Trichoderma, mycorrhizal and endophytic fungi are the main groups of filamentous fungi studied and used as biological control agents (BCAs) against nematodes as resistance inducers. They are able to reduce the damage caused by plant-parasitic nematodes directly by parasitism, antibiosis, paralysis and by the production of lytic enzymes. But they also minimize harm by space and resource-competition, by providing higher nutrient and water uptake to the plant, or by modifying the root morphology, and/or rhizosphere interactions, that constitutes an advantage for the plant-growth. Besides, filamentous fungi are able to induce resistance against nematodes by activating hormone-mediated  plant-defense mechanisms. Additionally, the alteration of the transport of chemical defense components through the plant or the synthesis of plant secondary metabolites and different enzymes can also contribute to enhancing plant defenses. Therefore, the use of filamentous fungi of the mentioned groups as BCAs is a promising durable biocontrol strategy in agriculture against plant-parasitic nematodes.Plant-parasitic-nematodes represent a major threat to the agricultural production of different crops worldwide. Due to the high toxicity of chemical nematicides, it is necessary to develop new control strategies against nematodes. In this respect, filamentous fungi can be an interesting biocontrol alternative. The genus  Over 4100 species of plant-parasitic nematodes were described to date, among which, a restricted group of genera is considered as major plant-pathogens, whereas others are specific to a more limited range of crops, both causing a high impact to economically important crops. Damage caused by plant nematodes has been estimated as a projected yield loss of 12.3% ($157 billion) worldwide , more siMeloidogyne spp.) and cyst nematodes , although most species feed on roots. They need a protrusible stylet for feeding that they use to penetrate the plant cells. The stylet is connected to three to five pharyngeal glands that produce effector molecules, which are often secreted, facilitating penetration, internal migration, and parasitism . Based oOdontopharynx longicaudata, effective against M. incognita and M. javanica (among others) and M. gaugleri, effective against Heterodera oryzae and M. incognita  as they are harmful to human health and contaminant for the environment , 2017. SPseudomonas fluorescens CHA0 that induce mortality of nematode eggs and second-stage infective juveniles  enhance plant growth by colonizing the plant root system, but some PGPR showed also nematicidal activity against plant-parasitic nematodes. One clear example is the secondary metabolites produced by les J2s; . In a stPlants also have a series of innate defensive strategies to defend themselves from the attack of pests and pathogens in a targeted manner. Once the attack occurred, the plants recognize non-specific molecules of the cell wall of the microorganisms [pathogen- and/or Microbial-Associated Molecular Patterns (PAMPs/MAMPs)], the oral secretions of the herbivores [herbivore-associated molecular patterns (HAMPs)] or signs of cell-plant damage [Damage-Associated Molecular Patterns (DAMPs)], by cell surface pattern recognition receptors (PRRs) . NematodThe plant innate immune system comprises local and systemic defense responses. After the attack of a biotroph pathogen and the occurrence of a programmed cell death response in plants, called hypersensitive response (HR), a broad-spectrum immunity to reinfection through the whole plant body, called systemic acquired resistance (SAR) is activated in the plant. SAR signaling is mainly mediated by SA derived compounds, such as methyl-SA (MeSA). Similarly, numerous beneficial microorganisms are capable of inducing in the plant what is known as induced systemic resistance (ISR) against necrotrophic pathogens and herbivores. ISR is regulated mainly by JA/ethylene (ET) signaling, but dependence on SA signaling has also been reported . SystemiTrichoderma species, arbuscular mycorrhizas, ectomycorrhizas, endophytes, yeasts, and avirulent/hypovirulent strains of certain pathogens are among the main beneficial fungi with biocontrol capacity, also by induction of ISR  establishing a complex molecular dialogue with the plant-host. This relationship, together with its easy adaptation to various climatic and edaphic conditions, and its growth speed, give this genus an advantage over many other filamentous fungi and make them excellent candidates as BCAs. Currently, several mechanisms of action of Trichoderma are recognized as BCA: mycoparasitism, antibiosis, competition with the pathogen, promotion of plant growth, enhanced plant-tolerance against abiotic stresses and stimulation of its defenses against pathogens  and arbuscular mycorrhizal fungi (AMF) are the main groups and of great interest in forestry and agronomy, since the AMF are capable of forming symbiotic interactions with 80% of the plant species . ECMF maAt present, molecular and paleo-biological studies have shown how the origin of AMF and of terrestrial plants occurred simultaneously over time (about 470 million years ago) from epiphytic fungi that grew on the surface of the first vascular plants. They were also necessary for the success of plant terrestrial colonization . Thus, EDevelopment of a mycorrhizal symbiosis requires continuous signals exchange between the two symbionts, which triggers coordinated differentiation of both partners. Moreover, the intimate interaction of the arbuscules within the root cells requires also a partial suppression of plant defense responses . MycorrhThe similarities between the fungi structural organs used for nutrient uptake between the biotrophic phytopathogenic fungi (haustoria form) and the AMF (arbuscules form), together with the establishment of a long-term relationship with their host, lead to an incorrect response by the plant. First, the plant recognizes PAMPs/MAMPs type molecular patterns , which triggers a generalist defensive response of the PTI or MAMP-triggered immunity type. Subsequently, the recognition of effectors released by the fungus in response to plant defenses activates a more specific defensive response (ETI). This part of the plant responses establishes the main difference between the pathogenic fungus and the symbiont fungi . The conThe classic definition of plant endophytes refers to those microorganisms that can be isolated from plant tissues once they have been superficially disinfected. They also do not cause visible damage to plants. This group of microorganisms includes bacterial, archaeal, fungal and protist taxa. Among them, the fungal group play an important role in ecosystems, protecting plants against biotic and abiotic stresses . NumerouAlthough, endophytic fungi are found in a great variety of plants and ecosystems, there is a strong influence of the local environment in determining endophytic communities; hence, individual endophytes show a different niche occupancy , accordiAs mentioned before, endophytic fungi are capable of producing plant-associated metabolites and their analogs, bioactive compounds with diverse biotechnological applications, which have been extensively reviewed by numerous authors . Among tThe use of BCAs from endophytic fungi is a growing area of research as shown from numerous reviews on this topic . The maiEpichloë genus includes important endophytic fungi of grasses widely studied for their ability to protect the plants due to the synthesis of different alkaloids. Besides, these fungi enhance plant immunity against chewing insects by promoting endogenous defense responses mediated by the JA pathway  by Epichloë festucae var. lolii . Additionally, they observed a significant reduction in egg hatching, thus demonstrating that this species of the genus Trichoderma has significant potential as BCA against this plant parasite. Similarly, root colonization by T. harzianum impeded nematode performance locally at multiple stages of the parasitism: invasion, galling and reproduction in tomato  affected more negatively to the population of J2s, in addition to increasing plant growth more effectively than fungus exudates , the eggs are laid surrounded by a gelatinous matrix that constitutes an egg-mass secreted by the female, which is considered as a defensive envelope that protects the eggs against microorganisms allowing eggs survival on the soil. According to Trichoderma conidial union to the nematode M. javanica, thus explaining the parasitism resulting from some species of this genus of fungi. However, it cannot be generalized for all species since, e.g., the growth of T. harzianum used in this study was inhibited by this matrix, thus not being effective in biocontrol against M. javanica.Furthermore, approximately 1 month after the penetration of the J2 from the root-knot nematodes  that caused physiological alterations to the cysts  reduce tomato root penetration by false root-knot nematode Nacobbus aberrans  caused an increase in the population of nematodes Pratylenchus brachyurus in maize crop (Panicum virgatum) and miscanthus  that paralyzes and kills the root-lesion nematode  such as glutathione S-transferase or the superoxide dismutase (SOD), enzymes involved in the lignin biosynthesis, and in the shikimate pathway which in turn, produces precursors of various aromatic secondary metabolites against nematodes  hatching but they do play a role in host attraction and subsequent invasion  promoted a lasting SAR against the pine wilt nematode Bursaphelenchus xylophilus, which is transmitted by beetles of the genus Monochamus and feeds by colonizing the vascular bundles  content in tomato roots inoculated with R. irregularis, that also enhanced plant growth  with split-roots using AMF Glomus intraradices against the migratory nematodes Radopholus similis and Pratylenchus coffeae (P. penetrans infestation in apple seedlings by AMF (Meloidogyne arenaria in red ginger (Alpinia purpurata) by Gigaspora albida, Claroideoglomus etunicatum, and Acaulospora longula (Scutellonema bradys in yam (Dioscorea spp.) by F. mosseae and Glomus dussii , polyphenol oxidase (PPO), and SOD, together with a significant reduction of malondialdehyde (MDA) and hydrogen peroxide  and gibepyrone D, which, in addition to being toxic directly to the nematodes, induce defense mechanisms against nematodes in plants  against Meloidogyne spp.  by activating a defensive response mediated by SA  where the diversity of endophytic fungi in the roots was reduced to about 80% , lytic enzymes, and space competition by ic fungi .The scenario in agricultural systems is very complex as different microorganisms of the rhizosphere and plant-species are present; thus they may respond differently to BCAs. The integration of all microorganisms and plant-responses will determine the final output after the BCA treatment as it is a multifactorial response. Additionally, the strong influence of the local environment that for example, highly determine endophytic communities, is another complexity level to include in the agricultural systems. Therefore, BCAs can have variable control ability when established in different soils, and their success can be difficult to predict. However, there are commercial formulates with some of those filamentous fungi mentioned, effective for nematodes control in experimental conditions for particular crops, but scarce scientific information is still available of experiments on the field. The integration of empirical data knowledge in the field after the treatment with a particular fungi strain or formulate, together with detailed analysis of the plant responses at the molecular level in a particular crop could help to a deep understanding of those complex interactions. Yet, holistic approaches for soil-rhizosphere microbiota detection and characterization of specific plant responses could assist in identifying and predicting major problems as the presence of BCA antagonist in the soil or changes in the rhizosphere biota that may influence the final output. This would allow better practices for an effective nematode-control on a particular crop. Moreover, an in-depth knowledge on the molecular mechanisms of induced resistance by BCAs could allow perhaps to manipulate the plants directly, however, synergic effects derived for example of secondary metabolites induced also by some BCAs should also be integrated. Another question is that usually, BCAs based control methods are slow to implement as they may need time to increase their population up to the level required to be effective for PPN control. Yet, the growers need alternative control methods during this period. The durability of those BCA-based techniques is also a great interrogate because of the mentioned complexity of the agricultural systems.Perhaps, a feasible scenario would be to design integrated pest management based first on a well stablished method on a ground base, such as those chemically based, and slowly to introduce BCAs together with a detailed monitoring plan with the intention to gradually decrease the dependence on chemical control. We should not also discard the possible implementation of other complementary alternative control methods, including those based on host plant genotypes that may have an enhanced response in combination with BCAs.Trichoderma, mycorrhizal and endophytic fungi as BCAs is a promising durable biocontrol strategy in agriculture against plant-parasitic nematodes (In summary, the use of filamentous fungi of the genus ematodes  due mainJP and PA-U contributed to the search for information and references in different databases, they gathered most of the peer-reviewed manuscript used on this topic, and highly contributed to the manuscript writing. CE contributed to the manuscript writing and the correction and critical reading, as well as to the knowledge on the nematode field.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.


