Fetal brain is extremely plastic and vulnerable to environmental influences that may have long-term impact on health and development of the offspring. Both the Hypothalamic-Pituitary-Adrenal (HPA) and the Hypothalamic-Pituitary-Thyroid (HPT) axes are involved in stress responses, whereas, their final effectors, the Glucocorticoids (GCs) and the Thyroid Hormones (TH s), mediate several fundamental processes involved in neurodevelopment. The effects of these hormones on brain development are found to be time and dose-dependent. Regarding THs, the developing fetus depends on maternal supply of hormones, especially in the first half of pregnancy. It is acknowledged that inadequate or excess concentrations of both GCs and THs can separately cause abnormalities in the neuronal and glial structures and functions, with subsequent detrimental effects on postnatal neurocognitive function. Studies are focused on the direct impact of maternal stress and GC excess on growth and neurodevelopment of the offspring. Of particular interest, as results from recent literature data, is building understanding on how chronic stress and alterations of the HPA axis interacts and influences HPT axis and TH production. Animal studies have shown that increased GC concentrations related to maternal stress, most likely reduce maternal and thus fetal circulating THs, either directly or through modifications in the expression of placental enzymes responsible for regulating hormone levels in fetal microenvironment. The purpose of this review is to provide an update on data regarding maternal stress and its impact on fetal neurodevelopment, giving particular emphasis in the interaction of two axes and the subsequent thyroid dysfunction resulting from such circumstances. Evidence supports that stress during pregnancy may have long-term and detrimental consequences in the development of the offspring. “Maternal prenatal stress” can be defined as any exposure of the expectant mother to stressful life conditions, requiring psychological and physical adaptations. Maternal prenatal stress can be chronic, related to ongoing events, or acute, such as exposure to accidents or other sudden incidents. In addition to exposure to life events, maternal stress can also be related to perinatal mental disorders or physical illnesses and conditions, such as malnutrition, during pregnancy. The assessment of maternal stress varies across studies: stress can be “measured” using questionnaires, clinical interviews, or biomarkers .Stress can be defined as the condition of threatened homeostasis and it is associated with an activation of the stress system which includes mainly the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). The stress-induced adaptive neuroendocrine, metabolic, and cardiovascular changes take place both in the central nervous system (CNS) and the periphery of the organism. Centrally, the main mediators of the stress system are the hypothalamic paraventricular nucleus hormones corticotropin-releasing hormone (CRH) and arginine-vasopressin (AVP), the arcuate nucleus pro-opiomelanocortin (POMC)-derived peptides  alpha-meChronic stress-related dysregulation of the HPA axis may affect all endocrine systems including gonadal and thyroid axes. Stress hormones can inhibit the aforementioned axes at several levels, whereas estradiol and thyroid hormones (THs) stimulate the stress system . The actFetal life constitutes a critical developmental window, at which, the effects of stress can be transmitted from mother to child. Stress-related maternal, placental and fetal neurobiological alterations may affect the developing fetus, in a process also named “fetal programming” . NeurodeOf particular interest, as accrues from recent literature, is building understanding on how and in which way chronic stress and HPA axis dysfunction interact and influence the hypothalamic-pituitary-thyroid (HPT) axis and TH production. It seems that both axes, as stress-sensitive systems, also located in adjacent regions of CNS, interact with each other, and such relation may affect fetal neurodevelopment . The purGlucocorticoids, the end-effectors of the HPA axis, normally participate in brain maturation and CNS development through structural, molecular, and neurochemical procedures. Studies demonstrate that maternal GCs, that enter fetal circulation through the placenta, are important in several neurodevelopmental processes, such as remodeling axons and dendrites and neuronal and glial cell survival in critical brain regions of the fetus. Any deviation from their normal range of circulating levels is related to abnormalities in cell structure formation, neurotransmission, and function of fetal CNS .The levels of corticosteroids in fetal circulation, as well as their interaction with particular brain regions, are mediated by specific receptors  and enzymes such as 11β- hydroxysteroid dehydrogenase type 2 (11β- HSD2) . The afoin utero  expression which metabolizes serotonin and dopamine in placenta. The dysregulation of those systems can lead to neurodevelopmental defects and neurobehavioral disorders, including the increased risk of attention-deficit hyperactivity, extrapyramidal disorders and antisocial behaviors such as drug addiction  is responsible for the synthesis and secretion of thyrotropin-releasing hormone (TRH), which consequently stimulates the release of TSH from the anterior pituitary . HoweverThe role of the three types of iodothyronine deiodinases  that are expressed in different organ tissues and are responsible for the activation or inactivation of T4 and T3 is of great importance. Specifically, D1 is responsible for the large fraction of the circulating T3, by converting T4 to T3 and is expressed in multiple organs including placenta. D2, which is also active in placenta, participates in the local production of approximately 80% of CNS T3 from T4. Placenta mainly express D3, which is also present in brain tissue and blocks the action of T3 by restricting the transport of maternal THs to fetal circulation .The fetus collects iodine and synthesizes THs by 11–12 weeks of gestation, while the secretion of THs begins around week 16. Although fetal thyroid gland is capable of TH production, it is not fully matured during intrauterine life, thus maternal transfer of THs through the placenta occurs until birth and is responsible for normal TH levels in fetal circulation . THs areTHs are of significant importance