Handheld echocardiography is being proposed as the fifth pillar of bedside physical cardiovascular examination (PE) and is referred to as insonation. Although there is emerging consensus that insonation is superior to PE for diagnosis of various cardiac conditions, superiority has not been consistently demonstrated for various valvular heart disease (VHD) lesions. The objective of this review is to systematically review the accuracy of insonation and auscultation in published literature for detection of common VHD.An extensive literature search across three commonly used public databases allowed comparison of diagnostic characteristics of insonation and auscultation for common VHD including aortic stenosis, mitral regurgitation, aortic regurgitation, tricuspid regurgitation. Sensitivity, specificity, and accuracy of insonation and auscultation for the detection of these VHD lesions were extracted for further analysis. The quality of evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.Eight hundred eighty studies were screened, and seven observational studies were selected for full analysis. Due to heterogeneity of data, this study was not amenable to meta-analysis. Insonation was superior to auscultation for the detection of all regurgitant lesions, but there was no significant difference in diagnostic ability of the two strategies for detection of aortic stenosis.Compared to auscultation, insonation, in its currently available form, is a superior diagnostic tool for regurgitant lesions. However, insonation fails to improve upon auscultation for recognition of aortic stenosis. This limitation is likely due to absence of spectral Doppler and inability of HE to assess transvalvular velocity and gradient. Physical examination has remained the mainstay for bedside diagnosis of cardiovascular disease for centuries. Despite this, physical examination alone has limitations and has been subjected to increasing uncertainty in an era of evolving and advancing technology. In the last decade, handheld echocardiography (HE) has emerged as a novel and innovative adjunct to rapid diagnosis of disease 23.2The accuracy of auscultation for detection of cardiac pathology is variably subjective and highly performer dependent with low interobserver consistency 5. Althou6Recent American and European consensus guidelines have endorsed use of HE as a screening measure and an extension, not a replacement, to physical examination 9. It has1112131617In view of these facts, we conducted a systematic review of the available evidence on utility of HE in assessment of VHD. The purpose of this review was to: (1) synthesize the current literature examining both sensitivity and specificity of HE in VHD; (2) compare the diagnostic power of HE with auscultation; and (3) ascertain the limitations of HE in diagnosing VHD. We hypothesized that HE improves clinical assessment of valvular regurgitant lesions more robustly than stenotic lesions.This systematic review was conducted as specified by Preferred Reporting Items for Systematic Reviews (PRISMA).We conducted a systematic search across multiple databases including MEDLINE Ovid, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase to identify relevant articles published between January 1, 2000, to January 20, 2018. A medical librarian was consulted to optimize the search strategy and identify key search terms.The abstracts of identified publications were screened by two independent reviewers. Potentially eligible articles were then selected for full-text review and compared between reviewers to ensure congruence. Original studies comparing point-of-care ultrasound, with or without physical examination, to traditional physical examination alone were included in this review. Animal studies, conference abstracts, and non-English studies were excluded.Selected studies were extracted in full text and relevant study data were recorded on an electronic data collection sheet. The primary objective was to obtain data regarding the accuracy of point-of-care ultrasound compared to physical examination alone in identifying valvular heart disease. Measured values for sensitivity and specificity of HE were extracted for stenotic and regurgitant lesions as compared to physical examination of the same lesions. In the majority of the selected studies, a valvular lesion was defined as clinically relevant when it was moderate or greater in severity.Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was employed to determine the quality of evidence and the level of potential bias. In short, the GRADE approach assesses the combined quality of evidence for a given intervention by evaluating factors such as the risk of bias and any limitations of the data including incompleteness, imprecision, and indirectness. Using these parameters, the level of evidence for any given intervention was judged as being very low, low, moderate, or high. Two reviewers assigned level of bias and quality (DW and NM). Any discrepancies were resolved by a third-party reviewer (DS).Overall, HE was performed on 2090 patients across all the reviewed studies. The level of training varied in these studies from medical students, to hospitalists, to cardiologists. For the non-cardiologists, didactic and hands-on training  was completed to ensure overall competence in performing HE. Although different pocket-sized technologies were selected in these studies, all handheld devices used were two-dimensional echocardiographic applications with full-scale color flow. However, none these devices had spectral Doppler capabilities. The details of the reviewed studies are outlined in Table Four prospective cohort studies compared the efficacy of HE with physical exam in diagnosing aortic stenosis (AS) 19202122.192021Overall, low-quality evidence demonstrates no statistically significant advantage with HE in comparison to physical examination in detection of AS Table .Physical examination has limited ability in assessment of diastolic murmurs, with sensitivities as low as 14%–33% for diagnosing aortic regurgitation (AR) 2223. In 22Overall, very low-quality evidence supports superiority of HE to physical examination in identification of AR Table .Six prospective cohort studies evaluated the role of HE in detecting mitral regurgitation (MR)  1921. Sim19Overall, low-quality evidence illustrates that HE is a valuable tool in detection of TR Table .The purpose of this review was to rigorously evaluate and summarize, using GRADE methodology, the available evidence underpinning the utility of HE in assessment of VHD, focusing on the comparison of diagnostic power of HE compared to physical examination.Consensus guidelines endorse use of HE as a screening measure and an extension, not a replacement, to physical examination . RecentlOur review examined the diagnostic power of HE compared to physical examination with respect to four common valvular lesions – aortic stenosis, aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. We demonstrated that there is low-quality evidence showing no statistically significant advantage of HE in comparison to physical examination in detection of AS. In the four included studies, there was considerable heterogeneity in performer skillset in HE  and a lack of statistical power due to small sample. Ultimately, these limitations preclude important comparisons. Evidence was also insufficient to draw definitive conclusions from prospective studies with absence of randomization. Furthermore, none of the studies adjusted for potential confounders.Very low-quality evidence supports superiority of HE to physical examination in identification of AR. In general, physical examination has limited ability in assessment of diastolic murmurs. Cohort studies comparing HE to physical exam in evaluation for AR demonstrated that HE consistently improved detection of AR. The overall accuracy and concordance of HE for recognition of AR remained robust. The inconsistencies in quantifying severity of AR were partially attributed to inadequate training of HE performers with respect to the acquisition of color-flow Doppler images 20. DespiWith respect to evaluation of MR, low-quality evidence suggests that HE is markedly superior in screening for MR with a significantly higher sensitivity compared to physical examination. The enhanced diagnostic ability of HE is further pronounced in patients with severe left ventricular dysfunction, a clinical scenario where physical exam is known to more frequently miss or underestimate MR severity . Further2Overall, low-quality evidence illustrates that HE is a valuable tool in detection of TR. As with MR, HE had improved sensitivity in the diagnosis of TR when compared to physical examination. However, definitive conclusions cannot be attained due to small sample size of patients with TR in these studies (cumulative n = 105).Our review has several limitations. First, all of the included studies have inherent significant inter-study heterogeneity, and all of the data comes from observational studies rather than RCTs. Second, for practical reasons, we restricted our search to English-language studies, and thus, may have omitted some relevant studies. Third, as with all systematic reviews, there is potential for publication bias as studies with positive findings are more likely to be published than those with negative findings. Lastly, we were unable to confirm the consistency of valvular diagnoses across the studies. Although the cut-off for clinically relevant lesions were predominantly established as moderate or greater, a few studies included mild valvular pathology in the total number of detected lesions. This could potentially affect the calculated sensitivity and specificity.In conclusion, insonation in its currently available form is more diagnostically useful in the identification of regurgitant lesions. However, insonation fails to improve upon auscultation for recognition of aortic stenosis. This limitation is likely due to absence of spectral Doppler and inability of HE to assess transvalvular velocity and gradient.