The abuse of alcohol, one of the most popular psychoactive substances, can cause several pathological and psychological consequences, including alcohol use disorder (AUD). An impaired ability to stop or control alcohol intake despite adverse health or social consequences characterize AUD. While AUDs predominantly occur in men, growing evidence suggests the existence of distinct cognitive and biological consequences of alcohol dependence in women. The molecular and physiological mechanisms participating in these differential effects remain unknown. Transcriptomic technology permits the detection of the biological mechanisms responsible for such sex-based differences, which supports the subsequent development of novel personalized therapeutics to treat AUD. We conducted a systematic review and meta-analysis of transcriptomics studies regarding alcohol dependence in humans with representation from both sexes. For each study, we processed and analyzed transcriptomic data to obtain a functional profile of pathways and biological functions and then integrated the resulting data by meta-analysis to characterize any sex-based transcriptomic differences associated with AUD. Global results of the transcriptomic analysis revealed the association of decreased tissue regeneration, embryo malformations, altered intracellular transport, and increased rate of RNA and protein replacement with female AUD patients. Meanwhile, our analysis indicated that increased inflammatory response and blood pressure and a reduction in DNA repair capabilities are associated with male AUD patients. In summary, our functional meta-analysis of transcriptomic studies provides evidence for differential biological mechanisms of AUD patients of differing sex. Alcohol use disorder (AUD) is one of the most prevalent addictions in the world, according to data from the World Health Organization . AlcoholAUD is a multifactorial disease that is influenced by both genetic and environmental factors . AmongstDue to the high prevalence of AUD, any added information regarding disease mechanisms and organismal effects may be of huge importance. A better understanding of alcohol addiction may also allow for the development of personalized therapies, and any studies aiming to understand any differences between men and women could implicate currently unknown genetic factors. A comprehensive understanding of specific factors would be relevant when developing new therapies or highlighting risk factors to be considered in patients of each sex.As such, meta-analyses of transcriptomic studies conducted in the AUD field may provide some of the answers that we seek. The rapid development of the transcriptomics field has provided crucial information regarding how cell metabolism becomes altered in different situations, including the development of AUD . UnfortuGiven the utility of transcriptome analysis in understanding the molecular mechanisms of disease  and the The review and selection of studies were carried out between March to May 2020 in the Gene Expression Omnibus (GEO)  and ArraThe search identified a range of transcriptomics studies related to human AUD. Keywords used during this step included but were not limited to: “transcriptomics”, “alcoholism”, “alcohol abuse”, “alcohol dependence”, “alcohol”, “ethanol”, “Alcohol Use Disorder” and “Homo sapiens.” From this set of studies, those that fulfilled the inclusion criteria were selected, which included data derived from RNA sequencing or genetic expression microarray platforms; the study had information about the sex of the subjects; the study had not been performed on cell lines; the study included a control group; and a minimum size of three subjects per experimental group. The normalized data of selected studies were downloaded using the R package GEOquery .https://gitlab.com/ubb-cipf/metafunr.The same strategy was applied to the transcriptomic analysis of each selected study. This analysis included: data preprocessing, differential expression analysis, and functional enrichment analysis. Next, the functional results of all studies were integrated using meta-analysis techniques   was usedThe analysis of differential expression levels between sexes was performed by using the R package limma . For eve(AUD Women - Control Women) - (AUD Men - Control Men)p-values associated with the resulting statistics were adjusted using the Benjamini and Hochberg (BH) method [p-values obtained for every function were corrected again using the BH method. Functions with an adjusted p-value lower than 0.05 were considered statistically significant. The metabolic pathways of the Kyoto Encyclopedia of Genes and Genomes (KEGG) [) method . Functio) method , impleme) method . This mes (KEGG) ,26,27 ans (KEGG) ,29 were For each ontology  and KEGG pathways, we analyzed the number of overrepresented elements shared by the studies. These results were graphically represented as UpSet plots  to depicResults of the functional characterization of studies were integrated through a meta-analysis, which used the R packages metafor  and mdgsp-value, the LOR, and its confidence interval were calculated. p-values were adjusted using the BH method, and a particular term was considered significant if it had a p-value lower than 0.05. Significant terms with an LOR greater than 0 indicated an overrepresentation in women, while those with an LOR lower than 0 indicated an overrepresentation in men. Funnel plots and forest plots were used to evaluate the variability and the effect measure of every term in each one of the analyzed studies , which will allow users to review the results described in the manuscript and any other results of interest to researchers. The front-end was developed using the Bootstrap library. All graphics used in this tool were implemented with Plot.ly, except for the exploratory analysis cluster plot, which was generated with the ggplot2 package.The large volume of data and results generated in this work is freely available in the metafun-AUD web tool (This easy-to-use resource is organized into five sections: (1) a quick summary of the results obtained with the analysis pipeline in each of the phases. Then, for each of the studies, the detailed results of (2) the exploratory analysis, (3) the differential expression, and (4) the functional characterization are shown. The user can interact with the tool through its graphics and search for specific information for a gene or function. Finally, in Section (5), indicators are shown for the significant functions identified in the meta-analysis that inform whether they are more active in women or men. Clicking on each indicator obtains the forest plot and funnel plot that explain the effect of each function in individual studies, as well as an evaluation of their variability.We have organized the results into three sections. The first describes which studies were assessed and selected in the systematic review, the second section demonstrates the results of the bioinformatic analysis of each of the selected studies (with (i) exploratory analysis, (ii) differential expression, and (iii) functional enrichment), while the third section summarizes the overall results of the studies on the differential functional profiling by sex.We identified 1416 studies that described illnesses/disorders related to alcohol abuse during the systematic review, of which we selected only 72 after refining the search. With this refined search, we avoided interference from studies related to other illnesses associated with alcohol use, such as fetal alcohol spectrum disorders, or unrelated studies that employed alcohol as a reagent or as part of growth media. Of these 72 studies, we only selected those transcriptomic studies of AUD performed in humans, thereby reducing the number of valid studies to 23. Most studies excluded at this point had been performed in animal models , while we also discarded several studies with a methylome-based rather than transcriptomic approach, since we will subsequently need the same type of data in our bioinformatics strategy. Finally, we excluded those studies (74%) that lacked information regarding the sex of the subjects or had less than three subjects in any of their experimental groups. Remarkably, most of the excluded studies in this final step were due to the lack of a sex perspective. We also discarded studies without control subjects, which brought the number of applicable studies for meta-analysis down to four.Altogether, the number of samples in these studies amounted to a total of 151 individuals: 49 control men, 50 AUD men, 27 control women, and 25 AUD women. In three of the four studies evaluated, the age of participants was available (mean and standard deviation in years): GSE44456, 58.44 (10.36); GSE49376, 56.5(9); GSE59206, 29.18 (7.74). In both GSE44456  and GSE4The initial exploratory analysis helped to pinpoint any bias caused by the batch effect in the studies corresponding to GSE44456 and GSE59206 (detailed results in the metafun-AUD web tool). We corrected the batch effect using the limma package , which iWith the results of the differential expression analysis performed in each study, we also performed a functional enrichment analysis for every GO ontology and KEGG pathway. In this analysis, terms associated with one condition can be due to an overrepresentation of that term in the members of one sex when they suffer AUD, or the underrepresentation of the same term in the members of the opposite sex when they suffer AUD, and that could cause an indirect overrepresentation due to the relativistic nature of the results of the comparison performed.Individual functional enrichment analysis