The spontaneous regression or remission (SR) of cancer, often described as the partial or complete disappearance of a malignant tumor in the absence of all medical treatment and therapy, is a well-documented phenomenon. With efforts ongoing to establish cancer treatments that limit undesirable outcomes and adverse effects, these uncommon occurrences of SR carry significant implications for novel therapies and warrant further investigation. While several case studies have reported instances of SR in gastrointestinal (GI) malignancies, a comprehensive review of previous manifestations of SR in the GI tract remains lacking. The inclusion criteria for the rare phenomenon are also in need of an appropriate update that takes recent scientific advancements and emerging new medical technologies into account. Our analysis of 390 cases of SR in the GI tract focuses primarily on neoplasms of the hepatobiliary system and proposes an updated version of the older inclusion criteria for spontaneous regression. In 2021 alone, 372,470 new cases of primary gastrointestinal (GI) cancer were reported worldwide, and approximately 124,348 deaths occurred as a result, comprising 19.6% and 20.4% of total new cancer cases and deaths, respectively . OccurriA number of putative mechanisms have been proposed for the observed spontaneous disappearance of malignancies, including inflammation, apoptosis, ischemia, and immunological responses . Other mFocusing chiefly on malignancies of primary GI origin, this observational review of the literature hopes to bring further attention to the phenomenon of SR while also identifying some potential mechanisms that have been purported to contribute to this largely unreported phenomenon. Secondarily, this comprehensive review aims to introduce a revised and up-to-date version of the older inclusion criteria for SR throughout the body. This updated criterion has been modified in a way that takes into account recent scientific advancements and emerging new medical technologies, with the intent that it will also be easy to follow for physicians and clinical researchers alike. Finally, this study seeks to broaden the scope of how SR is perceived by clinicians and members of the medical community by encouraging a holistic view of the exceptionally rare phenomenon as a dynamic interplay of various modalities.Materials and methods: Search Strategy A literature search across five databases  was performed employing the following main keywords: gastrointestinal cancer, spontaneous regression, spontaneous remission, spontaneous necrosis, and abscopal effect. A full list of searched keywords is included in Appendix A. The clinical characteristics of each occurrence of SR within the GI pathway and the related long-term outcomes were then extracted. Articles were excluded if any systemic treatment was used or if any treatment directed at the lesion was utilized before the documented regression. All diseases were limited to the GI tract, spanning the oral cavity, esophagus, stomach, liver, bile duct, gallbladder, pancreas, mesenteries, peritoneum, small intestine, colon, and rectum. A manual search of each work’s citations was performed, utilizing additional published works listed in the supplementary materials or reference sections of each of the aforementioned studies. No restriction was applied to the date of publication, the form of publication, or the primary language of the publication.Inclusion CriteriaOnly publications that described the true SR of a histologically confirmed GI cancer were included following the inclusion criteria depicted in Figure Data Extraction and AnalysisThe following information was extracted and recorded from each article: patient age and sex, location and histological typing of the primary tumor, the site of regression, the period of regression or remission, and the etiological mechanism of regression proposed by the author. The demonstrated recurrence of cancer was also noted in some patients. Limited to each author’s interpretation and the duration of follow-up included in each study, the period of remission was defined as one of the following, whichever was found to be the longest: (1) the total period of time during which the tumor demonstrated a shrinkage in size, beginning with the date when the tumor’s size was found to be at its maximum to the date when the tumor’s size was found to be at its minimum, (2) The total period of time between the partial or complete disappearance of cancer and the most recent follow-up date in which the patient continued to show no signs of metastatic spread or recurrence of the malignancy; (3) the total period of time during which the tumor demonstrated a shrinkage in size prior to its resection, from the proposed date when the tumor’s size was found to be at its maximum size to the date of the resection. After the tumor was resected, the specimen was pathologically found to have shrunk or disappeared.ResultsOf the 390 cases of SR of GI malignancies reported meeting our criteria, a majority were noted in men  compared to women . The mean patient age was 63 years, with a majority of patients between 65 and 74 years of age  or 55 and 64 years of age . Overall, the literature search demonstrated a global incidence of SR, with cases spanning all six inhabited continents.All reported cases detailing the SR of GI malignancies throughout the clinical literature are comprehensively reviewed in Appendix B, with pertinent findings summarized in Table The vast majority of cases of partial or complete regression occurred within the primary tumor ; nonetheless, multiple cases demonstrated regression of liver metastases , lung metastases , lymph metastases , or other metastases . The period of regression (as defined above) varied greatly in these cases, with some cases reporting just a few days of regression and others expressing several years of remission. Cancer recurrence was reported in 24 cases of SR, comprising 6.2% of total cases of SR in the GI pathway (noted with an asterisk "*" in Appendix B).The authors proposed various putative mechanisms of SR, which are summarized in Table The majority of the reviewed authors provided at least one conjectural mechanism , with most citing immunological , ischemic , or idiopathic  processes.DiscussionThis systematic review includes the presentation of 390 cases reported in 346 scientific papers, journals, case studies, and published books. These publications were generated over the past 95 years. Interestingly, 325 cases were published in the modern era, defined as cases published in the past 30 years. Following the review of these articles, multiple common factors were revealed, including a tendency for SR to occur in patients over the age of 55 , patients of the male sex , and patients with primary liver tumors  or secondary liver metastases . The clinical features and proposed mechanisms surrounding these cases of SR within the GI pathway, along with the location and duration of remission, are documented in Appendix B. Patients within this cohort of reported cases displayed varied periods of stability, ranging from just a few days of observed partial tumor regression to several years of cancer remission, up to 20 years cancer-free.Mechanisms of Spontaneous RegressionHistorically, SR has been speculated to occur in the setting of a prolonged febrile illness due to viral or bacterial infection; nonetheless, only a fraction of cases of SR  have been attributed to a hyperthermic state and infection . In caseEnhanced antitumoral immunogenicity is proposed to play a profound role in the involution of several GI cancers. In fact, examples displaying the correlation between SR and the elimination of immunodisruptive factors  are perhaps the best evidence supporting the involvement of immunological mechanisms in the achieved SR of GI cancer ,25. TumoIschemic models of regression are also proposed to play a key role in the dynamic interplay of antitumoral mechanisms described in the SR of cancer. Tumor cells require an ample supply of blood, so limiting their blood supply and perfusion could intuitively starve the cells to death -29. ConsWhile endocrinologic mechanisms are largely considered to play a secondary role in the course of tumor regulation, notable hormonal changes are considered possible antecedents to SR . In a caSpontaneous Regression in Cancers of Specific PathohistologyHepatocellular carcinoma: While testicular germ cell tumors, neuroblastomas, and renal carcinomas are conventionally the most frequent types of histologically diagnosed tumors presenting this phenomenon, several recent studies report an increasing incidence of SR within the GI pathway, particularly in primary hepatic lesions ,40. CorrTo prevent a barrage of immune responses to innocuous materials while still enabling immunity to pathogens, the complex cellular, functional, and molecular modeling of the liver allows for a dynamic, multifaceted approach to immune surveillance that incorporates the tolerogenic organ’s inherently immunosuppressive microenvironment and its distinct hepatic regulatory pathways . It is pInterestingly, several of the changes associated with the SR of the poorly prognosed tumor can also be observed following transarterial chemoembolization (TACE) treatment, thus suggesting that the SR of HCC should, to some degree, involve ischemic processes . RegressPrimary oral and gastrointestinal lymphoma: Cases detailing the SR of primary oral and GI lymphomas were observed to span the entirety of the alimentary canal, from several primary extranodal lymphomas of the oral cavity to four cases of rectal lymphoma that regressed spontaneously. Regarding the spontaneous regression of aggressive NHLs of the digestive tract, several cases have been reported demonstrating the spontaneous involution of lymphoma following improved immunological status, particularly in HIV-infected patients receiving antiretroviral therapy -32.While SR is an exceptionally rare occurrence in aggressive lymphomas, such as DLBCL and ALCL, it can occur relatively frequently in low-grade lymphomas such as follicular lymphomas (FLs) and mucosa-associated lymphoid tissue (MALT) lymphomas. Generally, well- or moderately-differentiated forms of cancer are considered low immunogenic tumors due to their limited mutational load and concomitant limited neoantigen expression. In a retrospective analysis of 209 cases of NHL from 1965 until 1978, Gattiker et al. reported the occurrence of SR in 18 out of 140 (12.9%) cases of nodular type malignant lymphoma and 2 out of 69 (2.9%) cases of diffuse type malignant lymphoma . The relPancreatic ductal adenocarcinoma: With only a few cases reported in the literature, pancreatic tumors are seldom known to undergo SR, leaving clinicians skeptical of this lethal tumor’s ability to truly demonstrate involution when left untreated. Despite numerous molecular and immunological approaches, pancreatic cancer is typically poorly responsive to existing chemotherapeutic and immunological antineoplastic agents. This lack of response to immunotherapies is largely due to cancer’s low mutational burden and tendency to favor an immunosuppressive microenvironment characterized by self-isolating dense desmoplastic tissue and an exceptionally low number of infiltrating T cells ,48. In aColorectal cancer: Like pancreatic cancer, colorectal cancer has long been considered poorly immunogenic, largely based on indirect data from epidemiological studies on the lack of SR in colorectal cancer ,54. ThisStrengths and LimitationsWhile prior retrospective analyses have investigated the incidence of SR for specific cancers and its occurrence within the individual organs of digestion, an observational study of this scope, broadly examining all prior cases of SR throughout the entire GI pathway, has never been published to date. This first-of-its-kind study systematically and thoroughly extracts and organizes information from an array of 390 individual cases of SR within the GI pathway. Although the majority of reports were restricted to the English literature, cases in other languages, including Spanish, Chinese, German, and Japanese, are included in this broad review in order to better demonstrate the global incidence of the otherwise rare phenomenon. Putative mechanisms for SR, including immunological, ischemic, and idiopathic modalities, are also explored and discussed in a detailed manner with the hopes of aiding in an understanding of SR as a dynamic interplay of complex and interconnected antitumoral responses.In general, SR remains a poorly understood and somewhat vaguely defined phenomenon. Our review has multiple limitations. Recognizing true SR as a host response to specific tumors may continue to be obscured by bias in how the regression is reported. In addition to the possible underreporting of cases of SR by certain physicians, there is also a significant amount of variability in how SR is defined. Distinguishing SR from abscopal effects and tumor regression instigated by eradication therapy remains highly subjective and may result in the misreporting of true spontaneous antitumoral host responses to specific cancers. Overall, the literature is quite heterogeneous, and not every case study reported the duration of follow-up or the duration of remission in a similar manner as would be expected in a retrospective review of this kind.SR is an extremely rare occurrence. Nonetheless, certain recurrent patterns in cases of SR, as demonstrated in this review, deserve ample consideration. To better study SR in the future, there must be an emphasis on standardizing how SR is reported. A well-defined registry would also be helpful. Ultimately, this broadly encompassing yet focused assessment is meant to bring attention to the phenomenon of SR and perhaps aid in the investigative efforts in the burgeoning field of immunotherapies.