Individual differences affect the behavior of individuals in response to chronic pain, and such behaviors can lead to either disability or capacity . Their study, which includes seven articles in a narrative review, delineates the contribution of individual and parental resilience mechanisms and resources to resilience outcomes in children with JIA and their families. Hynes et al. highlight children's psychological flexibility, self-efficacy, treatment adherence, pain acceptance, and perceived social support as key contributors to resilience outcomes. The study of  Beeckman et al. examines the role of parental protective responses and instructions to engage in activities in adolescents' daily pain-related behavior. The results show an (indirect) adaptive role of parental psychological flexibility on adolescent daily pain-related behavior via its impact on parental protective behavior, highlighting the dynamic, and transactional nature of pain adaptation among adolescents in a family system. Finally,  Bartley et al. examined the association of multisystem resiliency with pain and psychological outcomes in a sample of older adults with chronic low back pain (cLBP). The aims were to empirically identify domains of resilience based upon psychological, social, and health-related factors and, using cluster analysis,explore whether resiliency phenotypes differ across measures of physical function, pain intensity, disability, and psychological functioning. Their findings indicate that individuals with a more resilient phenotype may present a greater sense of coherence that fosters successful mobilization of resources and navigation of ongoing challenges associated with pain. This study is among a small number to suggest the presence of resiliency profiles based upon psychological, social, and health-related functioning and, further, it suggests that health and psychosocial factors are differentially expressed across older adults with cLBP.There are nine manuscripts in this special issue, including eight original research studies and one narrative review. Three papers analyze the role of positive variables in different stages of the lifespan: Childhood, adolescence, and older adulthood. Pastor-Mira et al. aimed (1) to develop a Spanish version of the Goal Pursuit Questionnaire (GPQ); and (2) to explore the relationships between goal preferences and health outcomes, testing the moderating role of affect and the mediating role of chronic pain activity patterns in two studies. In Study 1, they adapted the GPQ to a Spanish-speaking population of women with fibromyalgia. The culturally adapted Spanish version resulted in a shorter version with content changes reflected in the list of proposed activities, as a result of the field testing within the target population. The findings of study 2 revealed that a preference for pain avoidance goals are related to pain, disability, and fibromyalgia impact through activity patterns. Affect ratings showed direct and indirect associations with health outcomes, mainly by increasing task-contingent persistence. The authors conclude that interventions should promote adaptive activity patterns  and reduce activity avoidance.Two papers analyzed the role of resilient variables in the adaptation of women with fibromyalgia. Cejudo et al. examined the effects of a mindfulness-based intervention (MBI) on the improvement of subjective well-being, positive affect, trait emotional intelligence (TEI), mental health, and resilience. A design of repeated measures with a control group (CG) was used: before and after the application of the treatment and a 6 months follow-up. The study demonstrates that MBI may be an effective intervention tool to foster resilience and related constructs.Also in a sample of women with fibromyalgia, The remaining four studies examine flexibility, pain-specific resilience, and frustration tolerance as adaptation resources for chronic pain patients, and flourishing as a measure of well-being.Gentili et al. examined the role of psychological flexibility  in relation to symptoms (pain intensity and anxiety), and functioning (pain interference and depression) among adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Their results show that psychological flexibility, as a resilience factor, significantly contributed to the prediction of pain interference and depression when adjusting for age, pain, and anxiety.Gonzalez et al. report that greater pain-specific resilience is significantly associated with lower levels of pain interference and pain catastrophizing, greater use of distraction and coping self-statements, and significantly greater heat pain tolerance. Authors suggest that pain-specific resilience may promote adaptation and positive coping in people living with HIV and chronic pain.In a study in people living with HIV and chronic pain, Suso-Ribera et al. assessed a sample of individuals with chronic pain at two time points: 2 weeks before starting medical treatment at a pain clinic, and 6 months after. Authors found a reduction in pain intensity and an improvement in physical functioning. The results of the regression analyses show that a decrease in pain intensity is significantly associated with improvements in physical health and that this association is moderated by frustration tolerance.In a longitudinal study, Trompetter et al.'s paper explores, in two samples of individuals with chronic pain, the prevalence and sociodemographic, physical and psychological correlates of flourishing, and complement this exploration with a similar examination of risk for psychopathology. Compared to those without chronic pain, people with chronic pain were as likely to flourish, but more likely to be at risk for specific indices of psychopathology. Both flourishing and risk for depression were related foremost to psychological correlates. While engaged living was the most important correlate of flourishing, pain catastrophizing and psychological inflexibility were the most important correlates of being at risk for depression, suggesting potentially distinct underlying pathways for resilience and vulnerability in chronic pain. The authors suggest the Psychological Flexibility model to explain both poor and optimal functioning in the presence of chronic pain.Finally, The papers included in this Research Topic demonstrate the positive contribution of a diverse array of psychological characteristics in the adaptation and well-being of individuals with chronic pain across the lifespan. Several clinical implications have been derived from the findings. More research is needed to further illuminate trajectories of effective pain management, which may have significant value for future clinical and empirical models in chronic pain.All 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.


Chloroplasts are the place for the major conversion of the sun’s radiation energy to chemical energy that is usable by organisms. Accordingly, they account for about 50% of the leaf protein , and theThe structure and dynamics of the chloroplast photosynthesis machinery is a central focus of molecular investigations on photosynthetic productivity and leaf senescence. Functional coordination among chloroplasts, cytosol, nucleus, and other subcellular compartments inspire many active research topics of chloroplast molecular biology. The transition from the engulfed autonomous cyanobacteria to a non-autonomous endosymbiont chloroplast requires new coordination signals, specific for the different plant cells, which have been actively investigated. In fact, the leaf’s green chloroplasts are members of the plastid organelles present in all plant cells. All plastids share the same DNA and a few structural features and functions (as the synthesis of fatty acids) and derive from the proplastids present in meristematic cells. The biogenesis of the different plastids, their interconversion and the molecular bases of the functions of some plastids  have also been actively investigated at the molecular level. Obviously, only a few research fields may be reflected in this issue which should be the seed for future issues of a broader scope.ndh genes [Although most of the original cyanobacterial genes have been lost early in the transition to the endosymbiotic chloroplast, a few of them, like the dh genes , have beAristolochia [Forsythia [Eucommia [Stemonaceae family [Catha [Primula [Caragana [Genciana [Quercus [Balsaminaceae [Meliaceae [Orchidaceae [Fabaceae [Sanionia uncinate [Ailanthus altissima [Urophysa [Therefore, the comparison of the sequences of the chloroplast DNA of different plants, provides valuable information on gene content, reordering in the circular chloroplast DNA and mutational genetic-derive, relevant to the evolution of chloroplast and its relations with ancient environments. Increasing facilities for intense genome sequencing have prompted many laboratories to focus on the chloroplast DNA. Reflecting these efforts, more than half of the articles on this issue deal with the functional or evolutionary investigations, based on sequence analyses of chloroplast DNA. Mainly focussed on phylogenetic comparisons of medicinal plant families, articles on tolochia , Forsythorsythia , EucommiEucommia , and thee family  report ay [Catha , Primula[Primula , CaraganCaragana , GencianGenciana , and Que[Quercus , and on minaceae , Meliaceeliaceae , Orchidahidaceae , and FabFabaceae . The chluncinate , on Ailaltissima , and on Urophysa .Arabis [Dendrobium led authors to identify the mutational biases affecting the GC (guanine + cytosine) content [Adding to the sequences reported elsewhere, the chloroplast DNA sequences described in this issue provide a background for precise bar codes that are useful in plant trade and medicinal applications. In addition, chloroplast DNA sequences are excellent tools for taxonomy and phylogeny. Thus, detailed comparison of the chloroplast DNA sequences of the species of Arabis  led the  content . Not clo content .Quercus and some related species led the authors to propose the intriguing possibility that the specific sequences of the atpF gene, encoding a subunit of the thylakoid ATP synthase, show significant positive selection for evergreen sclerophyllous oak species, when compared to the deciduous oak species [Pointing to selective pressures reflected in the chloroplast DNA sequence, the comparison of chloroplast DNAs of  species .Chloroplast gene expression is under a complex post-transcriptional control involving C (cytosine) to U (uracil) editing, intron and polycistron splicing and ribosomal activity ,26. Tranin vitro reconstructed translation and incorporation systems, in an attempt to clarify the dual localization determinants of this protein [As pointed above, most chloroplast proteins are encoded in the nucleus. The importation of the nuclear-encoded proteins into chloroplasts is a complex process requiring, among others, the recognition of specific sequences in the amino-ends of the precursor proteins that direct them to the appropriate chloroplast substructure. The amino-end sequence of the amino acids required for chloroplast processing has been investigated for the pre-thylakoid rhodanase-like protein (TROL) and has been reported in this issue. Some researchers have combined the site-directed mutagenesis and  protein .Exposed to the changing environmental conditions, functions in chloroplasts are preserved by adapting their metabolism and molecular structures. The article by Shao et al.  reports Present knowledge of the mechanisms of the chloroplast division is updated in two review articles ,34. The Suetsugu and Wada described, in a brief report, the molecular mechanisms controlling the movement of chloroplasts . They exThe abundance of chloroplast DNA sequence articles in the issue reflects the predominant research projects in the last few years. Certainly, a refinement of the taxonomy and phylogeny investigations requires high numbers of chloroplast DNA sequences to observe the evolutionary trends. Wide analyses of the DNA sequences reported, surely, mark the starting references for further comparisons which could be useful in phylogeny and trade-vegetable characterisation.Chloroplast DNA articles do not shadow the variety of chloroplast molecular projects, as shown by the other articles on the issue. New technologies have far surpassed the methods and objectives collected in the pioneering methods book, thirty-five years ago .IJMS  will certainly include a number of articles dealing with chloroplasts. Many of the articles in this issue have resulted from collaborations of different laboratories, frequently of different countries, which indicates the universality of the field and the necessity of cooperation among specialised research groups, to attack the complex understanding of chloroplasts, at the molecular level. The key role of chloroplasts in the conversion of radiant energy suggests that basic advances in the field would improve plant productivity and environmental protection.In the coming months, the