of GO terms and KEGG pathways revealed the highly diverse nature of significant results among studies . The relWe performed four groups of functional meta-analyses, one for each GO ontology and another one for the KEGG pathways using every term found in at least two of the selected studies. As a result of these meta-analyses, we indicated a total of 285 BP terms, 96 CC terms, 79 MF terms, and 6 KEGG pathways as significant . These tThe functional groups with the highest overrepresentation for each sex have been summarized using treemaps and are shown in Among the terms overrepresented in male AUD patients and thus underrepresented in female AUD patients, we found significance for several terms related to tissue growth and remodeling. Interestingly, these terms also specifically link to tissues derived from the mesoderm, and we also identified terms related to growth factors, adherens junctions, and collagen. We also uncovered significance for terms related to an increased innate immune and inflammatory response, including an increase in the secretion of Interleukin (IL)-1 and the migration of cells of the immune system. We also observed a general overrepresentation of terms related to the sense of smell, neural regeneration, triglyceride synthesis, response to angiotensin, activity on the plasma membrane, transcriptional regulation, and inhibition of proteolytic activity in male AUD patients see .Among those terms overrepresented in female AUD patients and thus underrepresented in male AUD patients, we found significance in terms related to synaptic activity, vesicle formation, ciliary activity, melanosome organization, DNA reparation, protein transport, and growth factor inhibition. In this case, we also found significance with a considerable number of terms related with almost every step of gene expression, including nuclear and mitochondrial transcription, histone acetylation, RNA maturation involved in the formation of both tRNA and ribosomes, translation, and the degradation of both RNA and proteins see .https://bioinfo.cipf.es/metafun-AUD) contains information related to the four studies and 151 samples evaluated in this study. The portal includes fold-changes of genes and log odds ratios of functions and pathways for each evaluated study, which can be explored by users to identify profiles of interest.The Metafun-AUD web tool  and graphical representations by function (forest and funnel plots). This open resource aims to contribute to data sharing between researchers to aid the elaboration or interpretation of similar studies.We conducted a total of 18,212 meta-analyses. For each of the 466 significant functions, metafun-AUD demonstrated the global activation level by sex for all studies and the specific contribution of each study, using statistical indicators  . The appThe low number of studies selected represents a limitation with our systematic review; however, we preferred to keep strictly to our selection criteria to ensure comparability. We are also aware that the different types of tissue used in the studies and an unbalanced group of samples by sex in some cases decreases the statistical power. Given these points, and the knowledge that these studies are independent and derive from different environments, we treated this specific variability using a meta-analysis of random effects that detects those mechanisms with a similar pattern in the set of studies. Furthermore, we carried out a subsequent evaluation to confirm that no studies displayed a constant atypical pattern in functions and genes, ensuring the robustness of the obtained results.The central nervous system is one of the organs most affected by chronic alcohol consumption. Studies in human postmortem brain samples have identified specific pattern of gene expression in brain of alcoholics when compared with controls ,45. MoreWe also observed sex-based differences in the immune system response, which agrees with a previous study that described brain region-specific increases in microglial markers in human postmortem brain samples from moderate alcoholics . For insWe also observed that alcohol induces wide-ranging alterations related to tissue regeneration and scarring. Male AUD patients exhibited an increased platelet activity, which could relate to the observed increased response to several growth factors, endothelial proliferation, and epithelial differentiation. This finding suggests that female AUD patients suffer more severe inhibitory alterations in these processes, and thus their response to the presence of wounds is slower and less efficient. These functions may relate to the formation of adherens junctions or binding of cells to the extracellular matrix, which we observed to follow a pattern similar to the aforementioned functions. However, on a more specific level, male AUD patients suffer more significant melanosome degeneration and loss of pigmentary function than female AUD patients, which would suggest a less efficient performance of the function of the skin as a pigmentary barrier and thus the more rapid formation of skin lesions due to exposure to the sun.At the cardiovascular level, we observed an augmented response to angiotensin in male AUD patients, suggesting a greater tendency to suffer high arterial pressure levels due to the vasoconstricting effects of angiotensin .We also noted an overrepresentation of terms related to microtubules, including cilia structure and protein and vesicle transport, in female AUD patients. These results are similar to those recently published by Hitzemann et al., which observed an increased preference for alcohol consumption and alteration in both ciliary organization and extracellular matrix in female mice . These fOf particular note, we observed the underrepresentation of several functions related with the development of tissues and organs in female AUD patients, which, together with terms related with embryonic development, agree with established knowledge regarding the negative impact of alcohol on pregnancy, especially in the development of nervous structures . These aFinally, in many of the observed processes and mechanisms, we observed the presence of terms implied in totally opposed functions; we hypothesize that this may represent an effort to compensate for the changes prompted by AUD.In summary, our findings provide new insight into the complex biological processes and the differential profile of the biological mechanisms in male and female AUD patients. Said functions and pathways might be helpful to better understand sex-based differences in AUD, and their in-depth study could open the door to the development of more effective, personalized treatments for this pathology.In conclusion, we provide further evidence for functional meta-analysis as a robust and efficient means of evaluating and integrating data derived from transcriptomic studies with differing approaches. Furthermore, the application of this method promotes the use of FAIR data in future biomedical studies. The strategy followed in this study fostered the detection and characterization of functional differences caused by sex in AUD-driven changes at a transcriptomic level. These alterations include decreased neuronal and tissue regeneration, malformations to the embryo during pregnancy, alterations related to intracellular transport, and the increased replacement rate of both RNA and proteins in female AUD patients. Meanwhile, male AUD patients displayed an increase in inflammatory responses and blood pressure and a decrease in the ability to repair DNA, which may relate to the increased risk of cancer.These results confirm the utility of incorporating the perspective of sex into biomedical studies, thereby improving our understanding of AUD-related mechanisms in men and women, and generating relevant information for the development of efficient, personalized treatments.


This study examines the development of an interprofessional training certificate program that prepares social work learners to infuse geriatrics and behavioral health into primary care settings. Since 2018, our program has trained 31 social work learners and 16 learners from counseling psychology and nursing. At the core of the certificate program is an emphasis on developing skills focused on the integration of geriatrics, behavioral health and primary care to address the lack of workforce trained at the intersection of these areas. Each series of workshop is aligned with core competencies that address the 4-M Model of Age-Friendly Health Care and SAMSHA’s Core Competencies in Behavioral Health. Our professional certificate includes training in Motivational interviewing, as well as Cognitive behavioral therapy, Mindfulness based cognitive therapy and Problem-solving therapy, Narrative Therapy, Strategic Therapy, Systemic Therapy, Life Review and Reminiscence Therapy. Additionally, students receive professionalization trainings to help prepare them for the job market. To measure the efficacy of this curriculum program, we examined the outcomes related to student knowledge of geriatrics and behavioral health including knowledge attainment, fidelity to modalities, learner self-efficacy, and learner satisfaction. The results of this study showed that integrating interprofessional education into social work settings can lead to positive outcomes for student knowledge, self-efficacy and learning satisfaction. Additionally, we found that having a curriculum that focused on interprofessional teams contributed to higher self-efficacy in completing tasks compared to previous cohorts. This has implications for the way that we conceptualization the use of interprofessional education.