Extracellular vesicles (EVs) are nanosized particles that arise from a wide range of cells and contain molecular cargo, including a variety of proteins, messenger RNAs (mRNAs), and microRNAs  and postmortem brain samples of sporadic or familial patients with AD, and observed that these EVs affected cell components of the neurovascular unit, such as astrocytes, endothelial cells and neurons, and induced cytotoxicity and astrocyte hyperreactivity in vivo. Neurovascular unit disruption and dysregulation of cerebral blood flow have been recognized to play an important role in the progression of AD pathology even in the initial stage  regulation between large  and small (30–150 nm) EVs derived from plasma of patients with various neurodegenerative diseases, such as AD, PD, frontotemporal dementia and ALS. Bioinformatics and pathways analyses indicated common transcriptomic profiling underlying neurodegenerative processes, although the specific RNA transcript signature for different diseases needs further investigation.Moreover, RNAs, such as mRNA and non-coding RNA, were prominently loaded in EVs and involved in intercellular communication. Utz et al. used flow cytometry to analyze microvesicles (EVs released from the cell membrane) in cerebrospinal fluid carrying total and phosphorylated tau, and synaptic-related proteins, and observed an elevation in the percentages of synaptophysin-bearing (but not tau-bearing) microvesicles in patients with AD compared with non-inflammatory neurological disease controls, classified according to the AT(N) biomarker system. This finding indicated that not only molecular concentration but also number or percentage of EVs carrying target molecules were potential biomarkers for disease diagnosis and activity.With respect to diagnosis, Zhang et al. reported that cerebral endothelial cell-derived small EVs (exosomes) from aged diabetes mellitus rats inhibited neurogenesis, whereas those from adult healthy normal rats alleviated diabetes mellitus-impaired neurogenesis, cognitive function and cerebral vasculature. These therapeutic effects of cerebral endothelial cell-derived small EVs, which crossed the blood brain barrier and were internalized by neural stem cells in the neurogenic regions of the subventricular zone and the subgranular zone of the dentate gyrus, might be attributed to increases of miR-1 and -146a and reductions of their target genes, such as myeloid differentiation primary response gene 88 and thrombospondin 1.In terms of treatment, Gao et al. reviewed the role of exosomes in the pathophysiology, diagnosis, prognosis, and treatment of some neurodegenerative diseases, including AD, PD, Huntington's disease, and ALS. Due to their peripheral availability and ability to cross the blood brain barrier, exosomes have the potential to be used both as diagnostic biomarkers as well as drug carriers for the treatment of neurodegenerative disease. However, as discussed in this review, therapeutic safety and technical issues present major challenges to the clinical application of exosomes.Although there are several limitations for most previous and current studies, such as standardization of methodologies including isolation, characterization and classification of EVs, and small sample size in different cohorts, EVs hold great promise for understanding the biological processes, discovering diagnostic tools and developing therapeutic approaches in neurodegenerative diseases.NZ drafted the manuscript. MG revised the manuscript for important intellectual content. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: The current scientific literature is inconsistent regarding the potential beneficial or deleterious effects of high-intensity physical activities on the pelvic floor (PF) in women. So far, it has not been established with certainty whether disparate breathing mechanisms may exert short- or long-term influence on the PF function in this context, although based on the established physiological interrelationship of breathing with PF activation, this seems plausible. Objective: To propose a basic concept of the influence of different breathing patterns on the PF during strenuous physical efforts. Methodical approaches: Review of the recent literature, basic knowledge of classical western medicine regarding the principles of muscle physiology and the biomechanics of breathing, additional schematic illustrations, and magnetic resonance imaging (MRI) data corroborate the proposed concept and exemplify the consequences of strenuous efforts on the PF in relation to respective breathing phases. Conclusion: The pelvic floor muscles (PFMs) physiologically act as expiratory muscles in synergy with the anterolateral abdominal muscles, contracting during expiration and relaxing during inspiration. Obviously, a strenuous physical effort requires an expiratory motor synergy with the PFM and abdominal muscles in a co-contracted status to train the PFM and protect the PF against high intra-abdominal pressure (IAP). Holding breath in an inspiratory pattern during exertion stresses the PF because the high IAP impinges on the relaxed, hence insufficiently protected, PFMs. It seems conceivable that such disadvantageous breathing, if performed regularly and repeatedly, may ultimately cause PF dysfunction. At any rate, future research needs to take into account the respective breathing cycles during measurements and interventions addressing PFM function. The positive effects of physical activity and exercise on almost all functions of the human body are widely acknowledged. However, the scientific literature suggests that the female pelvic floor (PF) may be exempt from these benefits in many cases ,2,3. In In 2005, the Pelvic Floor Clinical Assessment Group of the International Continence Society (ICS) presented a standardisation of the terminology of the pelvic floor muscle (PFM) functions and dysfunctions , which dThe standardisation of the terminology represented a milestone in the definition of PFM physiology. However, two fundamental aspects of PFM function were not considered at that time. First, the PFMs do not act in isolation but in synergy with the anterolateral abdominal muscles, and both muscle groups together are inseparably linked to breathing activities ,13,14,15To date, these issues cannot be clarified based on the available scientific literature. Most published studies regarding PFM functions and dysfunctions—even randomized controlled intervention trials—fail to provide information on the interrelationship between breathing and abdominal muscle function with PFM activation. Such a lack of a clear definition prevents meaningful systematic meta-analyses and reviews on this topic. Therefore, the aim of this narrative article is to propose a basic concept from a theoretical viewpoint on how PFMs contract in an expiratory synergy with the abdominal muscles to protect the PF during strenuous efforts and how they relax in an inspiratory synergy to allow atraumatic evacuation processes, if needed. The paper does not report new scientific data confirming or refuting a defined research hypothesis. Rather, the concept presented here combines recent scientific evidence obtained over the last two decades with a common knowledge of classical western medicine regarding the anatomy and functions of the thoracic diaphragm, PF, thoracic and abdominal muscles, principles of muscle physiology, and biomechanics of breathing. Schematic views and dynamic magnetic resonance imaging (MRI) support the presented concept and exemplify the involvement of the PFMs in the mechanisms of breathing and the concerted synergy between the abdominal muscles and the PFMs during physical activities.Similarly to the thoracic cavity, the abdominopelvic cavity is also surrounded by dynamic multilayer muscular structures. Three layers of anterolateral abdominal muscles  and rectus abdominis muscles constitute the lateral and anterior walls, respectively. The PFMs form the base and the thoracic diaphragm forms the top ,19. All The muscle groups surrounding the abdominal cavity show relevant differences in muscle composition and physiology. The deep muscles, i.e., the transverse abdominis and internal oblique in the abdominal wall ,23, the The superficially located muscles, i.e., the external oblique and rectus abdominis muscles in the abdominal wall, and the bulbospongiosus, ischiocavernosus, and transverse perineal muscles in the PF contain a high proportion of fast-twitch fibres. Their glycolytic metabolism enables them to react to immediate energy requirements and allows for fast and strong contractions during rapid movements and strenuous efforts. These muscles are predominantly innervated by fast-conducting large-diameter myelinated alpha-motoneurons and are mainly recruited during voluntary efforts ,28. AccoBreathing is a basic vital function, essential to sustain life processes. The life-long continuous mechanical act of breathing in and out is a whole-body process, accomplished by a highly coordinated rhythmic alternation of contraction and relaxation of the muscles surrounding the thoracic and abdominal cavities, in accordance with the main respiratory function of the thoracic diaphragm ,31. The At the onset of inspiration, the muscle fibres of the thoracic diaphragm contract via innervation by the phrenic nerve and the thoracic diaphragm flattens and descends caudally ,31. InspNotably, the thoracic and abdominal cavities are both widened during inspiration and narrowed during expiration and the diaphragms show a parallel downward movement during inspiration and a parallel upward movement during expiration; yet, the two main muscle groups are in different contractile states—the thoracic diaphragm and inspiratory muscles contract, while the expiratory muscles, including the PFMs, relax, and vice versa  Figure .Quiet breathing occurs largely independent of conscious perception  by meansHumans can consciously activate and contract these muscles independently , not onlIn our opinion, based on such fundamental physiological mechanisms, strenuous resistance training and intensive physical activities of any kind should be performed during an expiratory motor synergy, i.e., (1) while synchronizing forceful exertions with synergistic concentric contractions of the PFMs and all layers of the abdominal muscles, and (2) with the glottis open. Synergistic contractions of the PFMs and abdominals serve to protect the PF against high IAP and additionally to support posture and stability during stance, running, fighting, and straining, whenever necessary ,10,44,45To date, no clearly defined and generally accepted guidance is available on the influence of different breathing patterns and the contractile state of the respective trunk muscle groups during physical activities . The gui2O [Finally, even in medical practices, expiration is often considered the result from passive, elastic recoil of the thoracic diaphragm, the lungs, and the chest walls ,35. Resp2O . Obvious2O . On the In addition to these situations with a breath-dependent coordinated or dyssynergic interplay between the different muscle groups, it should also be noted that some people present an increased tone and persistently concentric co-contraction of both the PFMs and the abdominal muscles not only during strenuous endurance training ,56. TherOn dynamic MRI sequences, there is a striking similarity between the cyclic expansive and narrowing movements of the thoracic and abdominal cavities during breathing compared to the cyclic systolic and diastolic movements of the heart. Both seem to be very efficient by means of pumping either air or blood. In this context, it is interesting to compare the alternating breathing-dependent contractile states of PFMs and abdominal muscles with the cyclic changes in the myocardium during the cardiac cycle. During the systole, efficient muscle contractions and blood ejections