The occurrence of metastatic tumors in the orofacial region is rare and may represent the first clinical manifestation of occult malignant disease. An orofacial lesion diagnosed as a metastatic tumor from a renal cell carcinoma in a 68-year-old man is reported. This metastatic tumor caused significant facial asymmetry involving the parotid gland and mandible regions, and the patient died four months after diagnosis. Here, we discuss the clinical aspects, the diagnostic approach, and the importance of early diagnosis to obtain a better response to treatment and provide longer survival time. Oral metastatic tumors are uncommon lesions that can occur at any age and in both genders, which represent the systemic spread of the disease or initial presentation of an unknown malignancy at a distant place .Metastatic lesions to the oral cavity can occur in the jawbones and soft tissues, including salivary glands –5. Oral The clinical and radiological aspects of metastatic tumors are varied, making diagnosis and therapeutic management challenging , so it iHistopathological findings are essential and generally reflect the pattern of primary tumors . Due to Herein, we report and discuss a case of oral metastasis with significant facial asymmetry involving the parotid gland and mandible regions, resulting from a primary renal cell carcinoma.A 68-year-old male patient was referred by the public health service of his city for specialized care to the Oral and Maxillofacial Surgery Service of the Federal Hospital of Rio de Janeiro State Servers/Brazil for the evaluation of volumetric increase on the right side of the face. Medical history has reported systemic hypertension and gastritis, both conditions under drug control. He also reported having had surgery for an appendectomy at 25 years of age and denied allergies. The patient reported frequent use of alcohol and smoking for 35 years and having stopped smoking 4 years ago. The patient reported a progressive and painless growth of lesion in the genian region in the last four months.Extraoral examination revealed a tumor-like lesion, firm consistency, well-defined contours, and significant expansion near the parotid region . On intrFor an incisional biopsy, computed tomography (CT) images of the face and preoperative laboratory tests were requested. The results showed normal serum levels of most of the requested blood fractions, except for slightly elevated urea and creatinine. The axial CT image  revealedAn intraoral incisional biopsy was performed. In the first 72 hours after the biopsy, the patient developed significant local edema and volumetric expansion of the lesion, which became inaccurate . On grosMicroscopically, large neoplastic cells often eosinophilic and pale, sometimes clear, with reticulated cytoplasm, centralized oval nucleus and perinuclear halo, and prominent nucleoli were observed . The diaThe patient underwent primary CT scan of the abdomen, which showed the presence of lesion involving the right kidney cortex and parenchyma . The patMetastases to the oral cavity or head and neck region are extremely rare conditions , 9. MetaAs shown in our case, oral lesions have been reported among the first manifestations of an undiagnosed primary malignant disease , 11 or mInitially, the location, size, and limits of the lesion led to the clinical hypothesis of a primary neoplastic lesion in the parotid gland, mainly Warthin's tumor due to cigarette use. However, mandibular bone resorption was indicative of aggressiveness of the lesion. After the surgical intervention for an incisional biopsy and worsening of the clinical picture, our team began to consider a malignant or metastatic tumor. However, for cases with a history of cancer, the professional should evaluate the patients' complaint and reflect on the inclusion of metastatic disease among the diagnostic hypotheses , 14. OraIn the study by Liu et al. , all casSince metastases reflect the primary tumor pattern , microscAccording to Owosho et al. , adult pIn summary, the occurrence of metastatic tumors in the orofacial region is rare and may represent the first clinical manifestation of occult malignant disease. These lesions are very serious and have a poor prognosis. Wherever possible, early diagnosis should be performed to obtain a satisfactory response to treatment and provide better patient survival.


These rA balanced diet promotes good health as it provides adequate amounts of energy, proteins, vitamins, minerals, essential fats, micro, and macronutrients for the metabolic needs of the body to function properly at each stage of the lifespan. The absence of balanced food and nutrition security leads to health problems such as diabetes, obesity, and malnutrition . AlthougReductionist approaches fail to demonstrate how the cellular and molecular responses due to food produce health benefits . CurrentTo understand the underlying health dynamics while considering inter-individual variability and implementing personalized nutrition-driven interventions, efforts should focus on devising predictive methods that timely monitor the individual's health responses to food. A systems science perspective can help physicians tailor targeted treatment, comprehend the variability in response to treatments and design personalized nutrition approaches . PersonaRecent studies demonstrated successful application of providing personalized dietary advice at an individual level , 16. AltThese integrated data-driven approaches that build predictive computational models could be trained with additional features including phenotypic changes due to nutritional factors and changes due to interaction between genotypic and nutrient derived metabolic factors. The predictions from these models that include genotypic and metabolic features can aid the design of personalized diets based on the feature attributes that capture human diversity and variation. Thus, a unique comprehensive strategy that can automate data driven analytical model building, could be employed by focusing on the unique iterative integration of large-scale clinical record mining, -omic analysis, hypothesis-based modeling, simulation, and advanced ML approaches, to make tangible progress toward personalized nutrition and precision medicine. The vision for personalized nutrition has stimulated an immense interest for advancements in the diagnostics and decision support systems that allow continuous assessments of nutritional status. However, the advancement in the predictive technologies and their integration has posed numerous challenges. The focus of this review article is to put forth the major challenges    level. Tgabytes)  23). Ho. Ho21 gigabytes) . With angabytes)  and sociThe healthcare sector generates a large amount of data that would promote wide studies in terms of risk evaluation, disease management, and patient stratification. The major drivers of the increase in U.S. data analytics market will include the initiative to increase adoption of EHR systems, availability of healthcare information technology big data infrastructure in healthcare, and technological advancements in genome sequencing. To derive predictive insights from patient data we would need to employ data-driven modeling because systems wide advanced computational methods and data analytics platforms can help in the organization, interpretation, and pattern extraction from the health data , 6. Thesin silico clinical trials to optimize clinical trial design and (iii) compare the response to various treatment options and health outcomes. The application of ML techniques and AI technologies to build in silico pipelines with data analytics capabilities have the potential to tailor recommendations to achieve personalized nutrition and guide the design of human studies to improve success rate. These technologies are promising in terms of investigating the linkages between nutritional regimens and modulation of whole genome-scale molecular signatures predictive of: (i) health, (ii) future health deterioration, (iii) pre-disease, and (iv) diseased states.With the wider application of AI methods large data repositories have ceased to be a data warehouse and have become true brains for information and knowledge extraction. Advanced ML approaches and AI are transformative technologies  that canhttps://www.healthnewsreview.org/2017/02/md-anderson-cancer-centers-ibm-watson-project-fails-journalism-related/).During the adoption of the data analytics platform as a decision support system it is important to consider not only its scientific and functional capabilities but also the management and technology issues associated with it. The compatibility of EHRs software versions with the ML and AI technology is crucial. Further, it is important to have evidence based research regarding the success of the analytics platforms. Pilot and published studies that demonstrated improved outcomes due to the use of analytics platform  is required. The lack of the above listed points, were some of the reasons why the MD Anderson Cancer Center's efforts to use IBM Watson cognitive computing system, in the clinical decision making process were put on hold  responded inter-individually to multi-micronutrients supplement intervention . MathiasThus, these case studies demonstrated that ML architecture integrated with large-scale clinical data are capable of taking into account the inter-individual variability to an assigned diet and could help in moving away from the standardized approach of making general nutrition related recommendations. During a patient visit the integration of AI powered healthcare decision support systems could provide the clinicians with the EHR information, record of physical activity, microbiome information, and aid in forming tailored health recommendations. The aim of utilizing the healthcare information technology driven framework will be used to provide a predictive, personalized, and secured solution based on personal health record.Along with advances in ML models, deep learning has set a new trend  and advain silico testing of new nutritional interventions. These advanced analytics approaches can be employed to identify new molecular bio signatures as biomarkers which would be capable of defining individual responses, diversity and variation to a specific diet. The biomarker analysis tends to vary per individual especially based on age and other physiological factors. For instance, an increase in age changes the expression of gene or protein over time, for e.g., a disease biomarker for a younger adult will be different compared to an elderly. Although, there are available biomarkers for nutrition which includes the measure of essential dietary acids in