As countries continue to respond to the COVID-19 pandemic, the importance of ensuring that fair and equal access to healthcare for all is more urgent than ever. Policies that promote social capital building along all levels of society may offer an important avenue for improved healthcare delivery and health systems strengthening in the COVID-19 response.In reference to the established and emerging literature on social capital and health, we explore the role of social capital in the COVID-19 health policy response. We analyse current research with respect to mental health, public health policy compliance, and the provision of care for vulnerable populations, and highlight how considerations of bonding, bridging, and linking capital can contribute to health systems strengthening in the context of the COVID-19 response and recovery effort.This article argues that considerations of social capital – including virtual community building, fostering solidarity between high-risk and low-risk groups, and trust building between decision-makers, healthcare workers, and the public – offer a powerful frame of reference for understanding how response and recovery programs can be best implemented to effectively ensure the inclusive provision of COVID-19 health services. The global response to COVID-19 has required decisiveness, resilience, and resolve from governments around the world. However, economic, legal, technological, geographic, and cultural barriers can limit the ability of a government to effectively respond to critical public health needs. The intricate network of stakeholders that operate within and interconnect with the public health space is an essential component of a health system’s response. In this context, considerations of social capital emerge as a powerful frame of reference for understanding how health interventions may be best implemented to effectively ensure an inclusive extension of health services for all members of society. It is patently clear that if a population group is excluded from accessing the health system and its attendant services and products, the efficacy of any pandemic response or recovery program may be severely undermined.the behaviour of social networks and relationships, characterized by the qualitative presence of enhanced trust and reciprocity [Putnam conceptualizes social capital as iprocity . Within iprocity . Bondingiprocity . Expressiprocity .As countries adopt urgent public health measures in response to the many challenges posed by COVID-19, lessons learned from public health intervention studies that link enhanced social capital with improved mental health outcomes, greater community buy-in, and the extension of health services to vulnerable populations suggest a critical role for social capital in ensuring a rapid adjustment to today’s new public health reality.Preliminary studies conducted in the United States lend support to the importance of social capital in the COVID-19 response, with the growth rate of new COVID-19 cases found to be negatively associated with the amount of social capital at both the state and county levels . HoweverIn countries around the world, social distancing policies have emerged as a central component of the COVID-19 response. Measures including post-exposure quarantining, shelter-in-place orders, and limits on the size of social bubbles have been credited with ‘flattening the curve’ and reducing the growth of new infection cases. However, these have also contributed to the dramatic disruption of normal patterns of social interaction, raising serious mental health concerns amongst the general population and high-risk groups alike. As social distancing measures continue to limit access to customary channels of social support – such as spending in-person time with family members, friends, and colleagues of different households – studies within communities affected by COVID-19 report consistent observations of elevated mental health concerns. For example, heightened levels of anxiety and depression have been reported in China, greater stress and mental morbidity have been observed in Iran, higher levels of fear and panic behaviour have been noted in Japan, and increased health anxiety has been studied in Canada .Addressing the potential mental health consequences of social distancing measures thus necessitates a conscious inclusion of psychological interventions in the international pandemic response. This is particularly true for high-risk groups, such as the elderly, those with underlying health conditions, and front-line health workers, since these groups represent the populations that are most likely to adhere to stricter forms of social distancing . In thisEffectively containing the spread of COVID-19 demands a unified response from all members of society. This is particularly true with respect to preventative public health measures that intrinsically require broad public buy-in, such as physical distancing or public mask-wearing. However, with some groups of individuals perceived to be at significantly lower risk to the most severe symptoms of COVID-19, psychological tolerance to reduced levels of precaution may vary considerably within a given population. If expressed through the refusal to comply with public health directives, the efficacy of preventative public health measures may be severely undermined. In this way, perhaps one of the most challenging obstacles to achieving public health policy compliance in the context of COVID-19 lies in persuading individuals to make decisions according to the exposure tolerance of high-risk individuals – potentially to whom they have no personal connection – rather than according to their own personal willingness to incur risk. Indeed, while full public buy-in to public health directives is an undoubted prerequisite to an effective pandemic response, communities with weak bridging capital between high-risk and low-risk populations may find this difficult to achieve. Initiatives that aim to build social capital by fostering enhanced solidarity and empathy between high-risk and low-risk groups are thus particularly important to the COVID-19 response. A recent set of studies investigating the role of empathy on physical distancing and mask-wearing compliance reinforces the potential impact of such initiatives, finding that public motivation to adhere to these preventative public health measures is promoted when empathy for those most vulnerable to COVID-19 is elicited . ExtendeIn comparison to authoritarian systems of government, where public adherence to strict pandemic response measures may be unilaterally compelled through the use or threat of excessive force, compliance with government-mandated health directives among democratic systems requires that the public embrace a set of pro-health social norms that can weather the spread of scientifically unsupported information and/or a lack of trust in national health leaders. Measures that protect linking capital between democratic public health authorities and members of the public thus cannot not be overlooked. To this end, the dissemination of transparent and accurate public health information, enforcing expectations of public health policy compliance among political leaders, policy consistency between domestic agencies and departments, and policy congruency with recognized international health organizations stand as actionable social capital-centric options that may enhance public faith in the legitimacy of national COVID-19 responses.Equally important is the role of linking capital in ensuring that the needs of the vulnerable are not ignored. Particularly in the context of the current COVID-19 pandemic, it is vital that individuals can access lifesaving health services regardless of their socioeconomic or legal status, cultural identity, or geographic location. In Italy, the exclusion of irregular migrants from receiving free COVID-19 testing was shown to undercut the government’s pandemic response , illustrA social capital-centric public health response is one that recognises the limitations of top-down policy and the value of social networks in achieving desirable public health outcomes. As concerns over mental health, public health policy compliance, and equitable access to healthcare services and products continue to confront the global COVID-19 response, measures that integrate considerations of bonding, bridging, and linking capital stand as immediately available options for health systems strengthening. Efforts to address the ongoing pandemic increasingly demand the participation of actors across different nationalities, disciplines, socioeconomic backgrounds, and political identities. As such, we must acknowledge the inherent importance of social solidarity and trust in achieving today’s urgent public health goals.


Unlike the conventional techniques used to construct a tissue scaffolding, three-dimensional (3D) bioprinting technology enables fabrication of a porous structure with complex and diverse geometries, which facilitate evenly distributed cells and orderly release of signal factors. To date, a range of cell-laden materials, such as natural or synthetic polymers, have been deployed by the 3D bioprinting technique to construct the scaffolding systems and regenerate substitutes for the natural extracellular matrix (ECM). Four-dimensional (4D) bioprinting technology has attracted much attention lately because it aims to accommodate the dynamic structural and functional transformations of scaffolds. However, there remain challenges to meet the technical requirements in terms of suitable processability of the bioink formulations, desired mechanical properties of the hydrogel implants, and cell-guided functionality of the biomaterials. Recent bioprinting techniques are reviewed in this article, discussing strategies for hydrogel-based bioinks to mimic native bone tissue-like extracellular matrix environment, including properties of bioink formulations required for bioprinting, structure requirements, and preparation of tough hydrogel scaffolds. Stimulus mechanisms that are commonly used to trigger the dynamic structural and functional transformations of the scaffold are analyzed. At the end, we highlighted the current challenges and possible future avenues of smart hydrogel-based bioink/scaffolds for bone tissue regeneration. There are a number of challenges associated with the current restoration methods for bone defects, such as autografts and allografts  and magnetic resonance imaging (MRI) are the imaging technologies commonly used  and a layer of bioink; and a receiving substrate such as quartz disk  whose end groups can react with each other. There are a number of flexibilities offered by PEG: easily changed molecular configuration, number of branches, type of end groups, and length of the arms, which offer a great platform for hydrogel reinforcement  when changing the molar ratio of folic acid to zinc ions from 1.7 to 2.0. The adjustable mechanical properties could be invaluable to suit the requirements for