are only possible when the myocardial muscle cells relax sufficiently to allow for filling of the ventricle with blood during the preceding diastole ,60.To exemplify the consequences of common activities on the PF and their relation to the respective phases of breathing, we have previously reported dynamic MRI findings that demonstrated movement of the thoracic diaphragm, abdominal wall, and PF in real-time and indicated the corresponding muscle contractile status during the different phases of breathing, as well as while coughing, straining, and performing the Valsalva manoeuvre ,43. To sThe dynamic MRI images were exclusively obtained to support and better visualise the presented concept and were not created as part of another study. The investigated volunteer carried out the “incorrect” straining manoeuvres intentionally.The views on the role of breathing in connection to the PF have changed several times since PFM exercises were first described by the gynaecologist Arnold Kegel in the late 1940s . DiffereDue to the narrative character of this article, the authors have neither intended to cite all recent and relevant publications nor to evaluate or qualify established diagnostic or therapeutic measures and recommendations regarding PFM function and dysfunction or PFM training. However, they believe that the consideration of respiratory mechanics may serve to open different perspectives and to enhance the effects of many of such interventions. Above all, however, the authors wish to emphasize that future research on both diagnostic and therapeutic measures related to PFM (dys-) function requires specific and clear terminology and definitions of the muscular contractile status and position of the PF with respect to the different phases of breathing before obtaining measurements of any kind and relating data to the outcome of the interventions. Without these prerequisites, much of the research is not comparable, not reproducible, and risks becoming obsolete.Physical activity and strenuous efforts can stress the PF, and may, if performed repetitively, ultimately cause PF dysfunction when performed during inspiration or breath-holding, because high IAP impinges on non-contracted, hence, non-protected PFMs. In contrast, it seems conceivable, based on physiological synergies, that an expiratory motor pattern during body workouts and strenuous efforts is likely to protect and even train the co-contracted PFMs and lower abdominal muscles. Future studies which imply exact definitions of respiratory phases and contractile muscle states, will contribute to enhance the usefulness and comparability of the obtained data and will serve to support or refute the herein presented concept. Finally, they will ultimately enable further development of this hypothesis, which may lead to better understanding of PF disorders and their management.


Lycopene is a nutraceutical with health-promoting and anti-cancer activities, but due to a lack of evidence, there are no recommendations regarding its use and dosage. This review aimed to evaluate the benefits of lycopene supplementation in cancer prevention and treatment based on the results of in vivo studies. We identified 72 human and animal studies that were then analysed for endpoints such as cancer incidence, improvement in treatment outcomes, and the mechanisms of lycopene action. We concluded that the results of most of the reviewed in vivo studies confirmed the anti-cancer activities of lycopene. Most of the studies concerned prostate cancer, reflecting the number of in vitro studies. The reported mechanisms of lycopene action in vivo included regulation of oxidative and inflammatory processes, induction of apoptosis, and inhibition of cell division, angiogenesis, and metastasis formation. The predominance of particular mechanisms seemed to depend on tumour organ localisation and the local storage capacity of lycopene. Finally, there is a need to look for predictive factors to identify a population that may benefit from lycopene supplementation. The potential candidates appear to be race, single nucleotide polymorphisms in carotene-cleaving enzymes, some genetic abbreviations, and insulin-like growth factor-dependent and inflammatory diseases. Lycopene is a carotenoid nutraceutical that enhances protection against cancer, cardiovascular disease, hypertension, and neurodegenerative and inflammatory diseases . It is nLycopene has no pro-vitamin A activity, but its 11 conjugated double bonds are twice as numerous as the physical quenching rate constant with singlet oxygen compared to β-carotene , resultiOur research aimed to assess whether the successes of in vitro studies are reflected in human and animal studies where the final effect of lycopene depends on other factors, such as its absorption and distribution, the influence of the microenvironment, and drug interactions.The PubMed, Scopus and Web of Science databases were comprehensively screened for papers about lycopene in cancer. The search keywords were “cancer” and “lycopene”, and results were limited to original papers published in English until June 2022. The search terms are shown in Data extraction was performed twice to avoid bias. The papers were divided into four subgroups depending on their content: human studies concerning cancer treatment, prevention, or with other endpoints that mostly concerned the mechanism of lycopene action, and animal research . The datThe search algorithm that we used enabled us to identify 86 in vivo studies on lycopene in cancer . Of the We found 20 papers on lycopene and the risk of prostate carcinogenesis in humans . Most ofThe animal studies had inconclusive results regarding the preventive role of lycopene in prostate cancer . In threThe role of lycopene in cancer treatment in humans was studied only in prostate cancer , and theAll six animal studies that examined the therapeutic effect of lycopene on prostate cancer obtained positive results and showed that supplementation caused tumour volume or weight reduction, apoptosis augmentation, prostate cancer-specific mortality decrease, or prostate cancer-free survival prolongation ,27,36,54The preventive potential of lycopene in female cancers was demonstrated in an animal model of ovarian cancer with predominant antioxidant and anti-inflammatory mechanisms . In cervH. pylori status [With regard to cancers of the digestive system, lycopene intake showed a strong protective effect against stomach cancer, regardless of i status . The meci status ,81,83,93i status . Two indi status ,76. Lycoi status . A lycopi status . In hepai status ,62,88.All the studies about lycopene in head and neck cancer confirmed its anti-cancer activity. The levels of lycopene were inversely associated with incidence and mortality in these cancers ,67. AnotThere are limited data on the role of lycopene in urological neoplasms other than prostate cancer. However, in bladder cancer the lycopene levels were shown to have been lowered at a borderline level of significance, which may suggest a causal relationship . SimilarIn the animal model, lycopene supplementation prevented type B ultraviolet-induced photocarcinogenesis, which was not shown in the human observational studies ,87. LikeOnly 5 of the 39 studies about the anti-cancer role of lycopene in tumours other than prostate cancer had negative results. In humans, neither higher dietary levels nor higher plasma lycopene levels were shown to be associated with a reduced risk of breast cancer . In addiThe identified mechanisms of lycopene’s interference with carcinogenesis in vivo cover the whole range of intracellular processes and their impacts on the tumour microenvironment , which gOne of the debatable results seems to be the influence of lycopene on angiogenesis. A large study observed that dietary intake of lycopene was associated with a reduced risk of lethal prostate cancer and a lower degree of angiogenesis in the tumour . In factAnother questionable result is the effect of lycopene on the IGF-mediated pathway. In a study about lycopene in prostate cancer treatment, the supplementation did not alter the IGF1 and IGFBP3 levels . The levH. pylori-induced gastric cancer, colitis-associated colorectal cancers, pancreatic cancer related to chronic pancreatitis, or hepatocellular carcinoma caused by chronic inflammation of the viral, toxic, metabolic, or autoimmune aetiology [H. pylori-induced gastritis, inflammatory bowel diseases, toxin- and viral-induced hepatitis, and alcoholic and non-alcoholic fatty liver disease [Another issue worth commenting on is the anti-inflammatory effect of lycopene, which has been comprehensively discussed by some studies  and may etiology ,108,109. disease ,117,118. disease ,60, respA very important aspect in the design of clinical trials with lycopene is appropriate population selection and attention to racial differences, which affect pharmacodynamics and are associated with different baseline levels of lycopene in populations with different diets . The relThe population of patients who could benefit from the anti-cancer properties of lycopene can be found by identifying the predictive factors for lycopene supplementation. In one of the prospective studies about lycopene in prostate cancer, it was found that supplementation always raised the serum level of lycopene but did not always enhance the accumulation of lycopene in the prostate, and that not serum but low prostate lycopene levels were correlated with prostate cancer . From thThe use of nutraceuticals and dietary supplements in the prevention and treatment of cancers is highly controversial due to the likely additive effect of many substances from the daily diet and the difficulty of designing selective studies identifying the specific substances and doses at which the nutraceuticals and dietary supplements exhibit anti-cancer effects. The lack of established daily references for lycopene consumption has resulted in various dietary supplements’ unregulated lycopene content. A European Food Safety Authority panel recommends a lycopene intake of 0.5 mg/kg body weight per day, at most 75 mg per day, but some reviews have shown that a dietary or formulated lycopene consumption of even up to 3 g per day is safe ,128,129.In the cited intervention studies, lycopene was supplied as a dietary component (tomato paste) or as ready-made supplements available in the countries where the studies were conducted see . None ofLycopene has been reported to improve treatment outcomes in prostate cancer when used with docetaxel, soy isoflavones, and orchidectomy to treat advanced prostate cancer ,33,36,51To our knowledge, the present study is the only one to date that has comprehensively assessed the anti-tumour role of lycopene in humans and animals in a clinical setting. As a result, we confirmed that in vivo lycopene exhibits anti-cancer effects previously observed in in vitro studies. However, we are aware that the limitation of the presented analysis is its qualitative nature and the inclusion of studies regardless of the risk of bias. We have deliberately not limited this review to high-quality studies because the available data on intervention studies are too little and heterogeneous to be used in statistical analyses. Further population-specific studies are needed to quantify the anti-tumour role of lycopene.Most in vivo studies have confirmed the anti-cancer activities of lycopene, particularly in prostate cancer. Human and animal studies have confirmed the influence of lycopene on some hallmarks of cancer, but the contributions of particular mechanisms seem to depend on the tumour organ localisation. The heterogeneity of the analysed interventions shows the need for systematised prospective studies to determine the appropriate recommended dose of lycopene in the daily diet and to search for predictive factors for the use of lycopene, particularly for oncological indications.