plasma, protein intake, sodium and potassium levels  . The need for research infrastructures in the specific areas of food and nutrition area were recently highlighted by the EuroDISH project  which maH model) . The manH model)  that is Nutrition quality is influenced by the environment, how and where the food is grown, transported and stored . AdditioThe utilization of data from already existing infrastructures that can be applied and extended to the food, nutrition, and health interface is crucial. These include the application based infrastructures provided by LabKey (used to store laboratory based research projects) and REDCap (used to store patient oriented research) that can be utilized to build data linkages related to food and nutrition . AdherenThe use of EHRs and FHIs could ease the accessibility to patient health records that contain information determining patient care. The transition of patient records from paper to electronic format maintained in EHRs is beneficial in terms of proper diagnoses based on the patient history and cost saving thereby giving rise to better patient outcome and healthcare decisions. However, digitization in electronic format can cause—(i) improper standardization formats, (ii) erroneous documentation of diagnostic codes resulting into incorrect reporting and denial from insurance companies, (iii) lack of user engagement if not trained and additionally (iv) poorly designed technology can lead to error and give rise to issues that can cause the insufficiencies within the EHRs . FurtherWith the emergence of the new data driven technologies, the demand for individuals trained at the interface between computational and clinical or translational approaches has risen exponentially. Application of variety data analysis skill sets are required to interpret large and complex databases which would not only include EHRs but also external data such as claims data, public repositories, and curated data sources such as ClinVar  among otModeling Immunity to Enteric Pathogens project, a summer school and symposium on computational immunity was organized to provide experiential learning to individuals from varying backgrounds ranging from experimentalists, mathematicians, bioengineers, physicist, and nutritionists  as opposed to a replacement for the human experts. The most important part of the system is the “user” that is required to make sense of large complex datasets. Humans and their expertise would be an integral part of the data knowledge discovery process. Thus, in order to utilize the advanced predictive capabilities of the AI system, a partnership of the experts with AI advanced capabilities is crucial. These can include experts in the fields of nutrition, bioinformatics, computer science, statistics, immunology, biochemistry, physiology, endocrinology, exercise science, and mathematics. Further, since the predictive models are trained on data that needs to be cleaned before the analysis, domain specific knowledge experts are an inevitable part of the discovery process. The AI technologies have accelerated to a point where it should be accessible to all . There aWhen handling clinical data pertaining to EHR, one of the main challenges is the high dimensionality and sparsity of the data. The EHR store every clinical event during patient visit or stay in the hospital. Zeevi et al. examined the fluctuation in glucose levels in response to nutrition, physical activity, and sleep; with a high-density data matrix on glucose levels that was available through continuous glucose monitoring . HoweverThe imputation with mean and mean is easy to implement wherein the missing values are substituted with the mean or median values from the distribution of data, however, that introduces biases, and large errors if the missing value belonged to the tail of the distribution . In caseSince, the high dimensionality and rich volume of EHR data are valuable for personalized nutrition research it is crucial to develop improved methods to deal with the missingness. The currently available imputation methods introduce bias errors and are computational intensive. Also, the required run time for the imputation methods increases with the volume of data. Along with improved methods, better documentation along with well-versed knowledge in statistical methods regarding missing data can help.An individual's nutritional status can be determined by the integration of various factors including food intake, physiological health, diet, and nutrition, -omics, metabolism, and physical activity measures. To make accurate personalized nutrition recommendations and accelerate the goal of better and health well-being, advanced computational technologies such as AI, ML, and deep learning are promising in terms of providing an integrated framework. The use of data-driven methods will require the development of a personalized food and health infrastructure system comprised of advanced computational technologies with data storage, processing and sharing capabilities. The integrated and standardized infrastructure system will strengthen and enhance the patient care based on the collection of longitudinal data related to physiological measures, gut microbiome and other relevant biomarker measures. From legal and ethical consideration, it is important to take into who will have access to an individual's personal data. It is important to protect the privacy of data and prevent discrimination in terms of—eligibility for health insurance from the insurance companies, services from the hospitals and hiring decisions or terms from the employers. Overall, the standardized personalized nutrition framework approaches with protection of patient privacy can help establish preventive and predictive guidelines for promotion of health and better disease management.MV, RH, VA, and JB-R designed the architecture of the review. MV, NT-J, RH, and JB-R performed the searches for the review. MV, VA, RH, and JB-R helped with the edits. MV and JB-R wrote the 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.


Reporting standards in biomedical research have been shown to be suboptimal. The publication of the PRISMA statement has improved the completeness of reporting of systematic reviews, but several issues specific to diagnostic test accuracy are not included in the PRISMA statement. Therefore, a diagnostic test accuracy extension of the PRISMA statement, PRISMA-DTA, was created. This commentary addresses completeness of reporting in systematic reviews, the PRISMA-DTA statement, and strategies for optimal uptake of reporting guidelines. Inadequate reporting in biomedical research is a long-recognized issue, with the concern being that it does not allow for assessment of methodological quality and applicability of results, and consequently leads to wasted research that may be prone to bias , 2. PoorWhile the focus of PRISMA was to help improve the completeness of reporting systematic reviews examining the effects of health interventions, several key issues in systematic reviews of diagnostic test accuracy (DTA) were not adequately addressed –12. SevePRISMA-DTA and PRISMA-DTA for abstracts publication is available (open-access) in the Journal of the American Medical Association (JAMA) [The EQUATOR Network and the PRISMA websites [A systematic review of the literature regarding reporting of DTA systematic reviews was performed followed by a three-round Delphi process and an in-person consensus meeting to generate the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy (PRISMA-DTA) extension of the original PRISMA statement , 10. PRIn (JAMA) . PRISMA-websites , 14. ThiSystematic Reviews, along with other leading journals in fields commonly producing DTA systematic reviews, such as Clinical Chemistry and Radiology. Implementation is the action(s) taken by journals to ensure that authors adhere to an endorsed reporting guideline. This may include requiring a checklist of the relevant reporting guideline be submitted with the manuscript prior to consideration of the manuscript by the journal editorial team. Adherence refers to action(s) taken by authors to ensure that a research report is compliant with the items recommended by the appropriate/relevant reporting guideline. Adherence is the responsibility of the manuscript author to create well-reported and reproducible research. As the editorial burden of manually assessing and enforcing adherence of all submitted manuscripts would be enormous, enforcement of adherence currently largely relies on peer reviewers and editors. From the perspective of the author submitting a review, using PRISMA-DTA will ideally improve the completeness and clarity of reporting of the submitted work, perhaps aiding peer reviewers and editors to more quickly reach a decision of the merits of the review for publication.Optimal uptake of reporting guidelines has three main constituents: endorsement, implementation, and adherence. Endorsement is a policy decision by a journal to recommend that authors submit the appropriate reporting guideline for their research type, as is the case with the journal Reporting of systematic reviews has been shown to be improved since the publication of the PRISMA statement . StudiesWhile fixed abstract word count limitations by journals were not associated with completeness of abstract reporting, it was shown that abstracts with higher word counts were reported more completely . Thus, wSeveral DTA-specific issues were found to be reported in less than one third of reviews in the PRISMA-DTA adherence assessment . These iInterestingly, a recently published study found that study authors found reporting guidelines to be most useful when used early in the research process, rather than after the manuscript was complete or requested by a journal editor . This shWith the publication of the PRISMA-DTA and PRISMA-DTA for abstract checklists and the continued efforts of authors, peer reviewers, and journal editors, hopefully we can raise the quality of reporting in DTA systematic reviews.


Nutrient pollution, now the leading cause of water quality impairment in the U.S., has had significant impact on the nation"s waterways. Excessive nutrient pollution has been linked to habitat loss, fish kills, blooms of toxic algae, and hypoxia (oxygen-depleted water). The hypoxic "dead zone" in the Gulf of Mexico is one of the most striking illustrations of what can happen when too many nutrients from inland watersheds reach coastal areas. Despite programs to improve municipal wastewater treatment facilities, more stringent industrial wastewater requirements, and agricultural programs designed to reduce sediment loads in waterways, water quality and nutrient pollution continues to be a problem, and in many cases has worsened. We undertook a policy analysis to assess how the agricultural community could better reduce its contribution to the dead zone and also to evaluate the synergistic impacts of these policies on other environmental concerns such as climate change. Using a sectorial model of U.S. agriculture, we compared policies including untargeted conservation subsidies, nutrient trading, Conservation Reserve Program extension, agricultural sales of carbon and greenhouse gas credits, and fertilizer reduction. This economic and environmental analysis is watershed-based, primarily focusing on nitrogen in the Mississippi River basin, which allowed us to assess the distribution of nitrogen reduction in streams, environmental co-benefits, and impact on agricultural cash flows within the Mississippi River basin from various options. The model incorporates a number of environmental factors, making it possible to get a more a complete picture of the costs and co-benefits of nutrient reduction. These elements also help to identify the policy options that minimize the costs to farmers and maximize benefits to society.