repairing various biological tissues from cartilage to cancellous bone. Moreover, the simple preparation, excellent printability, biocompatibility, and mechanical properties of supramolecular hydrogels provide an excellent platform in applications such as drug delivery.Wang and colleagues , where each network is connected by covalent bonds, and ion-covalent entanglement networks (ICEs), where two networks rely on ionic bonds and covalent bonds, respectively  as well as a high adhesion energy, above 5,000 J m−2. The prepared double network structure can also withstand swelling.The extensive presence of covalent bonds ensures that there is a substantial bond energy within the DNs. However, a long bonding time is required for the DNs, which might compromise their self-support ability following a bioprinting process. The interpenetrating networks of long-chain and short-chain molecules equip the DNs an excellent elasticity under deformation of up to 50%. The short chain network in the DNs would collapse first to dissipate energy, followed by the disintegration of the long chain network when the DNs undergoes a large deformation. Since the rupture of the DNs network is irreversible, their overall mechanical properties are primarily determined by the long-chain network that has a better elasticity than the short-chain network provides. For example, two networks, a hydrogel network and a hydrophobic elastomer network containing interlink initiators, were printed simultaneously , such as hydroxyapatite NPs, Fenanofibers , bacterial nanocellulose (BNC), cellulose nanofibers (CNF), microfibrillated cellulose (MFC), cellulose microfibrils, and nanowiskers   bioprinting method has been developed in recent years , agarose and gelatin undergo a reversible volume change due to the collapse or expansion of the polymer chains in the solvent at lower critical solution temperature (LCST) or upper critical solution temperature (UCST) (Altomare et al., According to the nature of the triggering mechanisms, the stimuli used in 4D bioprinting are categorized as physical stimuli such as temperature, electric field, magnetic field, acoustic, light, shear stress; chemical stimuli including pH, ions and gases; and biological stimuli such as enzymes (Koetting et al., Materials that are responsive to the pH of the surrounding medium have equally been widely used in tissue engineering – they are polyelectrolytes that contain functional groups such as carboxyl, sulfonic, phosphate, and pyridine (Dai et al., 2+ and Zn2+. Changing ion types or concentrations will affect the magnitude of the electrostatic interaction and consequently control the mechanical properties of the hydrogels (Zhou et al., 2+ has been widely applied in bioprinting (Rastogi and Kandasubramanian, The same configurational transition mechanism can be applied for ion-responsive materials where the crosslinking and dissociation of the polymer chains are dependent on ions such as CaAlthough reconstructing the structure and function of a defective bone tissue is an extremely complex process, bioprinting technique has shown a spectrum of great advantages in fabricating biomimetic implants, with significant progress being made in the selection of bioink components, the processibility of hydrogel-based bioink formulations, and the compatibility and mechanical properties of the biomimetic scaffold. However, bionic scaffolds are not as “intelligent” as natural tissues yet. It remains a pressing and significant challenge to improve the bioink formulation to improve the dynamic relationship between natural tissues, cells, and the environment. A comprehensive understanding of the composition of the specific osteoblast extracellular matrix (Lamers et al., in situ vascularization of tissue repair. To improve the mechanical properties of the bionic bone tissue, one could consider a combinatorial approach of the enhancement strategies reviewed here: their synergistic effects warrant some in-depth investigations.It appears that an improved biocompatibility, using smart materials, will facilitate the differentiation and proliferation characteristics of the encapsulated stem cells (Anjum et al., Designing novel bioink formulations, in conjunction with using 4D bioprinting technology, to fabricate a scaffold with desired properties such as environmental sensitivity have shown significant progress and great potential. However, the complexity of the process, technique, and materials involved in reconstructing a defective bone tissue remain a challenging task. In this review, various requirements of the bioink/scaffold used for bone regeneration have been systematically discussed, and complemented with exemplar studies. The mismatched characteristics offered by the hydrogels used in the repair of hard tissues will certainly prompt the research communities to develop new solutions based on the existing reinforcement technologies. It is highly desirable to construct scaffolds replicating natural tissues in the ability of stem cell proliferation and differentiation, biomimetic material degradation, matrix remodeling, etc. Adding suitable smart materials to the bioink formulations could open up new opportunities to trigger shape transformation and adjust the aforementioned factors under specific environmental changes.NL drafted the original manuscript with contributions by RG and ZZ. NL and ZZ contributed to the revision of the draft. ZZ and RG contributed to the supervision, validation, and funding acquisition. All 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.


Side effects caused by the concomitant irradiation of normal tissue during radiotherapy for cancer treatment can negatively affect the patient’s quality of life and limit the radiation dose that can safely be administered to the tumor. Recently, considerable developments have been achieved in radiotherapy and imaging technologies, allowing the selective sparing of the regions within organs that contribute most to the development of these side effects. This review discusses regional variation in the response to radiation in several organs, including the brain, salivary glands, cardiopulmonary system, pancreas, and bladder. Regional responses are shown to originate from general principles, such as the localization of target cells or function. We conclude that regional responses are a general phenomenon that should be studied in other organs. This will facilitate further optimization of the use of modern radiotherapy technologies.Normal tissue side effects remain a major concern in radiotherapy. The improved precision of radiation dose delivery of recent technological developments in radiotherapy has the potential to reduce the radiation dose to organ regions that contribute the most to the development of side effects. This review discusses the contribution of regional variation in radiation responses in several organs. In the brain, various regions were found to contribute to radiation-induced neurocognitive dysfunction. In the parotid gland, the region containing the major ducts was found to be critical in hyposalivation. The heart and lung were each found to exhibit regional responses while also mutually affecting each other’s response to radiation. Sub-structures critical for the development of side effects were identified in the pancreas and bladder. The presence of these regional responses is based on a non-uniform distribution of target cells or sub-structures critical for organ function. These characteristics are common to most organs in the body and we therefore hypothesize that regional responses in radiation-induced normal tissue damage may be a shared occurrence. Further investigations will offer new opportunities to reduce normal tissue side effects of radiotherapy using modern and high-precision technologies. Radiotherapy remains a mainstay in cancer treatment. Over 50% of cancer patients receive radiotherapy ,2, accouTo achieve this, radiotherapy technology is continuously being developed to improve precision. Examples of such developments are transitions from early photon-based techniques, like 3D conformal radiotherapy, to more recent techniques such as intensity modulated radiotherapy, volumetric modulated arc therapy, and the use of image-guidance. In addition, the use of particle-based therapies is increasing. Due to their physical properties, particles often allow a large reduction in dose to the normal tissues. In contrast to photons, most of the energy of charged particles is released in the Bragg peak, which can be positioned to the target volume . Each ofThe increased precision of modern radiotherapy technologies can be used to spare radiosensitive tissues. The term radiosensitivity is broadly used in radiation oncology as the susceptibility to develop radiation-induced side effects ,6. RadioA number of preclinical and clinical studies have tried to identify such regions/structures within tissues and organs. In this review, we discuss regional variation in radiation-induced normal tissue damage in several organs, addressing whether they play a significant role in their functional response. We discuss if these regional responses are rare or if their occurrence in organs can be considered a general phenomenon.The radiation-induced side effects of the brain include neurocognitive dysfunction, endocrine dysfunction, and neurosensory impairment ,12,13. BThe hippocampus is a bilateral structure located in the brain temporal lobe. The hippocampus consists of several sub-structures, including the dentate gyrus (DG) containing the subgranular zone (SGZ). Together with the subventricular zone (SVZ) of the lateral ventricles, the SGZ is considered the primary region of neurogenesis in the adult mammalian brain . The maiIrradiation of the hippocampus leads to early loss of proliferating progenitor cells and immature neurons in the SGZ . Whole-bIn patients, a reduction in hippocampal volume has also been reported after radiotherapy ,25,26 anA correlation between dose to the hippocampus and verbal recall was found in adult patients in 6- to 18-month follow-up studies ,34,35. BSimilar to the SGZ, irradiation of the SVZ leads to apoptosis of neural progenitor cells ,38. HoweThe risk of contrast-enhancing brain changes on magnetic resonance imaging (MRI) is increased in the periventricular region after irradiation ,43. ThesTo what extent irradiation of the SVZ contributes to radiation-induced neurocognitive decline is still unclear. Studies in pediatric patients have not found a correlation between dose to the SVZ and cognitive decline ,44. In cThe cortex is important for several higher-order cognitive processes. It consists of four major lobes: the frontal, occipital, parietal, and temporal lobes. Radiotherapy can cause dose-dependent cortical thinning, which is associated with cognitive decline . Dose-deRadiation dose to the temporal lobe has been associated with memory impairment in both pediatric ,52,53,54Oligodendrocytes are glial cells whose main function is the insulation of axons with myelin