The PHIRI federated approach has consisted of the development of four research queries (use cases) mobilising individual data from a number of data hubs (nodes in the federation). Methodologically speaking, use cases have required the creation of specific cohorts of patients, population subgroups or populations, and the identification of events of interest - over-time differences in health status and care healthcare utilisation before and during the pandemic. Technologically speaking, PHIRI infrastructure consists of a distributed end-to-end analytical pipeline containing the statistical analysis workflow, including data quality assessment at origin and the mathematical algorithms. Once datasets are prepared in each data hub, partners run the analyses and produce a research output (dashboards containing the research results and tables with aggregated data) that is shared for results compilation and comparative analysis. An enhanced version of the PHIRI infrastructure should allow more complex data distribution. The research questions covered so far are aiming inference on populations or providers, which implies a very simple distribution methodology, as described. However, when the research questions requires inference on the individuals , when the inference requires a hierarchical approach  or when, several rounds of training are needed  the approach would require sharing coefficients, distances in n-dimensional spaces or models, and, some times various rounds of distribution. Finally, an enhanced version of the PHIRI infrastructure should generalise the current FAIR approach limited to the publication of the analytical pipeline in ZENODO, setting up the services and tools required for an improved version of the PHIRI open-science strategy.


The application of radiogenomics in oncology has great prospects in precision medicine. Radiogenomics combines large volumes of radiomic features from medical digital images, genetic data from high-throughput sequencing, and clinical-epidemiological data into mathematical modelling. The amalgamation of radiomics and genomics provides an approach to better study the molecular mechanism of tumour pathogenesis, as well as new evidence-supporting strategies to identify the characteristics of cancer patients, make clinical decisions by predicting prognosis, and improve the development of individualized treatment guidance. In this review, we summarized recent research on radiogenomics applications in solid cancers and presented the challenges impeding the adoption of radiomics in clinical practice. More standard guidelines are required to normalize radiomics into reproducible and convincible analyses and develop it as a mature field. Currently, tumour tissue biopsies are the protocol for cancer diagnosis . HoweverFortunately, radiomics, a medical imaging method, holds great promise to address the problem of spatially and temporally heterogeneous solid cancers in a noninvasive way. Radiomics was first presented by Lambin et al. in  and invoWith the success of the Human Genome Project (HGP), the application of genomics in medicine shows strong feasibility and prospects, which has brought an anticipated transformation in the prevention, diagnosis, and treatment of diseases. Projects such as The Cancer Genome Atlas (TCGA) have witnessed tremendous strides towards comprehensively cataloguing human genes and mutations. Some specific ones were found to be capable of serving essentially as ‘drivers’ of oncogenesis, primarily via exome or genome sequencing of large numbers of tumour samples matched with normal tissues , 5. AccoGenerally, the radiomics workflow consists of the following main steps: imaging data collection, imaging preprocessing, identification and segmentation of the region or volume of interest, feature extraction, feature selection, model establishment, and model validation , 10.The original medical images are necessary for performing radiomics analysis. Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) have been extensively applied in the field of oncology to assist diagnosis and guide treatment. Images can provide detailed information about tumours’ anatomical and functional features. Medical imaging technology has made tremendous progress in the past, enabling the emergence of radiomics as a promising methodology for solving the complex problems of oncology. The development of medical imaging devices has moved from single-slice CT to multi-slice CT, which allows dynamic radiomics at multiple time points. In addition, dual-energy CT has been explored to improve the identification of tissue composition and density . DiffusiThe preprocessing step is crucial to obtain medical images with preferred quality for subsequent analysis . ImagingImage normalization is the process of changing the range of pixel intensity values, which is the foundation of medical image analysis. Conventional normalization approaches are generally used per dataset, such as generalized scale normalization, histogram normalization, and spatial normalization , 15. RecThree primary approaches are used to segment the region of interest (ROI) in two dimensions or the volume of interest (VOI) in three dimensions: manual, semiautomatic, and fully automatic. In comparing these approaches, semiautomatic segmentation is considered optimal . ROIs/VOQuantitative radiomics features extracted from segmented ROIs/VOIs can be divided into several major categories, including shape, statistical, and texture features . Shape fThe core of the radiomics approach is to establish a predictive model. The modelling process is based on the training data analysis. It is indispensable to apply the model on testing data to evaluate its extrapolation performance, proving the model's precision, fit, and feasibility. Generally, hundreds of radiomics features can be extracted from images. Therefore, feature selection needs to be performed to identify the most valuable traits to avoid overfitting, since the incorporation of redundant features into a model will degrade the performance of model extrapolation. Least absolute shrinkage and selection operator (LASSO) plays a prominent role in selecting informative features . PrincipIn addition, deep learning provides a non-engineered radiomics modelling methods and has been applied in various medical image analysis tasks, including supervised learning, unsupervised learning, and semi-supervised learning . ModelsThe last step of the radiomics approach is assessing performance and external validation based on other datasets to prove the credibility of the established model. The performance can be evaluated using the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and the C-index to assess the discrimination of the model, and calibration curves can be used to appraise the calibration in the training and validation sets. The model's potential clinical value can be estimated by using decision curve analysis (DCA) . In addiThe literature on radiogenomics has greatly expanded in the past decade. Radiogenomics has been applied in various types of cancer, including lung cancer –72, breaRadiomics predictive models have diagnostic value capable of assisting clinicians in making decisions based on big data evidence. Chen et al.  establisCancers can be devastating on account of the high recurrence rate. Recently, Shim et al.  proposedBased on a radiomics cohort of medulloblastoma (MB) patients with MRI data, Yan et al.  construcContrast-enhanced CT is also a critical imaging examination method in clinical applications. Huang et al.  enrolledTo assess the ability of a model constructed by integrating radiomics, genomics, and clinical features to predict the metastasis of colorectal cancer (CRC) patients, Liu et al.  retrospeIt is difficult to predict patient response to treatment on account of the heterogeneity of solid tumours, the absence of consistent and accurate biomarkers, and a vague understanding of resistance mechanisms. The approach of radiogenomics has shed light on addressing these challenges through the untapped and abundant resource of imaging data . Aiming Through the combination of genomics data and CT radiomics features, it is likely feasible to predict the molecular characteristics of patients with cancer. In research on ccRCC, Zeng et al.  applied Another multi-institutional retrospective study conducted by Park et al.  showed tRadiomics analysis is also capable of helping with the establishment of a molecular typing system. By performing quantitative radiomics analysis, Li et al.  demonstrDespite the great potential shown by radiomics in clinical guidance, no developed radiomics signature is currently applied in the clinical field. There are still many challenges regarding the application of radiomics. A significant variation exists in every step during the whole analysis process derived from different sources, leading to the poor generalizability and reproducibility of the radiomics signatures previously published , 97. ForThe application of radiogenomics in oncology shows great prospects in precision medicine. The methodology of radiogenomics integrates large volumes of quantitative yet significant imaging phenotypes extracted from medical digital images and tumour genetic profiles derived from high-throughput sequencing, together with clinical-epidemiological data, into mathematical modelling. The amalgamation of radiomics and genomics provides an approach to better study the molecular mechanism of tumour pathogenesis, as well as new evidence-supporting strategies to identify the characteristics of cancer patients, make clinical decisions by predicting prognosis, and improve the development of individualized treatment guidance. However, many challenges hinder the application of radiomics in real clinical situations, such as the poor generalizability and reproducibility of the previously published radiomics models. Therefore, more standard guidelines are needed in future research to normalize radiomics into reproducible and convincible analysis and develop it as a mature discipline.


