. Patients were followed for median of 42 months for major adverse cardiovascular events (MACE). The parameters of clinical severity were compared using logistic regression analysis. Cox regression were used to analyze the relationship between MetS and its components and prognosis.

Results

A total of 772 patients were included in the analysis. Hyperglycemia was associated with multi-vessel disease (OR=1.700, 95% CI 1.172–2.464, P=0.005) and Syntax score ≥33 (OR=2.736, 95% CI 1.241–6.032, P=0.013).Increased MACE were observed in the MetS group (17.9% vs 10.3%, P=0.004) after 42 months follow-up. The Kaplan-Meier curve also showed significant differences (P<0.001). MetS was an independent risk factor for MACE (HR=2.181, 95% CI 1.392–3.418, P=0.001). Of each component of the definition, BMI ≥28.0 kg/m2 (HR=2.047, 95% CI 1.229–3.410, P=0.006) and hyperglycemia (HR=2.911, 95% CI 1.850–4.580, P<0.001) were independent risk factors for MACE.

Conclusions

In patients with PMI, (1) hyperglycemia usually indicates more severe lesions; (2) MetS as a whole was an independent risk factor for MACE; (3) Of each component of the MetS, BMI ≥28.0 kg/m2 and hyperglycemia were associated with MACE.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This research was supported by the Key Project of Scientific and Technological Support Plan of Tianjin in 2020

[Transcriptomic analysis of tuberculosis peptide-based vaccine MP3RT in humanized mice]

Objective: To identify the differentially expressed genes (DEGs) induced by tuberculosis peptide-based vaccine MP3RT in a humanized mouse model using transcriptomics technology. Methods: This study was conducted from August 2019 to February 2022. We used edgeR software to screen DEGs with a fold change greater than or equal to 1.5 and a P value less than 0.05 as screening conditions. Gene ontology (GO), Kyoto encyclopedia of genes and genomes (KEGG), and protein interaction network analyses were performed on the screened DEGs. Then, these DEGs were verified by RT-qPCR and statistically analyzed by GraphPad Prism 8 software. Results: A total of 367 DEGs (214 up-regulated and 153 down-regulated) were identified by transcriptomics. Bioinformatics analysis showed that the GO enrichment of the DEGs mentioned above significantly focused on cell metabolism, growth, apoptosis, inflammation, and other terms. In contrast, the KEGG enrichment significantly focused on inflammatory pathways such as the MAPK signaling pathway. Protein interaction network analysis showed that protein Abl1 had the highest aggregation, the highest aggregation coefficient, and the best connectivity. RT-qPCR results showed that gene expressions of cpne4 (t=2.48, P=0.048 0), h2-q10 (t=2.95, P=0.025 6), mef2c (t=2.87, P=0.028 4), cr2 (t=3.23, P=0.178), ablim1 (t=2.91, P=0.033 5), dll1 (t=2.70, P=0.027 3) and ms4a2 (t=3.03, P=0.019 2) genes in the MP3RT group were significantly up-regulated than those in the PBS group, while gene expressions of cd163l1 (t=2.56, P=0.043 0), il1r1 (t=2.91, P=0.022 7) and cd34 (t=2.42, P=0.046 2) genes in the MP3RT group were significantly down-regulated than those in the PBS group. Conclusions: The MP3RT vaccine induced 367 DEGs in humanized mice, which were associated with metabolic and immune responses. Furthermore, we found that p38 MAPK and JNK/MAPK signaling pathways played an important role in the molecular mechanism of the MP3RT vaccine.

[Nutrition management of patients with acute exacerbation of chronic obstructive pulmonary disease hospitalized in Respiratory Intensive Care Unit]

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is an important part of the course of COPD. Patients with life-threatening acute exacerbation need to be admitted to the respiratory intensive care unit (RICU) for treatment in time. Malnutrition is common in COPD patients, and nutritional risk also has a high prevalence in patients with COPD exacerbation, which is closely associated with the clinical outcome and mortality of these patients. Identifying patients with high nutritional risk and providing appropriate nutritional treatment will help to improve survival rate, shorten length of hospital stay and reduce complications. This review describes the potential mechanisms of malnutrition in patients with COPD, the nutritional risk assessment of patients with COPD exacerbation hospitalized in RICU, the selection of nutritional treatment methods and formulas, and the relevant problems of nutritional management of patients required noninvasive ventilation, hoping to provide information for the optimization of nutritional treatment strategy for acute exacerbation of COPD and the exploration of clinical research in the future.