sheets, thereby protecting the neurons and facilitating fast conduction of signals along the axons. In the brain, outside of the SVZ and the SGZ, the majority of cycling cells are oligodendrocyte precursor cells (OPCs). OPCs can undergo apoptosis within days after irradiation, followed by progressive demyelination months later . RemyeliRadiation-induced WM changes can be monitored longitudinally using MRI-based imaging techniques, such as diffusion tensor imaging ,60. WM vLittle is known about subregional differences in WM sensitivity. A small clinical study with 22 patients showed increased WM damage in the frontal lobe compared to the parietal lobe in pediatric medulloblastoma survivors who received the same radiation dose to both regions . The froThese effects might not all be due to direct irradiation of the WM. Beera et al. reported that focal irradiation of the WM region anterior commissure in young mice did not lead to a volume reduction in this region. In contrast, irradiation of two non-WM regions, the olfactory bulb and the SVZ, resulted in a volume reduction in the anterior commissure and other WM regions . This inPosterior fossa tumors, located near the brainstem and the cerebellum, account for more than half of all pediatric brain tumors and 20% of all adult brain tumors. Progressive neurocognitive decline is frequently seen in these patients; however, the effect of radiation on the normal tissue of the cerebellum is not well understood . The cerIn addition to motor function, the cerebellum contributes to neurocognitive tasks such as language, processing speed, and working memory. Specifically, the posterior cerebellum is engaged during cognitive processing . RadiatiIrradiation of the hypothalamus and anterior pituitary gland can lead to endocrine dysfunctions, which are common in both pediatric and adult patients ,82.The hypothalamus and pituitary gland are localized close together and interact via the hypothalamic–pituitary–adrenal and –gonadal axis. Several studies showed primary function loss of the hypothalamus . Growth The optic nerve—which is the structure connecting the retina to the brain—, and the optic chiasm—the region of the brain where the optic nerves cross, which is important for the transmission of the visual information from the optic nerve to the occipital lobe of the brain—are both seen as organs at risk in brain and head and neck tumors . IrradiaThe spinal cord is an organ at risk in the treatment of many tumors as well as metastases . DependiIn rats and swine, neurological symptoms following irradiation of the cervical spinal cord were primarily related to WM necrosis, without clear damage to the grey matter c 88,89,,89,90,91The use of radiotherapy in head and neck cancer patients inevitably comes with exposure to radiation of normal tissues such as the salivary glands. Dysfunction of salivary glands can lead to secondary complications such as xerostomia, loss of teeth, and problems with eating, speaking, and sleeping, which all strongly impact the patient’s quality of life ,96,97. TMorphologically, the parotid gland consists of a ductal system that branches from the excretory duct toward their secretory units, the acini, both supported by stromal tissue. The acinar cells are capable of transporting water from the adjacent vasculature into the ductal system . In ratsThe localization of these two cell populations may lead to regional variations in radiation response. Loss of saliva production was more pronounced after irradiation of the cranial half of the rat parotid gland compared to the caudal half . This enThe current clinical approach to minimizing the risk of xerostomia is preservation of salivary function by minimizing the dose to the parotid glands in treatment planning. Several studies have indicated that post-radiotherapy parotid gland function and xerostomia are better predicted by dose to regions or spatial features of the dose distribution ,114,115.As frequently noted by authors of studies reporting regional or voxel-wise analyses, strong correlations between doses in different regions or even organs complicate the interpretation of the results. However, the combination with independent development and testing of the hypothesis in preclinical models provides confidence in the interpretations described above .The saliva production and composition of the different glands varies with time of the day. For example, the parotid gland produces almost no saliva at night ,121,122.In the treatment of thoracic tumors, coincidental dose to heart and lungs frequently leads to side effects such as pericarditis, cardiomyopathy, or myocardial fibrosis in the heart occurring months to years after radiotherapy, and early pneumonitis and late pulmonary fibrosis in the lungs. To address this, current practice is to minimize mean lung dose (MLD), mean heart dose (MHD), and/or volumes of these organs receiving a specified minimum dose . HoweverIn several preclinical studies in mice and rats, more pronounced effects in terms of survival and respiratory rate enhancement were observed after irradiation of the basal parts of the lung compared to the apical parts ,131,132.The effect of lung irradiation is not limited to the irradiated part, but also occurs in surrounding shielded tissue ,135,136.In addition to the alveoli, the pulmonary vasculature was found to be a target for radiation-induced loss of function . Damage A relation between the irradiation of different lung regions and the occurrence of radiation-induced lung injury was also reported in patients. Dose to patient-specific regions exhibiting a higher density before radiotherapy was predictive of post-treatment damage. These regions were mainly found in the base of the lung, likely indicating functionally important areas . InteresAs the heart is an organ which consists of several different structures important for organ function, like valves and big vessels, it is likely that there are differences in the radiation response of these structures. Since precise irradiation of specific structures of the heart is challenging in small animal models, only few preclinical studies on the sensitivity of cardiac substructures are available . A recenThese findings are in line with several studies in patients reporting associations between dose to structures at the base of the heart and outcome. In studies in non-small cell lung cancer (NSCLC) patients, non-cancer mortality was associated with irradiation of upper regions of the heart, including big vessels  and the right atrium ,143,144.Clinically, both lung and heart frequently receive a non-negligible radiation dose that can lead to radiation-induced side effects. In rats, an enhancement of radiation damage was found when irradiating both heart and lung . In thisClinical studies regarding the impact of heart irradiation on lung function had varying outcomes and conclusions. A large retrospective study including around 600 patients did not find an impact of heart irradiation on lung function , whereasThe pancreas has both endocrine and exocrine functions. Radiation-induced injury of the endocrine pancreas is known to increase the risk of diabetes mellitus ,151.The concentration of islets of Langerhans is higher in the pancreatic tail than in the rest of the pancreas  Figure c. RetrosRadiotherapy remains a mainstay in the management of cancers in the pelvic region, including cancers to the rectum, urinary bladder, uterus, ovary, and prostate. Bladder irradiation is associated with acute and late genitourinary (GU) side effects such as cystitis. This affects the quality of life of a significant portion of patients . A revieThe trigone is a triangular region located at the bladder base just above the bladder neck. Its functions include preventing urine reflux and signaling the need for voiding . A numbeAs the life expectancy of cancer patients increases, reducing radiotherapy-induced side effects is becoming more important to preserve post-treatment quality of life. Continuous improvements in radiotherapy technologies allow further reduction in radiation dose to normal tissues as well as specific sparing of regions and sub-structures of organs. As indicated by the reviewed literature, a considerable reduction in side effects may be achieved by selective sparing of specific regions within organs. In various organs regional responses have been identified. Examples include critical roles of the hippocampus in cognitive dysfunction, the ductal region of the parotid gland in hyposalivation, and the tail of the pancreas in diabetes in patients ,110,151.Several approaches to obtain insight into regional effects have been used and were described in the above organ-specific sections. Clinical studies benefit from directly investigating radiation-induced side effects and their impacts in patients. However, the multidisciplinary nature of oncological treatments creates challenges for specifying the contribution of radiotherapy to side effects. For example, recent studies using immunotherapy and radiotherapy have highlighted an increased risk of developing MRI-based imaging changes  and sideNevertheless, preclinical studies are also subject to limitations that are not always recognized. Biological responses are often strongly species-dependent . ExampleA common challenge in clinical and preclinical work is that more detailed regional responses can only be investigated when technology is available. Clinically, association studies aiming at detecting regional variations require that the technology used can deliver radiation dose distributions with sufficient spatial variation to induce a detectable impact of regional responses on the clinical side effect. This implies that available clinical data usually lack information on the potential impact of the use of new, improved-precision radiotherapy when the latter becomes available. In this setting, the hypotheses generated in preclinical research can contribute to the optimal use of unique features of this new technology. The role of preclinical research for this purpose may increase with the recent availability of dedicated small animal irradiators in combination with the availability of histological information at the cellular level that can potentially be overlaid with the given radiation dose .As indicated, regional responses may be a common phenomenon. Several organs would be of particular interest to study. The kidney consists of structurally separated tissues with several potential stem and progenitor cell niches . RadiothThis review discussed current pre-clinical and clinical evidence of regional responses in radiation-induced normal tissue damage in a number of organs at risk for development of side effects after radiotherapy. These regional responses were shown to originate from rather general principles, which are present in most organs. Taken together, we conclude that regional responses are a general phenomenon that needs to be studied in other organs to facilitate further optimization of the use of modern technology in radiotherapy.