Connective tissue ageing is accelerated by the progressive accumulation of advanced glycation end products (AGEs). The formation of AGEs is characteristic for diabetes mellitus (DM) progression and affects only specific proteins with relatively long half-lives. This is the case of fibrillar collagens that are highly susceptible to glycation. While collagen provides a framework for plenty of organs, the local homeostasis of specific tissues is indirectly affected by glycation. Among the many age- and diabetes-related morphological changes affecting human connective tissues, there is concurrently reduced healing capacity, flexibility, and quality among ligaments, tendons, bones, and skin. Although DM provokes a wide range of known clinical disorders, the exact mechanisms of connective tissue alteration are still being investigated. Most of them rely on animal models in order to conclude the patterns of damage. Further research and more well-designed large-cohort studies need to be conducted in order to answer the issue concerning the involvement of ligaments in diabetes-related complications. In the following manuscript, we present the results from experiments discovering specific molecules that are engaged in the degenerative process of connective tissue alteration. This review is intended to provide the report and sum up the investigations described in the literature concerning the topic of ligament alteration in DM, which, even though significantly decreasing the quality of life, do not play a major role in research. A lack of physiological action of insulin in diabetes mellitus (DM) induces an impaired metabolism of carbohydrates, lipids, and proteins, which are the necessary components for cellular homeostasis and tissue activities . AlteredLigaments are compositions of collagenous tissue that create the joints and link bones together. Two-thirds of the inner biochemical content of ligaments is water, and one-third consists of solid components. Those in the majority consist of collagen (type I collagen accounting for 85% of the collagen), proteoglycans, elastin and other proteins, and glycoproteins such as actin, laminin, and integrins . LigamenIn the present study, we aimed to research the mechanism responsible for ligament disorders and malfunctioning in patients suffering from DM, based on the currently available literature, as well as to conclude the fields for prospective research that must be conducted to illuminate the concern.Persistent hyperglycaemia provokes glucose interference with plasma molecules, covalent formations with lipids, and proteins via non-enzymatic glycation, which determines the alteration of molecular mechanisms and the overall tissue condition .Protein glycation and the formation of AGEs play a crucial role in the pathogenesis of diabetic complications. AGEs create intra- and extracellular cross-links with proteins, sometimes lipids and nucleic acids, which participate in the progression of diabetic complications. They cause disruption in the molecular conformation, rearrange enzymatic activity, and disorganise molecule-receptor functioning ,11,12. TBeyond the most commonly occurring complications of DM, musculoskeletal disorders are commonly found, receiving unproportionally little attention in general. The evidence shows that musculoskeletal injuries in individuals with DM may occur due to the AGEs, increasing collagen crosslinking and generating abnormal collagen deposits in tendons and ligaments as well as abnormal thickening and joint rigidity ,16. ReseSince 12% of all patients visiting orthopaedists suffer from DM, it is important to order the current knowledge about its effects on the musculoskeletal system .A study conducted by Frisch et al. reported the connection between DM in patients undergoing surgery and an elevated complication ratio due to the poor quality of soft tissues, followed by prolonged hospital stays and higher perioperative mortality .In general, surgery induces metabolic stress, catabolic hormone secretion, and breaking of an anabolic hormone action such as insulin. Patients with DM, who do not have an impaired insulin secretion and are treated with a major surgery, have an even more exacerbated metabolic stress-related response for increased insulin demand. Major surgery provokes functional insulin insufficiency ; therefoStudies consistent support that well-controlled DM is key for a successful surgery. Management by a multidisciplinary team and attention to discharge planning are the key aspects of care during and after orthopaedic surgery performed on patients with metabolic disorders ,21,22. HIt is generally recognized among the population worldwide that ageing societies carry out less physical activity. Additionally, joint stiffness is provoked by increased quantities of collagen cross-linking, an effect of AGEs. Due to differential histological formation between tendons and ligaments, the pathophysiologies of both tissues are heterogeneous. Furthermore, the prognosis for ligament healing is much worse ,24.Despite ligaments and tendons being functionally and grossly similar, mainly composed of collagen type I (Col1A1) and collagen type 3 (Col3A1), they still present as heterogeneous according to histological and biochemical characteristics. Plenty of studies concern tendon alteration facilitated by DM, but the literature is lacking regarding ligament redaction. The differences in tissue-specific collagen-maturation processes in fibroblasts creating ligaments and tendons are still unknown, and they provide the reason for the inferiority of ligaments in terms of collagen synthesis, proliferation, and migration. Studies found it to be a crucial aspect of the relatively poor healing potential of ligaments in comparison to tendons ,22.Experimental studies relying on animal models compared the morphological and biochemical features of ligaments and tendons and revealed a higher ratio of enzymatic content of the lysine hydroxylase 2/lysine hydroxylase 1 in ligaments. The expression of lysyl oxidase has a regulatory effect on the amount of enzymatic cross-linking. The levels of Col1A1 and Col3A1 were additionally greater in the case of the ligament matrices than in the tendon matrices. Ligament- and tendon-derived cells have distinct collagen-maturation processes at the cellular level, and collagen maturation of ligament cells is not necessarily inferior to that of tendons with regard to collagen synthesis and maturation .The literature shows the decreased proliferation rate, higher turnover, and breakdown of fibroblasts derived from soft tissues induced by DM. These suggest that excessive proliferation together with an altered structure of the fibroblasts may contribute to a poor production of collagen ,25. FurtIt has long been analysed that people with RA have a higher risk of T1D, and vice versa, but recent studies have concluded that the association of RA and T1D appears to be limited and specific to those RA patients with positive anti-citrullinated peptide antibodies. The risk of developing RA in later life was attributed partly to the presence of a specific allele 620 W PTPN22, possibly representing a common pathway for both autoimmune diseases. To date, both animal and human studies have yielded conflicting and inconsistent results linking DM with OA initiation and progression, and more rigorous data are needed ,12. HypeThe study conducted by Njoto I. et al. confirms that DM with characteristic perlecan expression is a trigger for OA ,31. RadoStudies link a higher prevalence of hypertrophy of ligamentum flavum (LF) to DM. It contributes to lumbar spinal stenosis (LSS), including fibrocartilaginous pathological degeneration due to the excessive proliferation of collagen, calcium crystal deposition, collagen and elastin fibre changes, and metaplasia of the ligament fibroblasts. With age, the elastin-to-collagen ratio decreases, resulting in decreased elasticity and increased stiffness or fibrosis. In DM, LF degradation is even more prominent, and it is caused through the enzymatic degradation of ECM and tissue remodelling by MMPs, TIMPs, platelet-derived growth factor-BB, connective tissue growth factor, bone morphogenetic protein (BMP), and inflammatory cytokines ,34,35,36The changes that occur in the extracellular matrix of diabetic patients’ ligaments may differ from the normal ageing process in two important ways: an increased nonenzymatic cross-link of proteins by sugar glycosylation at lysine residues and a decreased rate of proteoglycan synthesis. Only a few studies linked diabetes and LSS ,34,35. OLin et al. found that culturing rat connective tissue in hyperglycaemia for up to 48 h not only causes decreases in the expression of Col1A1 but also scleraxis and tenomodulin, as well as apoptosis and decreased proliferation . Wu et aDiabetes-induced cytokine release activates the JAK/STAT pathway that is responsible for development of the majority of cell types, including chondrocytes, osteocytes, and fibrocytes. An error occurring in order to the local or systemic inflammation causes an immediate response in disturbed signalling in this tightly regulated process . DamerauThe process of ageing facilitates morphological and histological changes in the appearance of connective tissue. The glistening white appearance of connective tissue under the microscope is not recognizable anymore at a certain extent of ageing. DM was found to be a cofactor for exacerbating this change even more abruptly. Severely affected fragments show up greyish and amorphous, disproportionally distinguished into fusiform or nodular thickening portions .Histopathological screening reveals a decreased number of fibroblasts and tenocytes together with a significantly decreased number of collagen fibres. Furthermore, they seem disintegrated and frayed, and their elasticity is consistent. The prognosis is rather poor due to the fact that detection of the condition usually takes place when the ligaments and tendons are already significantly thickened. In such an advanced stage, the normal daily-life functioning remains impaired and both the quantitative and qualitative features of the tissue are irreversibly decreased. Moreover, disturbed blood flow as a result of the progression of DM disorganizes the fundamental components of the tissue, which hinders the recovery . InvestiTan J et al. found that, in an in vivo-induced hyperglycaemic microenvironment, high glucose inhibits the osteogenic differentiation of the periodontal ligament (PDL), thus inhibiting the synthesis and secretion of the collagen matrix and calcium salts to an adequate degree . EndoplaThe balance of MMPs and tissue inhibitors of MMPs (TIMPs) is crucial for the stabilisation of the ECM, with an MMP/TIMP imbalance associated with the pathologic breakdown of the ECM ,51,52,53A wide range of studies investigating the influence of diabetes on tendons in animal models have been conducted. Although tendons and ligaments differ significantly from their hierarchical structure, which lets them adapt to their function, there are also many similarities between the two tissues. There are no preclinical or clinical data focusing on biomechanical and histological changes in ligament properties on individuals with DM, as is evidenced in the case of tendons. While the cellular and molecular mechanisms of these alterations are still ambiguous, further well-designed clinical studies are needed to establish which diabetes-induced molecules influence the ligamentous fibres, causing their degeneration.According to the conducted studies, the correlation of AGEs, excessive induction of MMPs release, formation of reactive oxygen species, and accumulation of ECM inflammatory cytokines seem to play a crucial role in complications of diabetic ligaments. Diabetes-induced ligament alteration differs from normal ageing and occurs in the ECM within two patterns: (1) an increased nonenzymatic cross-link of proteins by glycation at lysine residues and (2) a decreased rate of proteoglycan synthesis. Diabetic alterations of ligaments may especially originate from excessive stimulation and interaction with PPARs, JAK/STAT pathways, ER stress, and ROS and AGEs accumulation, which remains the speculated topic for future studies.The present studies point to the contribution of DM to the loss of elastin fibres that occurs in ligament complications following DM. To date, the majority of original studies are obsolete and contribute only to LF and PDL. Hence, further research concerning knee and hip ligaments is required to detect alterations of the aforementioned mechanisms and molecules in joints that are frequently injured in OA.