Evidence for Nonlinear Gluon Effects in QCD and Their Mass Number Dependence at STAR

The STAR Collaboration reports measurements of back-to-back azimuthal correlations of di-π^{0}s produced at forward pseudorapidities (2.6<η<4.0) in p+p, p+Al, and p+Au collisions at a center-of-mass energy of 200 GeV. We observe a clear suppression of the correlated yields of back-to-back π^{0} pairs in p+Al and p+Au collisions compared to the p+p data. The observed suppression of back-to-back pairs as a function of transverse momentum suggests nonlinear gluon dynamics arising at high parton densities. The larger suppression found in p+Au relative to p+Al collisions exhibits a dependence of the saturation scale Q_{s}^{2} on the mass number A. A linear scaling of the suppression with A^{1/3} is observed with a slope of -0.09±0.01.

Residual feed intake in peripartal dairy cows is associated with differences in milk fat yield, ruminal bacteria, biopolymer hydrolyzing enzymes, and circulating biomarkers of immunometabolism

Residual feed intake (RFI) measures feed efficiency independent of milk production level, and is typically calculated using data past peak lactation. In the current study, we retrospectively classified multiparous Holstein cows (n = 320) from 5 of our published studies into most feed-efficient (M-eff) or least feed-efficient (L-eff) groups using performance data collected during the peripartal period. Objectives were to assess differences in profiles of plasma biomarkers of immunometabolism, relative abundance of key ruminal bacteria, and activities of digestive enzymes in ruminal digesta between M-eff and L-eff cows. Individual data from cows with ad libitum access to a total mixed ration from d -28 to d +28 relative to calving were used. A linear regression model including dry matter intake (DMI), energy-corrected milk (ECM), changes in body weight (BW), and metabolic BW was used to classify cows based on RFI divergence into L-eff (n = 158) and M-eff (n = 162). Plasma collected from the coccygeal vessel at various times around parturition (L-eff = 60 cows; M-eff = 47 cows) was used for analyses of 30 biomarkers of immunometabolism. Ruminal digesta collected via esophageal tube (L-eff = 19 cows; M-eff = 29 cows) was used for DNA extraction and assessment of relative abundance (%) of 17 major bacteria using real-time PCR, as well as activity of cellulase, amylase, xylanase, and protease. The UNIVARIATE procedure of SAS 9.4 (SAS Institute Inc.) was used for analyses of RFI coefficients. The MIXED procedure of SAS was used for repeated measures analysis of performance, milk yield and composition, plasma immunometabolic biomarkers, ruminal bacteria, and enzyme activities. The M-eff cows consumed less DMI during the peripartal period compared with L-eff cows. In the larger cohort of cows, despite greater overall BW for M-eff cows especially in the prepartum (788 vs. 764 kg), no difference in body condition score was detected due to RFI or the interaction of RFI × time. Milk fat content (4.14 vs. 3.75 ± 0.06%) and milk fat yield (1.75 vs. 1.62 ± 0.04 kg) were greater in M-eff cows. Although cumulative ECM yield did not differ due to RFI (1,138 vs. 1,091 ± 21 kg), an RFI × time interaction due to greater ECM yield was found in M-eff cows. Among plasma biomarkers studied, concentrations of nonesterified fatty acids, β-hydroxybutyrate, bilirubin, ceruloplasmin, haptoglobin, myeloperoxidase, and reactive oxygen metabolites were overall greater, and glucose, paraoxonase, and IL-6 were lower in M-eff compared with L-eff cows. Among bacteria studied, abundance of Ruminobacter amylophilus and Prevotella ruminicola were more than 2-fold greater in M-eff cows. Despite lower ruminal activity of amylase in M-eff cows in the prepartum, regardless of RFI, we observed a marked linear increase after calving in amylase, cellulase, and xylanase activities. Protease activity did not differ due to RFI, time, or RFI × time. Despite greater concentrations of biomarkers reflective of negative energy balance and inflammation, higher feed efficiency measured as RFI in peripartal dairy cows might be associated with shifts in ruminal bacteria and amylase enzyme activity. Further studies could help address such factors, including the roles of the liver and the mammary gland.