Children with critical illness frequently manifest imbalances in hemostasis with risk of consequent bleeding or pathologic thrombosis. Traditionally, plasma-based tests measuring clot formation by time to fibrin clot generation have been the “gold standard” in hemostasis testing. However, these tests are not sensitive to abnormalities in fibrinolysis or in conditions of enhanced clot formation that may lead to thrombosis. Additionally, they do not measure the critical roles played by platelets and endothelial cells. An added factor in the evaluation of these plasma-based tests is that in infants and young children plasma levels of many procoagulant and anticoagulant proteins are lower than in older children and adults resulting in prolonged clot generation times in spite of maintaining a normal hemostatic “balance.” Consequently, newer assays directly measuring thrombin generation in plasma and others assessing the stages hemostasis including clot initiation, propagation, and fibrinolysis in whole blood by viscoelastic methods are now available and may allow for a global measurement of the hemostatic system. In this manuscript, we will review the processes by which clots are formed and by which hemostasis is regulated, and the rationale and limitations for the more commonly utilized tests. We will also discuss selected newer tests available for the assessment of hemostasis, their “pros” and “cons,” and how they compare to the traditional tests of coagulation in the assessment and management of critically ill children. Hemostatic dysfunction and resultant pathologic bleeding and/or thrombosis is a common complication of critical illness in children. There are several important considerations of this dysfunction that are imperative for accurate diagnosis and clinical management in the pediatric population. First, the hemostatic system changes and develops from birth to infancy, childhood, adolescence, and ultimately adulthood. Understanding this evolution is important in the interpretation of physiologic and pathologic hemostasis. Second, traditional tests of hemostasis have focused on platelet count and plasma-based measurements of clot formation. There are limitations in this traditional approach including lack of consideration for (1) platelet function and activity, (2) the imperfect sensitivity of plasma-based tests, particularly to abnormalities in fibrinolysis and conditions of enhanced clot formation, (3) the critical role of the endothelium in hemostasis and crosstalk between the endothelial, inflammatory, and coagulation systems, and (4) the stages of clot formation and lysis over time. Newer studies address some of these challenges by directly measuring thrombin generation in plasma and assessing the stages of hemostasis in whole blood. Successful diagnosis and management of hemostatic dysfunction in critically ill children requires both an age-dependent understanding of clot formation and regulation of hemostasis as well as of the strengths and weaknesses of the tests employed.Hemostasis is the normal physiologic process by which blood is maintained in fluid state while also allowing for blood clot formation at the site of injury maintaining the integrity of the closed circulatory system after vascular damage . It is aThe hemostatic process starts with injury to the vascular endothelium . The undPlatelet activation and adhesion upon exposure to vascular injury occurs in a highly coordinated method involving tethering, rolling, activation, and firm adhesion , 5. The After platelet binding to subendothelial structures and subsequent signaling to the platelet cytoplasm, platelet granules fuse with the open canalicular system of the platelet membrane and empty their contents into the local environment. The paracrine and autocrine nature of these bioactive contents causes increased activation of nearby platelets in both number and degree . This reThe soluble phase of clotting primarily involves the clotting cascade , 2 13)..13). In The clotting cascade is initiated through the extrinsic pathway and starts with exposure of tissue factor (TF) at the site of injury. Blood is exposed to TF either directly by the subendothelial matrix or by cytokine-induced expression on endothelial cells or activated monocytes , 15. PlaThe intrinsic or contact activation pathway is initiated through the interaction of negatively charged surfaces resulting in the activation of factor XII, high-molecular-weight kininogen, and plasma kallikrein among others . ActivatFrom there, both the extrinsic and intrinsic pathway proceed to the common pathway. Factor V, which is released from platelet α-granules, is cleaved by thrombin to form activated factor V , 23. ActIntrinsic to the built-in amplification systems of formation of the platelet plug and the coagulation cascade, hemostasis also requires highly regulated mechanisms of control of clot extension and termination of clot formation . SystemiCessation of clot formation is critical in maintaining a targeted response and mediating the extent of the clot. Clot termination involves two key components, antithrombin  and the protein C pathway. AT is a serine protease inhibitor that neutralizes many enzymes in the clotting cascade by irreversibly binding to them . Its funAlso important to the limitation of clot formation is the regulation of vascular and platelet reactivity which is primarily modulated through prostacyclin, thromboxane, and nitric oxide. Specifically, undisturbed endothelial cells adjacent to endothelial injury release arachidonic acid which is subsequently converted to thromboxane A2 by cyclooxygenase-1 in platelets and prostacyclin via cyclooxygenase-1 on the endothelium . ProstacClot removal following hemostasis is achieved through fibrinolysis. Central to this process, plasmin is formed from the cleavage of plasminogen by bound fibrin and tissue-type plasminogen activator , 39. UroThe above discussion focuses primarily on plasma proteins with only limited mention of the role cellular components play in hemostasis. Indeed, a major limitation of plasma-based coagulation tests is that they do not take into consideration the myriad roles platelets, endothelial and leukocytes play in this process . PlateleDevelopmental hemostasis describes the physiologic changes that occur with an increase in age. These changes are particularly relevant in the pediatric population from birth through infancy when plasma levels of several important procoagulant and anticoagulant factors rapidly increase or decrease to normal adult levels. Because of the dynamic development of the hemostatic system, an understanding of age-specific physiology and quantification of normal reference ranges for coagulation parameters is of particular importance in pediatric medicine.Early study of developmental hemostasis included the establishment of reference ranges for basic global measures of coagulation in infants using cord blood , 47. And1-antitrypsin, α2-antiplasmin, α2-macroglobulin, and C1 esterase inhibitor were noted to be at normal or somewhat supra-normal adult levels at birth. Globally, both prothrombin time (PT) and activated partial thromboplastin time (aPTT) were prolonged in neonates. While there was wide variation in normal PT in infancy, mean PT normalized to adult levels by 1 month of age whereas aPTT normalized by 6 months of age .–55.51–55Monagle et al. described elevated D-dimer, reduced TFPI, and reduced endogenous thrombin potential in healthy neonates and children compared to established adult values . Appel e2-macroglobulin, is less efficient than is AT. However, other studies have shown that thrombin generation  is “normal” in infants if measured in the presence of added thrombomodulin and that thrombin generation in very pre-term newborns is not different than that in near term infants  knowledge of different hemostatic testing options, (2) an understanding of the strengths and weaknesses of each test, and (3) an awareness of utility in the pediatric population, particularly in the context of the developmental hemostasis consideration discussed above. The following are key tests of pediatric hemostasis with specific focus on platelet evaluation, clotting assays, and global measures. Logistics of testing as well as strengths and weaknesses are summarized in ex vivo was possible  was the first, and remains one of the only, test to evaluate assessed , 76. Forassessed , 105. Thonsuming , 105.in vivo following vessel injury. The hemostatometer, a commercially available clot signature analyzer, punches holes within a tube containing flowing anticoagulated blood. Under controlled conditions, the punched holes stimulate formation of the primary platelet plug and allow for the assessment of platelet function and of involvement of GPIb, GPIIb/IIIa, and vWf  platelets . Nucleicin vivo clotting measure the conversion of fibrinogen to fibrin and utilize the time to formation of a fibrin clot as determined by one of several methodologies each of which have a different degree of sensitivity. The most common of these tests are PT, aPTT, and thrombin time (TT) (The most commonly utilized tests measuring the effectiveness of ime (TT) . A few iime (TT) , 85. Secime (TT) . While tin vitro and in vivo factors that do not have any effect on in vivo clot formation  and the related rapid thromboelastography (r-TEG) as well as rotational thromboelastography (ROTEM) . In bothViscoelastic testing measures clot initiation or time to initial clot formation, kinetics or growth of the clot, clot strength, and clot lysis. All components are identified by specific measurements on a tracing produced by the device over time. Clot initiation or clot time provides an assessment of early activity of the clotting cascade before clot amplification and the burst of thrombin production. Clot kinetics or clot formation time assesses clot potentiation by activation of platelets and thrombin-mediated cleavage of soluble fibrinogen. Clot strength describes maximal clot strength achieved via GPIIb/IIIa-mediated platelet-fibrin interactions. Finally, clot lysis provides an assessment of activation of the fibrinolytic system , 92, 93.The diagnostic and prognostic role of viscoelastic testing is being studied in a range of clinical areas , 92, 93.Endogenous thrombin generation is a measure of the global efficiency of coagulation as thrombin sits at the key intersection of endothelial cell, platelet, and coagulation activation, clot formation, and fibrinolysis. Thrombin generated can be quantified in platelet-rich or platelet-poor plasma using the calibrated automated thrombogram (CAT) method. Specifically, CAT monitors the cleavage of a fluorogenic substrate that is compared to the known thrombin activity in a non-clotting plasma sample . The CATAnother potentially promising method is sonic estimation of elasticity via resonance. This technology applies acoustic radiation force to induce shear wave resonance within a rigid test chamber. The characteristics of this resonance are compared to numerical or analytical models to quantify the sample filling the chamber , 117. ThThere are a number of additional considerations in the assessment of hemostasis in the pediatric population. First, there are numerous technical challenges. This includes practical difficulty drawing sufficient blood volume from small infants and children given their small vessels for certain tests  and the overall smaller total blood volume infants and children which limits the quantity of blood that can safely be obtained to perform comprehensive diagnostic testing. Consequently, tests that use small volumes may be preferred and careful consideration is necessary to parsimoniously select appropriate tests given the clinical situation. While central lines help with the technical difficulties of obtaining adequate testing volumes, samples can be contaminated by anticoagulation or other medications running through the line itself. In fact, samples collected through central lines may require 10 mL of blood be withdrawn prior to sample collection for the result to be considered valid. Techniques to mitigate this waste include using the initial sample collection for other labs or reinfusing blood that would otherwise be discarded.There are also a number of infant and pediatric conditions and diseases that require special testing considerations. Pediatric trauma patients, particularly infants, demonstrate significant endothelial injury, present with acute traumatic coagulopathy and/or coagulopathy related to iatrogenic causes, and, while they may be at less risk of bleeding than their adult counterparts, they are also at risk of thrombosis during recovery from their injury –123. Whiex vivo. This practice does not account for the primarily anti-IIa action of UFH potentially introducing a degree of uncertainty regarding the extrapolated therapeutic threshold  tests of hemostasis have only recently been investigated in this patient population , 137. WhUnderstanding of hemostatic dysfunction remains a unique challenge in critically ill infants and children. It requires knowledge of physiologic hemostatic pathways, comprehension of the development of the hemostatic system by age, an understanding of logistics, advantages, and limitations in hematologic testing, and an awareness of the specifics of application to pediatric populations. Taken together, this knowledge will enable the practitioner to more accurately assess hemostatic dysfunction and determine bleeding and thrombosis risk resulting in more successful diagnosis and management of this vulnerable population.AN drafted all tables included. RP created all figures included in manuscript. Both authors participated in reviewing appropriate published literature, writing all drafts, and the final submitted draft manuscript.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.