Until December 2019, we were living in the world of successfully functioning vaccines and vaccination programs. Smallpox was eradicated, polio close to being eradicated, HBV infection controlled in endemic regions, flu counteracted by seasonal vaccinations, previously deadly bacterial infections almost forgotten; respective diseases often not recognized by the medical doctors when occasional cases occurred . This grSARS-CoV-2 pandemic has highlighted the importance of vaccine development and the role of vaccines in the disease prevention. It also put on trial the position of the traditional vaccine approaches based on the inactivated or live-attenuated microbial vaccines. Historically, the most successful vaccines of the pre-COVID-19 past have been based on the attenuated live viruses. To date, the yellow fever vaccine remains one of the most efficacious vaccines against an infectious pathogen. However, attenuated vaccines have distinct disadvantages, such as the risk to revert to the virulent wild type, as well as limitations associated with administration of these vaccines to immunocompromised individuals. Inactivated vaccines provided a safer option, however they are known to be less immunogenic than the live attenuated vaccines, which demands more frequent booster vaccinations. Additionally, they primarily induce humoral immunity with limited T-cell responses, thus limiting application against pathogens for which protection is based on cellular immunity.Thanks to the lessons learnt from the COVID-19 pandemics, these traditional vaccines and vaccination approaches may now be gradually, possibly rapidly, replaced with the novel ones exploiting modern technologies, such as viral vectors, synthetic nucleic acid (both RNA and DNA), virus-like particles, nanoparticles, and recombinant, often chimeric, protein subunits expressed from the synthetic genes. We have also matured to understanding of the necessity of adequate animal disease/infection models enabling tests of the efficacy of antimicrobial drugs and vaccines , alongsiNowadays, two years after the start of the COVID-19 pandemic, we evidence the amazing development in the field of vaccinology towards new vaccine platforms, proven to be safe after the wide application of COVID-19 vaccines. DNA vaccines have previously shown promising results in animal models, but failed to induce comparably strong responses in non-human primates. Recent strides in technological advancements, particularly, with regard to the delivery systems and adjuvants applied to SARS-CoV-2 DNA vaccine development, placed DNA vaccines in a favorable position to induce efficacious responses ,11. HundThese multiple-vaccine platforms and approaches are required to address the challenges posed by the emerging pathogens and provide the breadth of immunity required to withstand them. A critical role in this development will be played by adjuvants with research focused on the new ways to incorporate adjuvants into vaccine formulations to facilitate therapeutic vaccine applications. Previously important for the inactivated vaccines, they are nowadays applied for the enhancement of responses induced by the subunit vaccines since both, by the nature of their construction, are less immunogenic than replicating vaccines. An attractive alternative to such inactivated and subunit vaccines is offered by virus-like particles (VLPs), which have both a strong safety profile and less dependence on the adjuvants for immunogenic performance. The availability of human vaccines against hepatitis B and human papillomaviruses (HPV) based on VLP technology pays testimony to the effectiveness of this approach; multiple VLP-based vaccines are already in clinical trials for the renown “classical” public health threats, such as malaria and tuberculosis, as well as the recently emerged Zika virus disease .This development raises important questions. Would old vaccines be gradually exchanged for new-generation vaccines? Should we purposefully replace our “old/pre-COVID-19 world” vaccines, adjuvants, and delivery technologies with the new ones, is it worth and will it pay back to perform such an exchange? Or should we limit the application of new-generation vaccines to the areas where we do not yet have good vaccine coverage? The collection of research articles selected for inclusion into this special edition provides a tentative answer to this question. The selection focuses on understanding the immunogenicity of new-generation vaccines against “old/pre-COVID-19 world” pathogens of public health concern, on novel adjuvants to improve the efficacy of the new as well as traditional vaccines, and immunomodulation required for the successful therapy of chronic viral infections and cancer, as well as strategies for the monitoring of vaccination status and vaccine efficacy, i.e., on the ways to apply the vaccine knowledge acquired during pandemics to the creation of new as well as improvement of the old/traditional vaccines.In the stream of studies covering novel DNA and RNA-based vaccine candidates, Tipih et al. described the immunogenicity of a DNA-based Sindbis replicon expressing the nucleoprotein (NP) of the Crimean–Congo hemorrhagic fever virus (CCHFV) using a mouse model . CCHFV iA modified mRNA approach was described by Starostina et al. in their paper entitled “Construction and immunogenicity of modified mRNA-vaccine variants encoding influenza virus antigens” . To compM. tuberculosis antigens TB10.4 and HspX antigens in mice and guinea pigs [Mycobacterium tuberculosis strains to subcutaneous BCG immunization. In a guinea pig model, the candidate vaccine boosted the response induced in a heterologous prime-boost formulation using BCG prime immunization, and improved protection against M tuberculosis.In the stream of studies covering vaccine candidates based on the microbial vectors, Sergeeva et al. described the outcome for the trials of a mucosal influenza vector vaccine expressing nea pigs . TubercuDespite the express wide introduction of the novel vaccination technologies, an interest pertains in further development of the traditional vaccines and vaccination approaches. A good example is the inactivated polio vaccine that is of high significance for public health. An increase in the global availability of the polio vaccine is high public-health demand. The inactivated polio vaccines are in specific demand, since the existing oral attenuated vaccine can evolve into virulent forms and cause outbreaks of the disease . To ensuAs mentioned in our introduction, adjuvants can assist by significantly enhancing the immune responses. Chen et al. described the effectiveness of the alum Pickering emulsion as an adjuvant to improve the efficacy of the candidate malaria vaccine . MalariaAdjuvant effects are crucial not only for the development of efficient vaccines against infectious diseases, but also, and even more so, in the immunotherapy of cancer where efforts are needed to overcome cancer-induced immune modulation and immune suppression . In a muOne of the fundamental requirements for the development of next-generation vaccines is the understanding or adequate presumption of the immune correlates of the protection and identification of the appropriate components of a pathogen to be incorporated into the vaccine to induce protective immunity. Not least important is the assessment of the vaccine efficacy with regard to what parameters to monitor. There are challenges in the identification of the predictive markers of immunogenicity that align with immune correlates of protection. The collection of papers in this Special Issue included two review articles devoted to monitoring vaccine efficacy. In a review entitled “Predictive markers of immunogenicity and efficacy for human vaccines”, van Tilbeurgh et al. provided an overview of the vaccine-immune signatures in preclinical models and in the target human populations . The autVaccine development plays an important role in managing communicable and non-communicable diseases. New vaccines and new vaccination approaches will gradually change the vaccines we are currently using, improving some and replacing others. The successful development and use of all, new as well as “old”, vaccines require an understanding of the immune correlates of protection, application of multiple platforms to address the diversity of pathogens and cancers, development of new adjuvants to improve vaccine effectiveness as well as better strategies to monitor the immunogenicity, efficacy and reduction in disease burden from the application of the new and updated traditional vaccination programs.