Fn1 Regulates the Third Pharyngeal Pouch Patterning and Morphogenesis

The parathyroid and thymus are derived from the common primordia, the third pharyngeal pouch. During their development, endodermal cells actively interact with surrounding mesenchymal cells, mainly derived from neural crest cells (NCCs). However, the mechanism by which NCCs regulate the development of the third pharyngeal pouch remains largely unknown. In this study, we showed that fibronectin 1 (Fn1), which is synthesized by NCCs, modulates the functions of NCCs in the third pharyngeal pouch patterning and in the morphogenesis of the thymus/parathyroid. Loss of Fn1 in NCCs leads to decreased Foxn1 expression in the presumptive thymus domain at E11.5. In the mutant, we detected upregulation of the Hedgehog signaling activity in the presumptive parathyroid domain and downregulation of Bmp4 in the presumptive thymus domain. Tbx1, a Hedgehog signaling target gene in endoderm development, was ectopically expanded to the presumptive mutant thymus domain at E11.5. Fgf10, an important gene regulating the proliferation of endoderm development, was downregulated in the mutant NCCs. At later organogenesis stages, derivatives of the third pharyngeal pouch endoderm of mutant embryos were abnormal, showing conditions such as hypoparathyroidism, hypoplastic thymus, and ectopic thymus and parathyroid. These data support that Fn1 plays an important role in NCCs by regulating the patterning of the third pharyngeal pouch and morphogenesis of the thymus/parathyroid.

[Clinical characteristics and whole exome sequencing results of patients with Möbius syndrome]

Objective: To analyze the clinical characteristics of patients with Möbius syndrome (MBS) and to explore likely pathogenic genes. Methods: Cross-sectional study. The study enrolled 18 sporadic MBS patients who visited the Eye Center of Beijing Tongren Hospital Affiliated to Capital Medical University from July 2018 to December 2021. All patients completed the general information questionnaire and underwent detailed ophthalmic examinations and general physical examinations. Seventeen patients received MRI examination of cranial nerves and the orbit. The peripheral venous blood of all patients and their nuclear family members was collected, the genomic DNA was extracted, and the pathogenic gene variations that may lead to MBS were identified by whole exome sequencing and bioinformatics analysis. Results: Among the 18 patients, there were 8 males and 10 females, and the age was (4.5±4.0) years (range, 8 months to 17 years). All patients showed congenital, bilateral or unilateral abduction deficit and facial weakness, which met the minimum diagnostic criteria of MBS. Among them, bilateral abduction deficit (16/18) and bilateral facial weakness (15/18) were more common. Nine patients were orthotopic in primary position, eight presented with esotropia, and one showed hypotropia. All patients had ametropia, of which 4 patients were diagnosed as amblyopia. Fifteen patients were also accompanied by other multiple congenital malformations, mainly characterized by abnormal development of glossopharynx (14/18) and limbs (5/18), and 7 patients were also accompanied by motor retardation. In addition, 9 patients had intrauterine exposure to adverse factors. Among the 17 patients who underwent MRI, 15 patients had bilateral hypoplasia of the abducens nerve, two had unilateral hypoplasia of the abducens nerve, 14 showed bilateral hypoplasia of the facial nerve, and three showed hypoplasia of the left facial nerve. Besides, some patients were also accompanied by hypoplasia of other cranial nerves, mainly the glossopharyngeal nerve and the hypoglossal nerve. No definite pathogenic variations were found by whole exome sequencing and bioinformatics analysis. Conclusions: The main clinical features of MBS were congenital abduction deficit and facial weakness, with complicated manifestations and variable severity. MRI showed absence or thinning of the abducens nerve and the facial nerve. The results of MRI can be used as a supplement to the diagnostic criteria of MBS. The mutation detection rate of MBS was low, and half of patients had exposure to adverse factors during pregnancy, suggesting that there was a multifactorial pathogenic mechanism in MBS.

Susceptibility-weighted imaging cannot distinguish radionecrosis from recurrence in brain metastases after radiotherapy: a comparison with high-grade gliomas

AIM

To explore the efficiency of susceptibility-weighted imaging (SWI) in the differential diagnosis of recurrence from radionecrosis in brain metastases (BM) and in high-grade gliomas (HGG).

MATERIALS AND METHODS

From September 2016 to November 2018, 56 patients with BM and 42 patients with HGG were included in this retrospective study. BM and HGG were assigned to the recurrence and radionecrosis groups according to their histopathology or follow-up results. The proportion of dark signal intensity (proDSI), which was defined as the area of dark signal on SWI or the enhancing area on contrast-enhanced T1-weighted imaging (T1WI), was calculated for each patient. Analysis of variance (ANOVA) with Tukey's honestly significant difference test was used for the repeat multiple comparisons. Receiver operating characteristic curve analysis was performed to validate the diagnostic performance.