The field of neuronanomedicine has recently emerged as the bridge between neurological sciences and nanotechnology. The possibilities of this novel perspective are promising for the diagnosis and treatment strategies of severe central nervous system disorders. Therefore, the development of nano-vehicles capable of permeating the blood–brain barrier (BBB) and reaching the brain parenchyma may lead to breakthrough therapies that could improve life expectancy and quality of the patients diagnosed with brain disorders. The aim of this review is to summarize the recently developed organic, inorganic, and biological nanocarriers that could be used for the delivery of imaging and therapeutic agents to the brain, as well as the latest studies on the use of nanomaterials in brain cancer, neurodegenerative diseases, and stroke. Additionally, the main challenges and limitations associated with the use of these nanocarriers are briefly presented. Neuroscience is a multidisciplinary field that studies the macro- and microscale neuroanatomy, the functional organization of specific brain areas, and the electrophysiology of neurons and synapses. Moreover, neuroscience represents the means to understand the underlying mechanisms involving the structure and function of individual channels and receptor proteins, the development and repair signaling, and the assembly of proteins into molecular machines that regulate neuronal functions . A complNeurological disorders comprise a wide variety of sporadic and hereditary  pathologFurthermore, the presence of the blood–brain barrier (BBB) and the blood–cerebrospinal fluid barrier (BCSFB) represents the main cause for limitations in the management of neurological diseases . The BBBAdvances in nanotechnology have allowed for a better understanding of the pathological conditions of the nervous system and the development of formulations that could enhance the therapy of neurological diseases . ComprisThe scientific interest in designing nanotechnology-based approaches, including nanoparticles, liposomes, dendrimers, micelles, carbon nanotubes, quantum dots, viral vectors, and extracellular vesicles, which have the potential to deliver the appropriate amount of the therapeutic and imaging agent to the brain, has grown rapidly ,23. HencDelivering drugs to the brain represents a challenge because conventional neuropharmaceuticals do not possess the appropriate physicochemical characteristics regarding molecular size, lipid solubility, and surface charge . Hence, Polymeric nanoparticles used as nanocarriers involve matrix architectures, most commonly in the form of nanocapsules and nanospheres ,29. The The mechanisms for brain uptake and drug release of polymeric nanoparticles have been intensively studied in order to design nanocarriers that can efficiently deliver therapeutics to the central nervous system through systemic and local administration. Hence, the main strategies involve endocytosis or transcytosis through the endothelial cells, accumulation in the brain capillaries resulting in the transfer to the brain parenchyma owing to the high concentration gradient, membrane fluidization through lipid solubilization due to the surfactant effect, tight junctions opening , and resSolid-lipid nanoparticles are the new generation of colloidal nanocarriers consisting of surfactant-stabilized triglycerides, monoglycerides, hard fats, complex glyceride mixtures, or waxes, that are solid at both room and body temperatures ,33,34. TWith a size similar to other nanocarriers, between 50 and 1000 nm , solid-lAs they have the capacity to target the central nervous system and naturally cross the BBB due to their highly lipophilic nature, solid-lipid nanoparticles have been extensively used as nano-vehicles for the delivery of chemotherapeutic drugs into the central nervous system ,38. The Liposomes are artificial and spherical vesicles, consisting of single or multiple amphiphilic lipid bilayers which surround an aqueous solution core ,43,44,45Furthermore, liposomes have demonstrated their potential in neurological applications as they can cross the BBB through passive or active targeting and deliver the appropriate quantity of therapeutic and diagnosis agents to the brain . The maiDendrimers are a class of nanoscaled artificial, highly branched, globular macromolecules ,50. TheiDendrimers possess the capacity to overcome the BBB, and therefore, they have been widely applied in the therapy of central nervous system disorders . FurtherMicelles are amphiphilic nanocarriers with a particle size within the range of 5–50 nm that spontaneously form under certain conditions of concentration and temperature of the aqueous solution . The mecMicelles penetrate the BBB mainly through the mechanisms of endocytosis and/or transcytosis. Furthermore, the penetration capacity can be enhanced by conjugating specific ligands and antibodies or by applying external thermal or mechanical forces to disrupt the BBB .The significant amount of work in the area of inorganic nanoparticles synthesis and surface modification has contributed immensely to their applicability in the medical field . MoreoveInorganic nanoparticles, specifically metal, semiconductor, and metal oxide nanoparticles, have attracted great scientific interest owing to the possibility of tuning their size, shape, composition, structure, and porosity and to decorate their surface to facilitate the conjugation of ligands and polymers, thus enhancing their biological performances ,59. As tFurthermore, to increase brain uptake of these nanoparticles, the application of external stimuli, including near-infrared radiation and magnetic field, could enhance the on-demand drug release across the BBB and improve tissue imaging. Moreover, inorganic nanoparticles are characterized by a prolonged enhanced permeability and retention effect which makes them a great candidate for brain cancer therapy .Carbon nanotubes are the most commonly used among the class of carbon-based nanomaterials, comprising graphite sheets rolled into tubes with diameters within the nanoscale. Depending on their architecture, carbon nanotubes can be single-walled or multi-walled, with open ends or closed with fullerene caps . Carbon Quantum dots are zero-dimensional nanomaterials which have attracted considerable scientific interest owing to their exceptional optical and electrical properties . Their aThe use of viral vectors is based on the ability of viruses to enter and insert genetic material into the host’s cells. The application of viral vectors in the central nervous system is mainly represented by gene therapy, which usually involves the delivery of a normal copy of a defective gene and the reduction of the deleterious functions . The mosThe main strategies for the transportation of viral vectors across the BBB are the receptor-mediated pathway across the endothelial cells by transcytosis and the transient disruption of the BBB, which allows for the paracellular transport into the brain parenchyma. One method of disruption involves the intravenously administration of a highly concentrated mannitol solution which will result in the osmotic shrinkage of the cells .Studies reported the use of herpes simplex viral vectors to combat stroke by repairing or replacing genes that lead to neuronal damage. Similar results were obtained by using the adenovirus-mediated vectors. Although there are promising solutions and results, gene therapy is still in its infancy due to ethical issues and high risks of therapy failure .Extracellular vesicles represent a heterogenous class of cell-derived membrane structures, originating from the endosomal system, termed as exosomes, or shedding from the plasma membrane, termed as microvesicles. Extracellular vesicles can be ubiquitously found in biological fluids and have a role in various physiological and pathological processes . RecentlIn the central nervous system, extracellular vesicles are involved in the maintenance of normal neuronal functions and the development of neurodegenerative disorders. The pathways of BBB crossing by extracellular vesicles are mainly through adsorptive-mediated transcytosis or receptor-mediated transcytosis. However, the underlying and precise mechanisms of crossing in physiological and pathological conditions are not completely understood .The applications of extracellular vesicles as nanocarriers for brain disorders include the use of autologous exosomes containing glyceraldehyde-3-phosphate dehydrogenase that can deliver small-interfering RNA to neurons, microglia, and oligodendrocytes. Moreover, they were also used for the delivery of the APP cleaving enzyme for the downregulation of the BACE1 protein. The intranasal administration of curcumin-containing exosomes for the inhibition of brain inflammation and autoimmune responses has been reported. Exosomes can also be used to deliver Stat3 inhibitor JSI-124 to inhibit tumor growth in a glioblastoma model .Considering the abovementioned characteristics, solid-lipid nanoparticles might be preferred for the treatment applications using hydrophobic drugs as they are highly lipophilic, biodegradable, there are no neurotoxic effects reported in the literature, and they can cross the BBB through the paracellular pathway. Nevertheless, if the nature of the therapeutic agent is hydrophilic, polymeric nanoparticles can be applied, but their reported neurotoxicity must be considered. However, for the bioimaging applications, inorganic nanoparticles are the preferred nanocarrier type, as carbon nanotubes and quantum dots exhibit more serious neurotoxic effects.The central nervous system comprises hundreds of various highly organized subtypes of neurons and glia, thus being the most complex and specialized body system. Consequently, diseases associated with the central nervous system are equally complex, causing various diagnostically definitive disruptions in behavior . As nanoThe transport of anti-cancer drugs through the BBB for the treatment of brain tumors remains one of the major challenges in brain cancer therapy. Thus, the development of nanotechnology-based strategies for an efficient brain uptake and controlled release of the active compounds is essential. The characteristics of the nanocarriers mostly depend on the cancer type, tumor characteristics, stage, and location .Novel approaches for the diagnosis of brain cancer involve the use of nanoparticles, liposomes, micelles, and quantum dots for various neuroimaging techniques. Therefore, silica shells double-coated with semiconducting polymer layers were synthesized for fluorescence and photoacoustic brightness imaging . Moreoveco-glycolic) acid nanoparticles containing doxorubicin, cisplatin, and boldine resulted in an efficient internalization into the glioma cells, inducing cytotoxic effects [co-p-dioxanone) [co-glycolic) acid [Studies regarding the treatment of brain cancer focused on the delivery of various anti-cancer drugs using nanocarriers. Specifically, poly(lactide- effects  and an e effects . Other poxanone)  or polyeic) acid  block coic) acid . Liposomic) acid , doxorubic) acid , 5-fluoric) acid , and pacic) acid . The pasic) acid , an enhaic) acid ,93, and ic) acid . As previc) acid , or sialic) acid . Other cic) acid  and multic) acid . Additioic) acid .Neurodegenerative diseases are increasingly prevalent age-dependent disorders which represent a major threat to human health. The most common neurodegenerative diseases are Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and multiple sclerosis, each characterized by their own pathophysiology, from memory and cognitive impairments to motor dysfunctions, affecting the ability to move, speak, or breathe. As effective treatment strategies are urgently needed, extensive studies regarding the potential of nanotechnology have been performed .Characterized by conformational changes of native proteins which lead to the aggregation and formation of insoluble amyloid fibrils, neurodegenerative diseases therapy mostly relies on the development of adequate platforms that could detect the amyloid formations . Neuroimco-glycolic) acid biodegradable polymeric nanoparticles functionalized with specific antibodies [l-DOPA functionalized multi-branched nanoflower-like gold nanoparticles have shown potential in the treatment of Parkinson’s disease [The treatment of neurodegenerative diseases through nanotechnology approaches focuses on both organic and inorganic nanocarriers. Polyethylene glycol and/or poly acid nanoparticles