Abdominal aortic aneurysm (AAA) is a localized expansion of the abdominal aorta which can lead to lethal complication as the rupture of aortic wall. Currently there is still neither competent method to predict the impending rupture of aneurysm, nor effective treatment to arrest the progression of small and asymptomatic aneurysms. Accumulating evidence has confirmed the crucial role of extracellular vesicles (EVs) in the pathological course of AAA, acting as important mediators of intercellular communication. Given the advantages of intrinsic targeting properties, lower toxicity and fair stability, EVs show great potential to serve as biomarkers, therapeutic agents and drug delivery carriers. However, EV therapies still face several major challenges before they can be applied clinically, including off-target effect, low accumulation rate and rapid clearance by mononuclear phagocyte system. In this review, we first illustrate the roles of EV in the pathological process of AAA and evaluate its possible clinical applications. We also identify present challenges for EV applications, highlight different strategies of EV engineering and constructions of EV-like nanoparticles, including EV display technology and membrane hybrid technology. These leading-edge techniques have been recently employed in multiple cardiovascular diseases and their promising application in the field of AAA is discussed. Abdominal aortic aneurysm (AAA) is mainly characterized with immune cell infiltration, extracellular matrix (ECM) degradation and apoptosis of vascular smooth muscle cells (VSMCs), leading to the weakening of vascular wall and dilation of abdominal aorta. The prevalence of AAA reached up to 8% among males aged over 65 years old, and the major complication of AAA is aortic rupture, of which the mortality rate exceeds 80% and causes 150,000–200,000 deaths annually across the world . In contExtracellular vesicle (EV), an important medium for intercellular communication, has drawn researcher's attention in the last few decades and been placed in the limelight in different fields of diseases. EV was first identified in differentiated reticulocytes by Pan et al.  in the 1EVs consist of a phospholipid bilayer envelope structure with a characteristic cup-shaped appearance, and they can be secreted by almost all types of cells and distributed throughout body fluids, including plasma, saliva, cerebrospinal fluid, lymphatic fluid and urine –14. The After EVs are secreted from cells, they can stably exist in the interstitial fluid, owing to their lipid bilayer structure, which can not only protect EVs themselves from degradation but also ensure the integrity and security of the cargoes carried within. During the process of EV biogenesis, a series of molecular contents with cell biological activity are encapsulated into EVs, such as proinflammatory and anti-inflammatory cytokines, nucleic acids , enzymes and many other proteins , 17. TheEVs involve in multiple pathological processes by modulating cell-cell interaction, which significantly contributes to the progression of AAA. As mentioned above, immune cell infiltration is one of the major characteristics of AAA, and macrophages are found to account for the largest proportion of the infiltrated cells according to a recent single-cell RNA sequencing results . These mAt present, the diameter of the aorta measured by CTA is considered as the golden standard for AAA diagnosis, and regular follow-ups are required to monitor potential changes of AAA diameter. However, the progression of AAA follows a discontinuous pattern, which may accelerate unexpected between adjacent two follow-ups and cause serious adverse events. In such condition, the identification of effective biomarkers may help to predict the rupture of AAA and avoid potential death. EVs appear to be an intriguing source of biomarkers, for the changes of their circulatory numbers and contents can convey important information and reflect the pathological status of diseases. Martinez-Pinna et al.  performein vitro conservation and transportation as non-vital vesicles and more durable for long-term cryopreservation and freeze-thaw processes with little change in their biochemical activities  intravenously or directly to the adventitia of aortic wall, the development of AAA is evidently restricted –34. Furttivities . Most imtivities , 39. By tivities  transplativities , 42.The therapeutic potential of stem cell-derived EVs has been extensively explored in multiple cardiovascular diseases, especially in myocardial infarction and atherosclerosis –47. HoweAltogether, as important mediators of intercellular communication, EVs can incorporate bioactive molecules and are endowed with intrinsic targeting properties and low immunogenicity because of their inherited membrane from parent cells . These cThis section will highlight the current promising strategies of EV engineering technologies. Because only very few researches have focused on EV engineering in the field of AAA treatment, we will first broaden our outlook and introduce engineering strategies applied in cardiovascular diseases, and then proposed feasible utilizations in the area of AAA.Although the many advantages of EV bring it further attention as a drug delivery vehicle, an unsatisfactory targeting rate still hinders the clinical use of EV therapies. Natural unmodified EVs are enriched in and cleared by the liver, spleen, kidney and other organs after systematic administration, making it difficult to achieve effective therapeutic concentrations in target organs . SelectiA popular application of EV display technology is to add targeting ligands via transfection of parent cells with fusion genes of targeting peptides and EV membrane proteins. The overexpression of the fusion protein on the surface of EV membrane can steer the engineered EVs directly toward target area. Lysosomal-associated membrane protein 2 (Lamp2b) is expressed abundantly on the surface of EV, which is extensively chosen as a component of the designed fusion protein . Wang etVβ3 expressed on the surface of angiogenic blood vessels, RGD can guide bioengineered EVs to blood vessels and promote therapeutic angiogenesis. Likewise, Vandergriff et al.  clearance, thus providing membrane-hybrid EVs with immune evasion ability .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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Burkholderia pseudomallei and is characterized by high morbidity and mortality. Our report presents the diagnostic and therapeutic approach of the first case of neuromelioidosis confirmed in Europe. A 47-year-old man with a medical history of recurrent otitis with otorrhea and fever after tympanoplasty and radical cavity revision operation on the left ear was admitted with headache, decreased level of consciousness, dysarthria, left-sided hemiparesis, and urinary incontinence. After extensive investigations including MRI, microbiological, serological, and CSF analyses, and, ultimately, brain biopsy, a diagnosis of neuromelioidosis was established. Despite antibiotic treatment, the patient showed no clinical improvement and remained in a severely compromised neurological state under mandatory mechanical ventilation. Neuromelioidosis can pose a diagnostic challenge requiring an extensive diagnostic evaluation because of its uncommon clinical and radiological presentations.Neuromelioidosis is a rare CNS infection caused by  Burkholderia pseudomallei, a Gram-negative, aerobic, and non-spore-forming, soil saprophyte. The disease is endemic to tropical regions such as northern Australia and Southeast Asia , whereupon treatment with empiric intravenous triple therapy with acyclovir, ampicillin, and ceftriaxone was initiated. The new CT scan of the brain revealed partial compression of the right lateral ventricle. Subsequently, the patient was admitted to our general neurology ward for further diagnostic investigation. The Brain MRI showed FLAIR-hyperintense bihemispheric lesions (significantly more on the right than on the left) in the area of the thalamus and the internal capsule, and extensive brainstem involvement with faint contrast enhancement in the posterior limbs of the internal capsule along with the parapontine region. The progressive deterioration of the patient's level of consciousness resulted in transfer to our intermediate care unit and subsequently to our intensive care unit because of further worsening with a score of 6 on the Glasgow Coma Scale. Upon admission to the intensive care unit, the patient was hemodynamically stable, free of vasopressor support, and received 2 L of oxygen per minute B. pseudomallei. The supplementary imaging of the mastoid and the otolaryngological examination did not provide any evidence of mastoiditis or abscess. However, the antibiotic regimen was switched to ceftazidime in accordance with the antibiogram. The follow-up MRI imaging of the brain on day 4 showed an increasing size of the cerebral lesions and radiological features of elevated intracranial pressure. Consequently, an external ventricular drain system (EVD) was placed for intracranial pressure monitoring and management. For diagnostic clarification, stereotactic brain biopsy was performed. The histopathological assessment revealed an inflammatory process that could not be further specified. With a provisional diagnosis of an autoimmune/inflammatory encephalitis, intravenous methylprednisolone pulse treatment was initiated. In the further course, plasma separation was also initiated because of suspicion of an autoimmune inflammatory etiology. However, from both the CSF and brain biopsy samples, which were sent for a supplementary examination to the Bundeswehr Institute of Microbiology in Munich, B. pseudomallei was isolated. Based on the radiological and microbiological findings as well as the clinical presentation, which strongly indicated the presence of neuromelioidosis, the antibiotic treatment was escalated to meropenem. The re-evaluation of the mastoid CT-imaging revealed an exposed bone defect in the mastoid cavity of the left ear, which might have been the entry point of the detected pathogen to the CNS. Therefore, an uncomplicated radical cavity revision with bone reconstruction was carried out in collaboration with our otorhinolaryngology department. Another follow-up MRI imaging of the brain on day 25 revealed regression of the inflammatory changes but with significant residual florid inflammatory supra- and infratentorial lesions. Due to stable intracranial pressure in the range of normal standards, the EVD could be removed and the dexamethasone treatment gradually tapered. Nevertheless, no improvement in the neurological condition could be observed during the entire in-patient stay. In the further course, tracheostomy was performed as a result of the prolonged comatose state with mandatory mechanical ventilation due to lack of spontaneous breathing. Furthermore, a port system was placed for further administration of meropenem  followed by a maintenance phase with oral antibiotic treatment with cotrimoxazole for 6 months. At discharge, the patient showed no further clinical improvement and remained in the comatose state under mandatory mechanical ventilation. The patient was transported to a post-acute care facility for the purpose of further antibiotic administration.An extensive differential diagnostic, including cerebrospinal fluid (CSF) analysis, was carried out with regard to encephalitis of infectious, autoimmune, or malignant etiology. PCR testing for HSV 1/2, VZV, JCV, and HHV-6 was negative, and no organisms were isolated by culture. Anti-Zic4 antibodies were weakly positive in the CSF. A tumor search, including a chest and abdomen CT scan, showed no evidence of neoplasy. A smear culture of the drainage deriving from the left ear isolated The differential diagnosis for this presentation was wide. It included infectious, primary autoimmune, and malignant etiologies. The group of infectious causes included central nervous system (CNS) toxoplasmosis, tuberculous encephalitis, viral meningoencephalitis, listeriosis, and brucellosis. None of these organisms were isolated. Malignant differential diagnoses included CNS lymphoma. No malignant cells were identified on CSF cytology and cerebral biopsy.Burkholderia pseudomallei. It accounts for approximately 3% of all melioidosis cases and is statistically associated with much higher morbidity and mortality rate. The transmission of melioidosis is by direct inoculation, inhalation, or ingestion (via possible entry of the detected pathogen through an exposed mastoid bone defect. Extensive involvement of the brainstem in MRI imaging is common. This could be observed in our case, whose brain-MRI revealed bihemispheric distinctly right-sided accentuated FLAIR hyperintensities as well as rim-enhancing microabscesses spreading along white matter tracts predominantly in corticospinal tracts and cerebral peduncles (Neuromelioidosis is a rare infection of the nervous system caused by ngestion . Our caseduncles . Bearingeduncles . Our patNeuromelioidosis presentation can mimic other inflammatory or infectious conditions. Bearing the typical MRI pattern with typical rim-enhancing microabscesses spreading along white mater tracts in mind, this rare disease might get diagnosed more often, and initiating therapy in early phases might save patients from persistent disability and death.