RESULTS

For HGG, the proDSI in the recurrence group was significantly lower than that in the radionecrosis group (0.13 ± 0.05 versus 0.43 ± 0.11, p<0.001); however, for BM, no statistical difference was found between groups (0.49 ± 0.09 versus 0.46 ± 0.08, p=0.26). proDSI had the best diagnostic performance (AUC = 0.87, 95% CI: 0.76-0.98; sensitivity = 0.87; specificity = 0.88) for HGG, when a cut-off value of 0.21 was selected.

CONCLUSIONS

Semi-quantitative analysis using SWI is feasible for the differential diagnosis between recurrence and radionecrosis in HGG, but is not feasible in BM. Semi-quantitative assessment based on SWI should interpreted with caution in BM after radiotherapy in clinical practice.

Measurements of Proton High-Order Cumulants in sqrt[s_{NN}]=3 GeV Au+Au Collisions and Implications for the QCD Critical Point

We report cumulants of the proton multiplicity distribution from dedicated fixed-target Au+Au collisions at sqrt[s_{NN}]=3.0  GeV, measured by the STAR experiment in the kinematic acceptance of rapidity (y) and transverse momentum (p_{T}) within -0.5<y<0 and 0.4<p_{T}<2.0  GeV/c. In the most central 0%-5% collisions, a proton cumulant ratio is measured to be C_{4}/C_{2}=-0.85±0.09 (stat)±0.82 (syst), which is 2σ below the Poisson baseline with respect to both the statistical and systematic uncertainties. The hadronic transport UrQMD model reproduces our C_{4}/C_{2} in the measured acceptance. Compared to higher energy results and the transport model calculations, the suppression in C_{4}/C_{2} is consistent with fluctuations driven by baryon number conservation and indicates an energy regime dominated by hadronic interactions. These data imply that the QCD critical region, if created in heavy-ion collisions, could only exist at energies higher than 3 GeV.

Measurements of _{Λ}^{3}H and _{Λ}^{4}H Lifetimes and Yields in Au+Au Collisions in the High Baryon Density Region

We report precision measurements of hypernuclei _{Λ}^{3}H and _{Λ}^{4}H lifetimes obtained from Au+Au collisions at sqrt[s_{NN}]=3.0  GeV and 7.2 GeV collected by the STAR experiment at the Relativistic Heavy Ion Collider, and the first measurement of _{Λ}^{3}H and _{Λ}^{4}H midrapidity yields in Au+Au collisions at sqrt[s_{NN}]=3.0  GeV. _{Λ}^{3}H and _{Λ}^{4}H, being the two simplest bound states composed of hyperons and nucleons, are cornerstones in the field of hypernuclear physics. Their lifetimes are measured to be 221±15(stat)±19(syst)  ps for _{Λ}^{3}H and 218±6(stat)±13(syst)  ps for _{Λ}^{4}H. The p_{T}-integrated yields of _{Λ}^{3}H and _{Λ}^{4}H are presented in different centrality and rapidity intervals. It is observed that the shape of the rapidity distribution of _{Λ}^{4}H is different for 0%-10% and 10%-50% centrality collisions. Thermal model calculations, using the canonical ensemble for strangeness, describes the _{Λ}^{3}H yield well, while underestimating the _{Λ}^{4}H yield. Transport models, combining baryonic mean-field and coalescence (jam) or utilizing dynamical cluster formation via baryonic interactions (phqmd) for light nuclei and hypernuclei production, approximately describe the measured _{Λ}^{3}H and _{Λ}^{4}H yields. Our measurements provide means to precisely assess our understanding of the fundamental baryonic interactions with strange quarks, which can impact our understanding of more complicated systems involving hyperons, such as the interior of neutron stars or exotic hypernuclei.

A food-grade vector for Streptococcus thermophilus based on the α-complementation of β-galactosidase

Streptococcus thermophilus is a common yogurt starter that consumes lactose as its primary carbon source. The enzyme β-galactosidase is essential for the lactose metabolism and the growth of this species. Streptococcus thermophilus appears to be a promising cell factory. Food-grade vectors have advantages in heterologous protein expression. This study aimed to determine whether the β-galactosidase of S. thermophilus has the α-complementary characteristic and to develop a novel food-grade vector based on this phenomenon. The N-terminal 7 to 36 AA residues of the β-galactosidase in S. thermophilus were deleted. The obtained mutant S. thermophilus Δα lost β-galactosidase activity and growth ability in the lactose medium. Subsequently, plasmids expressing α-fragments with different lengths of 1 to 36 (Sα1), 1 to 53 (Sα2), and 1 to 88 (Sα3) AA were constructed and transformed into S. thermophilus Δα. Recombinant S. thermophilus Δα expressing Sα2 or Sα3 recovered the ability to grow in the lactose medium, and their β-galactosidase activity accounted for 24.5% or 11.5% of the wild strain, respectively. These results indicated that the α-complementation system of β-galactosidase existed in S. thermophilus. Based on the characteristic, a food-grade vector pSEα was constructed. Except for Sα2, vector pSEα expressed the α-donor derived from E. coli β-galactosidase. This facilitated the construction of recombinant plasmids in E. coli DH5α and thus improved the transformation efficiency of S. thermophilus. Green fluorescent protein as a reporter protein could be highly expressed in S. thermophilus using this vector. As a result, pSEα is an efficient and safe vector for S. thermophilus with potential food applications.