functionalized with chlorotoxin as a targeting ligand for the co-delivery of Lexiscan and Nogo-66, for the simultaneous improvement of the BBB permeability and effective targeting of the stroke site. This system has proved its potential for stroke therapy as results showed an increased stroke survival [Studies for stroke therapy reported the use of poly, formerly LipoBridge® by Genzyme, and G-Technology® , using BBB targeting delivery systems are in the clinical development pipeline. On one hand, the Cerense® technology utilizes short-chain oligoglycerophospholipids that can transiently open the BBB tight junctions and facilitate the drug transport. On the other hand, the G-Technology comprises liposomes coated with polyethylene glycol and covered with glutathione to facilitate drug transport across the BBB through receptor-mediated transcytosis [Moreover, the Cerensescytosis .The continuous emergence of nanotechnology in the biomedical field has raised some concerns regarding the potential health risks as opposed to the associated benefits. In certain conditions, the numerous advantageous physicochemical properties of nanomaterials, such as reduced size, reactive surface, high surface to volume ratio, or tunable shape might cause serious toxic effects .On one hand, their unique tunable characteristics might provoke unpredictable biological responses when introduced into the body . As it lMoreover, the administration of nanomaterials for neurological purposes might lead to immediate and direct neurotoxic effects. Therefore, oxidative stress, induced cell apoptosis and necrosis, and immune responses and inflammation as main neurotoxic effects, result in the activation of specific signaling pathways that will further affect the function of the BBB. Additionally, the neurotoxic effect could directly alter the structure and activity of the neurons, or, due to the activation of glial cells and interactions between glial and neuronal cells, it might result in a cascade of effects. Neurotoxic effects manifest immediately or after certain periods of time, leading to reversible or permanent consequences that can affect parts of the nervous system or the whole system . Table 4Another challenge for the administration of nanomaterials in biological systems is the formation of the biocorona on the surface. The biocorona might lead to alterations of the physicochemical properties, functionality, and biodistribution, and induce highly toxic effects .On the other hand, the application of nanotechnology in the field of biomedicine is limited by the lack of standardized model systems, experimental assays, and in vivo monitoring systems to accurately determine the toxic effects of nanomaterials. Current BBB models involve the use of primary co-cultures of mouse brain endothelial cells and astrocytes, primary mono-, co-, and triple-cultures of rat endothelial cells/astrocytes/pericytes, bovine co-cultures of endothelial cells and astrocytes, porcine monocultures of endothelial cells, and human cultures using either the cCMEC/D3 endothelial cell line or stem cells. As the BBB is a highly dynamic barrier and its properties change in various physiological and pathological conditions, these models should be further refined to allow for the translation of results to the in vivo settings . AdditioNeuronanomedicine has merged the fields of neuroscience and nanotechnology, through which nanomaterials, nanoformulations, and nanofacturing processes are effectively applied in neurology to further understand the physiological and pathological mechanisms. By this means, novel strategies for diagnosing and treating the disorders of the central nervous system have emerged. Specifically, nanotechnology mostly focuses on the development of organic and inorganic nanocarriers, but also on the use of biological entities, such as viral vectors or extracellular vesicles, that could efficiently deliver imaging and therapeutic agents across the BBB, into the brain parenchyma. Although studies are showing promising results, there are several limitations regarding the immediate and long-term interactions of these nanocarriers with the biological tissues. Additional coatings using extracellular matrix-derived polymers or anti-microbial materials and antibiotic treatments might offer possible solutions to reduce neurotoxic effects and to avoid bacteria adherence on the surface of the nanocarrier.Besides the development of standardized experimental assays, future perspectives might also focus on the development of nanotechnology approaches for neuronal cell regeneration and reconstruction. Furthermore, there are promising possibilities in the field neurosurgery that could benefit from the advantages of nanotechnologies. One example is represented by the implementation of nanorobotics in neurosurgery that involves several manipulation technologies, such as the assembly of nanosized objects and biological cell and molecules manipulation. Moreover, this could also represent a solution for the early diagnosis and therapy monitoring of central nervous system disorders.


Since the discovery of the hepatitis B virus (HBV) by Blumberg et al. in 1965, its genome, sequence, epidemiology, and hepatocarcinogenesis have been elucidated. Globally, hepatitis B virus (HBV) is still responsible for the majority of hepatocellular carcinoma (HCC). HCC is the sixth-most common cancer in the world and the second-most common cancer death. The ultimate goal of treating HBV infection is the prevention of HCC. Fortunately, anti-HBV treatment with nucleos(t)ide analogues (NAs), which began with lamivudine in 1998, has resulted in remarkable improvements in the survival of patients with chronic hepatitis B and a reduced incidence of HCC. These results were documented with lamivudine, entecavir, and tenofovir. Nonetheless, as the duration of antiviral treatment increases, the risk for HCC still remains despite undetectable HBV DNA in serum, as reported by different investigators with observation up to 4–5 years. In our own experience, we are witnessing the development of HCC in patients who have received antiviral treatment. Some have enjoyed negative serum HBV DNA for over 12 years before developing HCC. Current treatment with NAs can effectively suppress the replication of the virus but cannot eradicate the covalently closed circular DNA (cccDNA) that is within the nucleus of hepatocytes. There still remains a great need for a cure for HBV. Fortunately, several compounds have been identified that have the potential to eradicate HBV, and there are ongoing clinical trials in progress in their early stages. Since the discovery of the hepatitis B virus (HBV) by Blumberg et al. in 1965 ,3.Once infected with HBV, one of the main risks is the development of cirrhosis, hepatic decompensation, and ultimately HCC. Without treatment, 15–40% of these individuals will develop these sequelae during their lifetime .HBV is indeed the most significant hepatocarcinogen responsible for the development of HCC, which currently ranks as the sixth-most common cancer worldwide and the second-most common cause of cancer death ,8,9,10.Since the first report by Beasley et al. , the conCurrently-available therapies have shown the ability to delay disease progression and reduce the incidence of HCC with lamivudine, entecavir, and tenofovir disoproxil fumarate ,19,20. FHowever, as the antiviral treatment period is prolonged, the risk for HCC persists in CHB patients even after more than a decade of successful viral suppression as reported earlier . In our After the detection of the small tumor, all patients underwent local tumor ablation with continued antiviral therapy and were closely monitored. Five patients developed new or recurrent tumor and eventually died. On the other hand, 7/12 have remained tumor free (Patient 8 underwent liver transplantation) and have continued antiviral therapy.Our experience is perhaps the longest with oral antiviral therapy since lamivudine, the first nucleoside analogue, was approved in 1998. Given the persistent risk of HCC even after two decades of antiviral (nucleos(t)ides) therapy, there is a desperate need to develop new drugs to cure HBV.In addition to the persistent risk for an initial diagnosis of HCC, we have also observed the development of de novo or recurrent HCC appearing at 10, 11, and 15 years after the successful ablation of the initial HCC despite continued HBV suppression with antiviral treatment .With the recent development of a cure for the hepatitis C virus, the time now seems ripe to unpack the remaining mysteries of HBV and develop a cure for a virus which continues to cause significant morbidity and mortality worldwide.Much of the genome and replication cycle of HBV has been elucidated since its original discovery in 1965 . The virThe viral replication cycle begins when HBV recognizes highly-sulfated heparin sulfate proteoglycans (HSPGs) on the surface of liver cells, and binds sodium taurocholate co-transporting polypeptide (NTCP or SLC10A1) to gain entry into the host cell ,32. UponAs previously stated, infection with HBV has a well-established connection with the development of HCC ,13,14,15Nevertheless, the entire carcinogenic process of HBV-associated HCC is not fully elucidated, and studies have suggested that the mechanism is most likely multifactorial. In addition to the integration of HBV DNA into host chromosomes, there could be the activation of cellular oncogenes, inactivation of tumor suppressor genes, chronic liver injury, inflammation and regeneration , activation of cellular proto-oncogenes or suppression of growth regulating genes, and an increase of the HBx protein, which plays an important role in the transcription of HBV DNA as well as in hepatocarcinogenesis. As suggested earlier, the pathogenesis of hepatocellular injury and ultimately cirrhosis seems to result from the host immune response against infected hepatocytes, as opposed to being a result of viral replication itself. Similarly, the carcinogenesis of HBV infection results from creating an environment of chronic inflammation, as well as interactions the virus has with signaling pathways in both the innate and adaptive immune system of the infected host. For example, NF-kB, a signaling molecule involved in the pro-inflammatory response of the innate immune system, and the Tim-3/galectin-9 signaling pathway, associated with the HBV-mediated T cell dysfunction within the adaptive immune system, have both been shown to play a role in the development of HBV-associated HCC .One of the more important factors in the hepatocarcinogenesis of HBV is likely to be the integration of the virus into the host genome. By integrating into the host genome, endogenous genes can be affected and, subsequently, their expression can become dysregulated. One such example is the TERT gene, which encodes telomerase reverse transcriptase, and is often found to be overexpressed in cancer cells . In 2012In addition to causing altered expression of endogenous genes by integration into the host genome, the HBV genome itself, and the viral proteins it encodes for, carry properties that increase the risk for HCC. One such property is the relatively high rate of mutation of the HBV genome, and recent work by Park et al. has now identified eight specific mutations within the HBV genome that indicate an increased risk for the development of HCC ,38. HBV Current treatments for hepatitis B include interferon and the nuceleos(t)ide analogs lamivudine, adefovir, entecavir, telbivudine, tenofovir disoproxil fumarate and, recently FDA-approved tenofovir alafenamide. Interferon works primarily through immune modulation and has only a weak antiviral effect, while the nucleos(t)ide analogs suppress the replication of the viral genome by selectively targeting the viral reverse transcriptase ,40. UltiMultiple emerging drug therapies are currently in the early stages of development as part of the growing effort to find a true cure for HBV . GeneralIn light of the growing understanding of HBV and the focus on the need for continued HBV basic science research, there still remain several unanswered questions. There are obstacles to solving the remaining questions, such as the current lack of a robust tissue culture system for in vitro studies and the lack of practical animal models for in vivo studies. However, the future is promising, and each remaining unanswered question about HBV represents an unexplored opportunity to discover a new potential strategy in the effort to cure HBV.