The use of synthetic fungicides represents the most common strategy to control plant pathogens. Excessive and/or long-term distribution of chemicals is responsible for increased levels of environmental pollution, as well as adverse health consequence to humans and animals. These issues are deeply influencing public perception, as reflected by the increasing demand for safer and eco-friendly agricultural commodities and their by-products. A steadily increasing number of research efforts is now devoted to explore the use of safer and innovative approaches to control plant pathogens. The use of microorganisms as biological control agents (BCAs) represents one of the most durable and promising strategies. Among the panoply of microbial mechanisms exerted by BCAs, the production of volatile organic compounds (VOCs) represents an intriguing issue, mostly exploitable in circumstances where a direct contact between the pathogen and its antagonist is not practicable. VOCs are potentially produced by all living microorganisms, and may be active in the biocontrol of phytopathogenic oomycetes, fungi, and bacteria by means of antimicrobial activity and/or other cross-talk interactions. Their biological effects, the reduced residuals in the environment and on agricultural commodities, and the ease of application in different agricultural systems make the use of VOCs a promising and sustainable approach to replace synthetic fungicides in the control of plant pathogens. In this review, we focus on VOCs produced by bacteria and fungi and on their role in the cross-talk existing between the plant pathogens and their host. Biologic systemic effect of the microbial volatile blends on both pathogen and host plant cells is also briefly reviewed. Aspergillus fumigatus and other human pathogenic fungi to azoles  as reviewed by Synthetic biocides are the major route to control plant pathogens . HoweverThese reasons have a strong influence on the public perception and market demand, posing the need to move toward the production of pesticide-free commodities, in a healthier and more ecologically friendly context. In this view, a promising pest management alternative is represented by the biological control approach, where the human intervention exploits the natural antagonistic effects of some agents  to mitigate the detrimental effects of pathogenic (micro)organisms . BiologiOther pathogen suppression mechanisms include the production of volatiles, antibiotics, and other secondary metabolites of the microbial lifecycle. Volatile organic compounds (VOCs) production is gaining a constantly increasing interest by the scientific community, owing to the diverse advantages of their application. VOCs are a blend of volatile metabolites potentially produced by all living microorganisms and were observed to be active in the control of phytopathogenic oomycetes, fungi, and bacteria by means of antimicrobial activity and other cross-talk interactions. Their antimicrobial effects, along with the reduced hazard for both environment and human beings and their possible application without the need of a supplemental spray or drench, make the use of VOCs a promising and sustainable approach to replace fungicides of synthetic origin in the control of plant pathogens .In the current review, we focus our attention on the VOCs production by BCAs, intended as active effectors of the dynamic network of cross-relations existing among microbial entities and their host. Their potential exploitation as effective mechanisms to control the causal agents of diseases of economically relevant plants is discussed.The volatile metabolites of both microbial and plant origin are gaining a steadily increasing interest, and the term “volatilome” has been relatively recently adopted to refer to this complex heterogeneous ensemble of metabolites .2, H2, N2, O2, NH3, H2S, NO2-, SO2, SO3, and HCN are the most relevant and are involved in a wide variety of biological functions ranging from electron acceptors/donor to acting as defense compound , carbon-based molecules featured by a low water solubility and a high vapor pressure that makes them available in a gaseous status in the normal ambient conditions  . From a In agriculture, the use of VOCs of microbial origin in the biocontrol of plant pathogens has received a reduced marginal in the past years; however, progresses recently made, along with the overall tendency of the scientific community toward the adoption of a holistic approach, highlighted the potential benefits of microbial VOCs in this field.VOCs are generally effective already at a very low concentration . Being vBiosynthetic pathways leading to the production of microbial VOCs are yet poorly understood; however, omics-based studies so far performed link the VOCs production to either metabolic transformation products of lipids, proteins, and other building blocks of living tissues, or as the result of degradation  of catabolic reactions . On thisThe composition of microbial VOC blends depends on several factors. These include the microbial entities  producing the VOCs, the substrate they are grown on, temperature, radiation, presence of other microorganisms, and the type of ecosystem . Also, VRegardless of the emitting species and the specific VOCs blend composition, several studies are nowadays being performed with the aim to exploit the countless benefits of employing a natural antimicrobial mixture to prevent plant pathogens by replacing traditional chemical approaches. Unanimously, studies performed so far recommend VOCs application under air-tight environment, in order to rapidly saturate the atmosphere with the volatile antimicrobials. Particularly effective application of VOCs is reported in the control of storage pathogens on fresh fruit  but also other commodities such as nuts, grains, and seeds .Bacteria produce volatile metabolites as part of their normal metabolism . BacteriIn this view, only a handful of studies have so far been performed to elucidate the metabolic effects of the bacterial volatilome on the target organism, while it is well known that bacteria-derived VOCs have a pivotal role in stimulating or repressing other bacterial species .Bacillus amyloliquefaciens strain SQR-9 has been reported as effective against the tomato wilt pathogen Ralstonia solanacearum . Growth inhibition was dependent on the BCA load; however, the inhibitory effects produced by the bacterial VOCs were reversed by BCA removal, indicating a bacteriostatic effect of the B. amyloliquefaciens-derived VOCs on R. solanacearum  effect; it may also imply a synergistic/cooperative activity among bacterial species. A recent investigation performed on soil bacteria showed that the volatilome of four genetically diverse isolates results in antithetical phenotypes of  strains .Besides intra-kingdom interconnections, bacteria are also involved in sophisticated bi-directional cross-talks involving phylogenetically higher species such as fungi and plants: bacteria-fungi interactions are very dynamic, depending on the interacting species and are strongly exploited in the modern agricultural practice to control important phytopathogenic taxa .S. plymuthica, Serratia odorifera, Stenotrophomonas maltophilia, Stenotrophomonas rhizophila, P. fluorescens, and Pseudomonas trivialis are known to produce VOCs mixtures with antifungal properties active against a wide array of both pathogenic and non-pathogenic fungi , A. flavus, Aspergillus ochraceus, Aspergillus niger, and Penicillum citrinum , and ocimene were considered as the most effective ones , represents the first commercially available BCA acting through its volatilome  yielded over 50 isolates, among which A. niger was found to produce high amounts of 2-phenylethanol  emits a mixture of volatile metabolites including sabinene, 1-butanol, 3-methyl, benzene ethanol, 1-propanol, 2-methyl, and 2-propanone. An artificial mixture of such volatiles had remarkable antifungal properties against several oomycete and fungal pathogens, including Pythium, Phytophthora, Sclerotinia, Rhizoctonia, Fusarium, Botrytis, Verticillium, and Colletotrichum spp. In addition, the fungus was shown to tolerate and survive in the presence of the volatile metabolites produced by the antagonistic M. albus  have shown that the antimicrobial effectiveness of yeast-derived volatilome is mainly attributed to ethyl acetate, enabling for a successful control of Penicillium roqueforti during air-tight storage of grain  both in vitro and in planta  and of two low-fermenting (C. intermedia and Lachancea thermotolerans) yeast strains, resulting in the inhibition of both mycelial growth and toxigenic potential of the pathogen Aspergillus carbonarius. Subsequently, the chemical composition of the four yeast strains volatilome was characterized: although more than 20 different compounds were identified as components of the yeast-derived volatilome, 2-PE was found to be the most abundant one in all tested volatile blends (C. intermedia volatilome in the inhibition of the ochratoxin A (OTA) producing fungus A. carbonarius revealed that yeast VOCs target a plurality of fungal metabolic routes, inducing a marked reduction of the protein biosynthetic activity, proliferative activity, energy metabolism, and inhibiting the fungal detoxification system. Nevertheless, exposure to the sole 2-PE  can only partially reproduce the metabolic alteration provoked by the whole yeast-derived volatilome, thereby suggesting that other minor and still unidentified yeast VOCs components are likely to involve a plurality of metabolic targets, resulting in a higher effectiveness of the treatment over the long-term period . Moreover, by analogy with animal-oriented research  that should allow better handling, storage, and safe deliver to open fields .Microbes produce a wide array of volatile metabolites linked to a complex network of interactions, involving intra- and inter-species relationship. Most of the studies so far performed have focused on the unidirectional effect of the microbial VOCs produced by a single microbial entity in regard to another microbial species or strain . AlthougMoreover, we are now suffering from a lack of knowledge related to VOCs emission by protists, archaea, or other rhizosphere organisms, such as nematodes or earthworms . These gAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.