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.ND and MG: acquisition of the data and drafting of the manuscript. GF, SZ, and BT: acquisition and interpretation of the data. AA: acquisition of the data and revision of the manuscript. SGM and H-PH: revision of the manuscript for intellectual content. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Consumer wearables and smartphone devices commonly offer an estimate of energy expenditure (EE) to assist in the objective monitoring of physical activity to the general population. Alongside consumers, healthcare professionals and researchers are seeking to utilise these devices for the monitoring of training and improving human health. However, the methods of validation and reporting of EE estimation in these devices lacks rigour, negatively impacting on the ability to make comparisons between devices and provide transparent accuracy.The Towards Intelligent Health and Well-Being Network of Physical Activity Assessment (INTERLIVE) is a joint European initiative of six universities and one industrial partner. The network was founded in 2019 and strives towards developing best-practice recommendations for evaluating the validity of consumer wearables and smartphones. This expert statement presents a best-practice validation protocol for consumer wearables and smartphones in the estimation of EE.The recommendations were developed through (1) a systematic literature review; (2) an unstructured review of the wider literature discussing the potential factors that may introduce bias during validation studies; and (3) evidence-informed expert opinions from members of the INTERLIVE network.The systematic literature review process identified 1645 potential articles, of which 62 were deemed eligible for the final dataset. Based on these studies and the wider literature search, a validation framework is proposed encompassing six key domains for validation: the target population, criterion measure, index measure, testing conditions, data processing and the statistical analysis.The INTERLIVE network recommends that the proposed protocol, and checklists provided, are used to standardise the testing and reporting of the validation of any consumer wearable or smartphone device to estimate EE. This in turn will maximise the potential utility of these technologies for clinicians, researchers, consumers, and manufacturers/developers, while ensuring transparency, comparability, and replicability in validation.PROSPERO ID: CRD42021223508.The online version contains supplementary material available at 10.1007/s40279-022-01665-4. VO2max), and energy expenditure (EE).Worldwide, the number of consumer wearable devices sold in 2020 is estimated to have reached almost 400 million units . The groTraditionally, the measurement of EE has been conducted via indirect calorimetry (where gaseous exchange is measured and converted to EE using standard formulae such as the Weir Equation ), directThe widespread availability, relatively low cost, and wearability of consumer activity monitors means that data that could only be captured in specialist settings are now available to the general population, and these devices are increasingly being used to provide measures of EE. Most users seek this information for either AEE in monitoring calorie consumption during a specific exercise activity, or to support them with their TEE across a day, possibly in the management of diet or weight loss. A variety of inputs, including user demographics such as age, sex, weight and height, and data from on-board sensors, including accelerometers and/or photoplethysmography heart rate sensors, are used to make estimates of EE –10. Howe2 max , comparison of means (e.g. t test) , and measures of relative reliability (e.g. intraclass correlation coefficient) . These approaches have been highlighted as inappropriate when assessing agreement between a measurement tool and the reference standard in medical instrument validation studies [When assessing the validity of an index device to a criterion measure, the levels of accuracy of the index device should be calculated with agreement between the two devices , 66. The studies .To comprehensively assess the validity of the index device in estimating EE, we recommend the use of Bland–Altman limits of agreement analysis in combination with mean absolute percentage error (MAPE). The Bland–Altman method provides a measure of the agreement between the criterion and index device; researchers should state if the assumptions for valid limits of agreement analysis were fulfilled , and, inTo allow readers to assess the validity of a device in estimating EE, it is important for the contextual use of the device to be considered. For example, a much greater level of accuracy would be required when applying the measure in a clinical trial setting compared with EE monitoring in a general wellness application. Regardless of the context, the level of error, limits of agreement and 95% confidence intervals should be reported clearly according to the validation conditions, with an avoidance of binary hypothesis testing, particularly when a sample size calculation has not been conducted.Based on the current state of knowledge and the evidence described within this statement, INTERLIVE recommends that manufacturers of consumer wearables and smartphones that provide an estimate of EE utilise standardised validation methodologies and report this in a transparent and replicable manner. Studies should be designed to validate devices across both specific sports/activities  and in uncontrolled environments. This evaluation should be conducted using the appropriate criterion measure with a relevant sample, in conditions that best reflect the expected use of the device.These recommendations aim to ensure that many of the sources of bias identified during the review of the literature are addressed. Table This INTERLIVE network expert statement aims to provide clear and actionable recommendations and guidelines for the comprehensive and replicable evaluation of the validity of consumer wearables in estimating EE. In consultation with the evidence base, wider literature and expert knowledge, a detailed validation protocol is described covering domains of the target population, criterion measure, index measure, validation conditions (exercise/activity-specific or free-living), processing and statistical analysis.The lack of both a regulatory standard for the validation process of consumer wearables and an acceptable context-specific level of accuracy facilitates the heterogeneity of methodologies used in the validation of EE estimation seen in this systematic literature review. This can lead to all stakeholders experiencing difficulties in comparing various devices and ultimately deciding which might be more suitable or appropriate for a specified purpose. A standardised approach to validation would benefit all stakeholders and ensure a transparent and objective method of validation, which will ultimately drive the sector towards more accurate, and therefore more useful, devices. This would benefit (1) consumers, facilitating them to be able to make an informed choice on the most suitable device or application; (2) healthcare providers, by being better placed to adopt such devices/applications as part of their digital health strategy; and (3) manufacturers and developers, who can clearly illustrate the value of their products.This transparency of reporting opens an interesting debate, as the ‘black-box’ nature of EE estimation algorithms means that manufacturers do not wish to divulge the proprietary information that constitutes these models. However, in order to make sufficient comparisons and maximise the accuracy of the device, we mirror calls in the literature for companies to be more open about the algorithms that they employ . While rThis systematic review highlighted a lack of studies validating EE from wearable devices during anaerobic conditions or during very high intensities (above lactate threshold). This leaves a gap in current validation studies as strength training, conditioning exercises and high-intensity interval training (HIIT) are growing in popularity . IndirecIt is important not to understate the challenges in implementing EE validation studies. The notable lack of free-living validation, which is an important step for many consumer users, is likely due to issues in feasibility, given the longitudinal nature of these protocols, the resources required for DLW, and the additional need to measure RMR. Nonetheless, there is currently a lack of evidence regarding the validity of consumer wearables in the measurement of AEE in daily life. One research group that has conducted validation in the free-living context showed close correlation between consumer devices and DLW for TEE; however, when assessing the estimation of AEE across a 15-day period, a far greater number of devices demonstrated significant differences to the criterion measure , 37. ThiAdditionally, these protocol recommendations do not include evaluation of reliability for activity-specific EE estimation, yet reliability is a prerequisite for validity. Therefore, researchers may want to consider the various aspects of reliability in their protocols depending on the intended use-case. This may include repeating a particular testing condition/intensity during the same session when the participant has recovered to RMR, or to repeat the protocol on an alternate day. Equally, many index device manufacturers do not provide exercise/activity modes for sport-specific activity, including soccer and basketball. This is potentially due to poor performance of these devices in estimating EE during such activities, but presents an interesting opportunity for manufacturers to develop exercise modes for popular recreational sports, which would make them more appealing to consumers. For these modes to be useful, their validation needs to mimic a range of actual sports-specific behaviours, and not only running with or kicking a ball.This INTERLIVE expert statement provides an evidence-informed best-practice protocol for the validation of consumer wearables in estimating EE. The systematic literature review conducted as part of the formation of this statement highlighted a heterogeneity between methodologies in key domains, particularly in the target populations, data processing and statistical approaches, giving rise to validation bias. Additionally, the lack of free-living validation leads to limited abilities of users to understand the accuracy of the device in its intended use case. The INTERLIVE network recommends that the proposed validation protocol is used when considering the validation of any consumer wearable or smartphone measure of EE to provide a robust validation of the device. Adherence to this validation standard will help ensure methodological and reporting consistency, facilitating comparisons between consumer devices and the amalgamation of standardised open datasets. This will ensure that manufacturers, consumers, healthcare providers and researchers can use this technology safely and to its full potential.Supplementary file1 (DOCX 145 kb)Below is the link to the electronic supplementary material.