Diabetic macular edema (DME) is the abnormal accumulation of fluid in the subretinal or intraretinal spaces in the macula in patients with diabetic retinopathy and leads to severely impaired central vision. Technical developments in retinal imaging systems have led to many advances in the study of DME. In particular, optical coherence tomography (OCT) can provide longitudinal and microstructural analysis of the macula. A comprehensive review was provided regarding the role of inflammation using OCT-based classification of DME and current and ongoing therapeutic approaches. In this review, we first describe the pathogenesis of DME, then discuss the classification of DME based on OCT findings and the association of different types of DME with inflammation, and finally describe current and ongoing therapeutic approaches using OCT-based classification of DME. Inflammation has an important role in the pathogenesis of DME, but its role appears to differ among the DME phenotypes, as determined by OCT. It is important to determine how the different DME subtypes respond to intravitreal injections of steroids, antivascular endothelial growth factor agents, and other drugs to improve prognosis and responsiveness to treatment. Diabetic retinopathy (DR) is a major microvascular complication of diabetes and a leading cause of visual impairment in the working-age population –4. The pDiabetic macular edema (DME) is characterized by the abnormal accumulation of fluid in the subretinal or intraretinal spaces of the macula and leads to severely impaired central vision . TechnicThe healthy retina is an immune-privileged organ because of the BRB, which consists of inner and outer layers. Under normal physiological conditions, the BRB regulates fluid entry and drainage of molecules and maintains the retina in a dehydrated and transparent state . BreakdoThe inner BRB has tight junctions (zonula occludens) between the endothelial cells of retinal vessels, allowing interactions with pericytes and smooth muscle cells . TransmeThe intercellular junction complex of the retinal pigment epithelium (RPE) forms the outer layer of the BRB . In partActivation of Müller cells and microglia initiates retinal inflammation , 21. Micα), interleukin- (IL-) 1β, and prostaglandins in the presence of inflammation and hypoxia, all of which aggravate vascular hyperpermeability , 3332, 3The diffuse thickening type of DME results from breakdown of the inner BRB due to inflammation and oxidative stress, which leads to increased vascular permeability , 35. TheThe subretinal fluid of the SRD type of DME might be due to the increased permeability of the choriocapillaris because of the dysfunctional RPE at an early stage of disease and then from the breakdown of the outer BRB through the permeable external limiting membrane , 38. TheNumerous studies investigated the association of inflammatory cytokines with different DME phenotypes (as determined by OCT) in an effort to better determine prognosis and to select the most appropriate drug for intravitreal injections. In particular, the intraocular levels of potent proangiogenic cytokine (VEGF) and proinflammatory cytokine (IL-6) are both increased in DME, but they are modulated differently, so intravitreal injections of anti-VEGF and steroids might lead to different responses , 40.Analysis of the intravitreal concentrations of cytokines in the eyes with the SRD type of DME indicated elevated intravitreal concentrations of VEGF, IL-6, and IL-8 . An elevThe increased image resolution provided by OCT allows detection of hyperreflective foci (HF), which appear as discrete intraretinal spots but differ from hard exudates  43]. So. So43]. The SRD type of DME is associated with an increased number of HF and significant functional impairment of the macula . The preUnfortunately, no available treatments target the early stages of DR (before the occurrence of sight-threatening complications), except for strict glycemic control , 51. IntMany clinicians have used focal/grid laser photocoagulation as a local treatment for DME to decrease the rate of severe vision loss, established in the Early Treatment Diabetic Retinopathy Study (ETDRS), the landmark randomized controlled trial , 58. In Intravitreal injections of anti-VEGF agents are replacing laser photocoagulation as the standard treatment for most patients with DME . All curIn terms of OCT-based morphologic findings, bevacizumab appears effective in the diffuse thickening type of DME , 69, andVarious studies have reported the use of steroids as a treatment for DME. Corticosteroids may improve DME by targeting different pathways than those targeted by anti-VEGF agents . IntraviIn a prospective case series, intravitreal injection of triamcinolone seemed to be also more effective than anti-VEGF therapy in reducing macular thickness and improving vision in patients with the SRD type of DME . This reBecause of the abundant evidence that inflammation has a major role in the pathogenesis of DME, there are many ongoing clinical trials using novel drugs that target inflammation  77]..77].Inflammation has an important role in the pathogenesis of DME, but its exact role appears to differ among the different DME phenotypes, as determined by OCT. It is important to determine how the different DME subtypes respond to intravitreal injections of steroids, anti-VEGF, and other drugs to improve patient prognosis and responsiveness to treatment. However, we are still far from a general consensus for OCT-based treatment regimens, so that further randomized controlled studies are needed to customize the best treatment for DME patients.