[Construction of a nomogram model for predicting 2-year survival rate of small cell lung cancer based on more comprehensive variables]

Objective: To construct a novel prognostic nomogram model based on more comprehensive variables for patients with small-cell lung cancer (SCLC). Methods: The data of 722 patients with SCLC confirmed by pathology in Affiliated Cancer Hospital of Shanxi Medical University from January 2015 to December 2018 were retrospectively analyzed [including 592 males and 130 females, aged from 23 to 82(61±9) years]. A random seed count of 133 was used to divide those patients into training set (n=422) and validation set (n=300). Kaplan-Meier was used for survival curves analysis and univariate Log-rank test was used for evaluating the influence of clinical variables on the prognosis of sclc, variables with P<0.05 in univariate analysis were included in a multivariate Cox regression model. The nomogram was constructed based on the variables which P<0.05 in multivariate analysis. Receiver operating characteristic (ROC) curve, calibration by Integrated Brier score (IBS) and clinical net benefit by decision curve analysis (DCA) were used to evaluate model discriminative power, prediction error value, and clinical net benefit, and compared with the American Joint Committee on Cancer 8th TNM. Results: Male, abnormal monocyte (MON) counts, abnormal neuron specific enolase (NSE), abnormal cytokeratin 19 fragment (Cyfra211), M1a stage, M1b stage, M1c stage, radiotherapy (RT), chemotherapy ≥4 cycles and prophylactic cranial irradiation (PCI) were prognostic factors for SCLC[HR(95%CI)=1.39(1.00-1.92), 1.29(1.02-1.63), 1.41(1.11-1.80), 2.02(1.48-2.76), 1.09(0.77-1.55), 1.44(0.94-2.22), 2.01(1.49-2.71), 0.75(0.57-0.98), 0.40(0.31-0.51)and 0.42(0.26-0.68), respectively, all P<0.05]. The area under ROC curve (AUC) of the nomogram in training set and validation set were 0.814(95%CI: 0.765-0.862)and 0.787 (95%CI: 0.725-0.849), which were higher than TNM [0.616(95%CI: 0.558-0.674) and 0.648(95%CI: 0.581-0.715)].The calibration curve showed a good correlation between the nomogram prediction and actual observation for the 2-year overall survival (OS). IBS indicted a lower prediction error rate (training set: 0.132 vs 0.169; validation set: 0.138 vs 0.169). DCA showed a wider threshold range than TNM (training set: 0.01-0.96 vs 0.01-0.85, validation set: 0.01-0.94 vs 0.01-0.86) and a greater improvement of the clinical net benefit (in training set the nomogram had a greater clinical benefit than TNM in the range of 0.19-0.96, and remained in validation set in the range of 0.19-0.94). Conclusion: The established nomogram model for predicting 2-year OS in patients with SCLC based on 8 variables, including gender, MON, NSE, Cyfra211, M stage, RT, CT cycles and PCI can be used for an more accurately prognosis prediction and reference for therapeutic regimen selection.

[The diagnosis and treatment of G3 neuroendocrine tumors according to the new NCCN guideline]

Gastrointestinal pancreas (GEP) is the most common site of neuroendocrine neoplasms (NENs). In 2019, the World Health Organization (WHO) classification for GEP NET was updated to include a new category of well-differentiated high-grade (Ki 67>20%) GEP-NET G3, distinct from high-grade poorly differentiated neuroendocrine carcinoma (NEC). As a new category, NET G3 are considered a molecularly, radiologically, and prognostically distinct entity compared to NEC and NET G1/G2. The management of NET G3 remains a challenge awaiting future trials taking into consideration the unique characteristics of this new category. The latest NCCN clinical guidelines of neuroendocrine and adrenal tumors firstly gave the recommendation of diagnosis and treatment of G3 NET separately from NEC and G1/G2 NET. Hereon,we aim to summarize the management of G3 NET in combination with the new NCCN guidelines and the current evidences.