Bone defects caused by fracture, disease or congenital defect remains a medically important problem to be solved. Bone tissue engineering (BTE) is a promising approach by providing scaffolds to guide and support the treatment of bone defects. However, the autologous bone graft has many defects such as limited sources and long surgical procedures. Therefore, xenograft bone graft is considered as one of the best substitutions and has been effectively used in clinical practice. Due to better preserved natural bone structure, suitable mechanical properties, low immunogenicity, good osteoinductivity and osteoconductivity in natural bone graft, decellularized and demineralized bone matrix (DBM) scaffolds were selected and discussed in the present review. In vivo animal models provide a complex physiological environment for understanding and evaluating material properties and provide important reference data for clinical trials. The purpose of this review is to outline the in vivo bone regeneration and remodeling capabilities of decellularized and DBM scaffolds in bone defect models to better evaluate the potential of these two types of scaffolds in BTE. Taking into account the limitations of the state-of-the-art technology, the results of the animal bone defect model also provide important information for future design of natural bone composite scaffolds. Bone is an organ that plays a major role in supporting and protecting. Mature bone tissue consists mainly of 20% cancellous bone and 80% compact bone . CancellTumor resection, pathological deformation, congenital deformation, sports injury, and infection all may cause bone defects ,4, and eDue to the unique physiologic microstructure of natural bone and guidance for bone development and physiologic regeneration, an ever-increasing number of synthetic grafts are designed to mimic bone microstructure ,11,12, sIn vitro evaluation, which is often used to assess the biocompatibility, mineralization and cytotoxicity of biomaterials, is essential in estimation of material properties. Although cells and signaling factors can be artificially loaded into matrices or scaffolds, in vitro assessment cannot fully reproduce the complexities of the real environment in vivo, in particular the lack of immune or inflammatory responses  and a seSelecting a particular animal as a model requires considering more factors. Animal species, animal age, defect size, defect generation method, duration of study, and fixation method all affect bone repair of graft after implantation ,24. MostThe aim of this article is therefore to highlight the current focus of two kinds of natural bone scaffolds: Decellularized bone scaffold and DBM scaffold, and their respective advantages and disadvantages. In addition, the capacity of in vivo bone regeneration and reconstruction of decellularized bone scaffold and DBM scaffold in different bone defect models was reviewed to better understand and evaluate the potential applications of these two types of scaffolds in BTE.Decellularized bone is the skeleton structure of natural ECM obtained by using physical methods  , chemicaThere are several key points to note when preparing acellular bone scaffolds. The first is the decellularized method, which affects the biochemical composition, tissue ultrastructure, mechanical behavior of bone scaffolds and the host response during in vivo experiments . In otheDBM is a complex of collagen, non-collagen and lower concentrations of growth factors made up of a series of physicochemical treatments   43]. Fi. Fi43]. However, there are also some disadvantages  that limThere are a number of factors that influence the osteogenic effects of DBM, such as species, age, gender , degree A total of 339 articles were retrieved from the PubMed database of National Center for Biotechnology Information (NCBI) using the keyword of “decellularized bone or demineralized bone, rat defect model.” It was found that literature on demineralized bone is 10 articles more than those on decellularized bone. At the same time, it was also found that more literature was published 10 years ago, and less high-score papers published in the past three years. Moreover, most of the literature focuses on the repair of rat calvarial defects and rat femoral defects, while other repairs such as mandibular and fibula only account for a small portion. In vivo results of different natural bone grafts implanted in different parts of the rat bone defect model are shown in The rat germline will affect the bone defects healing and reconstruction. Based on immunity, the rat used in the experiment can be divided into two groups: The rat with normal immune capacity  and nude rat without immunity. Immune suppression may occur during the repair of bone trauma. It can result in the loss of some key cell and molecular signals that regulate normal bone healing, which ultimately leads to the reduction of osteogenesis . TherefoThe most common type of rat model that uses in decellularized bone matrix and DBM is calvarial critical-size bone defect. Critical-size bone defect refers to the range of critical bone defects that cannot be spontaneously repaired at a specific bone trauma site in a given animal germline . Due to In the rat calvarial defect model, it was found that decellularized bone both had excellent repair whether implanted alone or in conjunction with other bone graft materials. For example, Lee et al.  found goHowever, there are differences among the results obtained in reconstruction of rat calvaria defect with DBM. Most studies showed that DBM, one of the components of bone implant, can significantly promote the regeneration and repair of the calvarial, such as DBM combined with PLA and stromal vascular fraction (SVF) , or comb+ and c-kit+ endogenous stem cells to the injure site after implantation for 3 days, which was favorable to the recombination of bone defect, mineralization accumulation and increase of bone mass. HE and Masson trichrome staining showed that CBD-SDF-1α modified DBM scaffolds comprised more osteoblasts and early remodeling of bone defects. Therefore, CBD-SDF-1α modified DBM scaffolds can promote bone regeneration by recruiting endogenous stem cells, which also provided more reference for designing or modifying DBM scaffolds.The rat femoral defect model is also one of the extensively used defect models. Earlier studies have showed that the DBM-induced bone in rat femoral defect model had comparable energy absorption capacity and stiffness as that in the intact rat femur. The DBM-induced bone gains 35% of the normal bone’s torsional strength and its ability to deform increases under load . RecentlIn addition to the calvarial and femur defect model, numerous other rat models have also been developed to assess the in vivo defect reconstruction effects of decellularized bone matrix and DBM, such as xiphoid cartilage  or otherOne of the most commonly used bone defect models in rabbits is the radial defect model, which is a load-bearing site and is therefore more appropriate as a defect site than an ulnar model. This model is often used as a load-bearing model and a nonunion repair model. In addition, compared to other models of skull and middle femur defects, the modeling process of this model is relatively simple and is therefore widely developed. By establishing this defect model, our group  discoverStill, other rabbit models such as femur , tibiofiAs mentioned earlier, decellularized bone matrix and DBM are decreasingly being investigated as separate bone graft because it can bring some inflammation and foreign body reaction . TherefoIn the first category, the stem cells can be anchored as seeding cells on a suitable scaffold to successfully repair the defect in the autologous environment. Previous studies showed that the osteogenesis of MSCs could be promoted by modifying the expression of cytotoxic T lymphocyte-associated antigen 4 (CTLA4). However, the mechanism is not clear. Zhang et al.  investigIn the second category, transforming growth factor-β1 (TGF-β1) , OncostaIn addition, the in vivo bioreactor principle has been considered as a promising method to reconstruct bone defects. In detail, it uses the body as a living bioreactor to culture stem cells, biological scaffolds and growth factors, and uses the body’s self-regenerating ability to regenerate new tissue. Periosteal has the ability to significantly induce bone growth and remodeling, indicating its suitability as an in vivo bioreactor strategy for prefabricating bone grafts . For exaIn addition to the most common mouse and rabbit models, some of the other larger animals, such as pigs ,88 Figu, dogs 8,90 sheepThe complete repair of osteochondral defects has been a major obstacle in the field of BTE because of the complex three-layered structure of cartilage . Currently, the maximum frequency used animal models for repairing this defect are small animal models, while the experimental data provided by large animal models is still relatively limited. The results of the study by Vindas Bolaños  suggest In addition, large animal models are commonly used for the reconstruction of facial bones. Reconstruction of facial bone poses great challenge because of the need to accurately reconstruct the original appearance and functional organization, which requires the design of the most complex facial bone graft. The current standard method is to collect bone from other parts of the body to reconstruct the defect site, but this inevitably brings massive limitations, including surgery-related pain and complications. Bhumiratana et al.  used cliOf course, a few evaluation experiments were conducted on the human body. This part of the study is even more persuasive. After all, the animal model was originally designed to simulate the final human experiment. Decellularized bovine trabecular bone loaded with autologous MSCs was implanted in bearing large segmental long bone defect  of a 58-year-old female after perfusion culture . New bonNumerous studies showed that the ability of scaffolds to repair and regenerate depends on many factors, including composition, fabrication method, macroscopic and microscopic structural, mechanical characteristics, premodification and whether coated with growth factors. By analyzing the composition of decellularized bone and DBM, we concluded that the bone microenvironment of the natural bone matrix is retained after these two treatments. Simultaneously, the 3D microporous structure is conducive to the adhesion and spreading of endogenous stromal cells and collagen deposition of ECM. In addition, the decellularization removes the immunogenicity of the implants, and the extracellular microenvironment constitutes a complex network that connects the tissue structure, which plays a key regulatory role in cell physiological activities such as cell survival and development. The natural ECM  has good mechanical properties, cell compatibility and biodegradability ,98. As fIn vivo bone regeneration and remodeling of decellularized bone matrix and DBM in different animal species such as mice, rabbits, dogs, pigs, sheep, as well as different defect sites such as the femur, tibia, mandible, radius and calvarial of the bone, were reviewed in the present study. Heterologous decellularized bone matrix can be designed as a personalized implant with complex custom geometry, and provide feasibility for personalized BTE especially the facial bone reconstruction . The resIsolated DBM showed limited bone formation . AnalysiWe acquired the following considerations. First, the choice of natural bone scaffolds needs to be based on the type of bone to be restored  when considering defect repair for a particular animal species. If necessary, further modifications  may be made. The superior repair and regeneration capabilities of grafts are also related to the manufacturing process of material. A large number of available 3D printing techniques and materials confirm that some of them may be feasible, but further research is still needed. In the 3D manufacturing process, additive manufacturing (AM) can bring us more and more surprises, such as 3D scanning, design and analysis opportunities. In addition, AM has the potential to improve performance and efficiency, improve field operation and save costs.Secondly, conversely, when evaluating the bone repair and reconstruction of the prepared bone graft, it is necessary to select suitable animal defect sites. For example, due to lack of muscle tissue, poor blood supply and poor bone regeneration, the cranial defect model became the most commonly used non-load-bearing bone defects in BTE . The femTaken together, these two kinds of natural bone materials have massive advantages as bone grafts in BTE, but the limitations should also be taken into consideration at the same time. In the actual design, through loading cells, coating specific functional factors and other methods, the function of decellularized bone matrix and DBM as the main framework of the matrix can be developed more profitably.The distinctive capability of natural bone implants to repair and reconstruct not only depends on the specific compositional structure, especially the retained natural bone microenvironment , but also on the manufacturing methods of decellularized bone and DBM, such as decellularization  and the choice of decalcification reagents , which greatly affect the biological performance of the prepared scaffolds. Additionally, pre-modified decellularized bone and DBM, such as surface physical modification, surface chemical modification, modification of matrix stiffness, loaded with seeding cells and coated with growth factors or other functional molecules prior to implantation, also have been demonstrated to have a significant effect on bone healing and reconstruction. These modifications are necessary to further fabricate more functional bone grafts, and these modifications can have a consequential impact on in vivo results. Therefore, in order to better understand the involved exact mechanisms and adverse effects, further investigation is required by animal experiments prior to clinical trials. Animal species, defect size and implantation time period will affect in vivo healing and repair of implanted grafts. Due to small size and characteristics of convenience processing, rats and rabbits are the most commonly used animal models. However, for their poor similarity to human bones, further investigations and more research on large animal models that are close to human skeletal characteristics is still necessary. Taken together, based on the information provided in this overview, it was confirmed that decellularized and DBM in the natural bone grafts can in fact reconstruct defective bone, even though the effects of different pretreatments still require further investigation in clinically relevant animal models of bone defects. By analyzing some of the existing research results, the authors hope that this review will provide a reference for the in vivo studies and new design of decellularized and DBM scaffolds to obtain preferable in vivo regeneration.