in maturation and functional formation of the brain throughout all trimesters of pregnancy, participating in neurodevelopmental procedures including neuron proliferation and migration, neuronal and glial cell differentiation, and synaptogenesis. TH level disruptions can also alter biochemistry of the brain. Animal studies have shown that an environment of hypothyroidism is related to a decrease in monoamines, such as epinephrine and NE, and a concurrent increase in γ-aminobutyric acid (GABA) . GABA isTH deficiency, especially during the early critical embryonic stages of development, has an impact not only in molecular and functional pathways of the brain, but also in morphology of brain regions such as cerebral cortex, hippocampus, and cerebellum . AdditioAnimal and human studies have demonstrated that HPT axis is also a stress-sensitive system that interacts with the HPA axis in multiple ways . Both axExogenous administration of GCs in humans has an inhibitory effect on thyroid function which is depicted in decreased plasma TSH levels, low response of TSH to TRH stimulation, and an enhancement of the negative feedback of T3 on TSH release. Regarding THs, elevated levels of GCs may lead to a reduction in T3 and an increase in reverse T3 (rT3) levels, while T4 may be unchanged or slightly decreased . Other aDepression, and any other condition which is related to maternal stress and increased cortisol levels, most likely lead to a reduction of maternal circulating THs, meaning that lower levels of maternal T4 cross the placenta and reach fetal circulation, and consequently fetal brain . RegardiDiversely, HPT dysfunction can affect HPA axis and influence adenocorticotropic hormone (ACTH) and GC production. High levels of THs accelerate HPA axis maturation by inducing hypersensitivity of cortisol to ACTH . FurtherNeurodevelopment and maturation of the brain is a complicated process that begins in fetal life and continues the years after birth. Production and circulated levels of GCs and THs depict the normal function of two important stress-sensitive axes, the HPA and HPT respectively . Such hoIt is acknowledged that abnormal concentrations of both GCs and THs can separately affect the neuronal and glial structures, as well as brain functions with a subsequent negative impact on cognition in later life. Specific brain structures including hippocampus, which is implicated in cognitive processes such as memory and learning, are more vulnerable to such modifications and could lead to long-term developmental implications for the offspring .Maternal stress has been related to the activation of the HPA axis and secretion of greater amounts of glucocorticoids that enter fetal circulation and affect fetal HPA axis development and fetal GC levels. The aforementioned mechanism can lead to severe deviation from normal neurodevelopmental procedures . Stress The placenta consists another target organ involved in maternal stress reactions, and several functional changes have been observed under stressful conditions. Modifications in the expression of critical placental substances, such as enzyme 11β-HSD2, contribute to the abnormal circulating hormone levels in the fetal environment .THs play a key role in the early development of the fetus, the placenta, and the differentiation of fetal developing tissues including the brain. It is well known that congenital hypothyroidism is related to severe neurological impairment and intellectual disability. Other thyroid dysfunctions, including maternal hypothyroxinemia due to iodine deficiency, are also risk factors for neurodevelopmental handicaps, particularly during the first half of pregnancy . As mentMultiple and different mechanisms through which THs participate in fetal neurological structure formation and function have been described, with some of them still not be fully understood. However, there is enough data to support the necessity of adequate supplied amounts of such hormones to ensure optimal neurodevelopment throughout ontogeny .Of particular interest is building an understanding on how chronic stress and HPA axis interact and influence HPT axis and TH production. Animal studies have shown that increased GC concentrations related to maternal stress, most likely reduce maternal TH levels, thus lower levels of THs reach fetal circulation. Interaction of the two axes seems to be direct, as well as indirect, through modifications in the expression of specific enzymes responsible for regulating TH levels in fetal microenvironment. From the above data, it can be hypothesized that chronic stress and activation of HPA axis seem to influence TH production through a premature maturation of fetal HPT axis .As published evidence is derived from heterogenous studies, regarding design and scope, further targeted research is needed to better understand the influence of gestational stress and HPA axis dysregulation on thyroid gland function. Given the association of thyroid dysfunction with maternal stress, pregnant women would be an interesting target of research. This would help to improve neurodevelopmental outcomes, and to prevent cognitive, behavioral and mental disorders related to maternal thyroid dysfunction later in life.FA and ME contributed to conception of the review and also wrote the first draft of the manuscript. PP, IL, KP, and NV contributed to manuscript revision, read, and approved the submitted version. 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.


Osteonecrosis without effective early treatment eventually leads to the collapse of the articular surface and causes arthritis. For the early stages of osteonecrosis, core decompression combined with bone grafting, is a procedure worthy of attention and clinical trial. And the study of bone graft substitutes has become a hot topic in the area of osteonecrosis research. In recent years, polymers have received more attention than other materials due to their excellent performance. However, because of the harsh microenvironment in osteonecrosis, pure polymers may not meet the stringent requirements of osteonecrosis research. The combined application of polymers and various other substances makes up for the shortcomings of polymers, and to meet a broad range of requirements for application in osteonecrosis therapy. This review focuses on various applying polymers in osteonecrosis therapy, then discusses the development of biofunctionalized composite polymers based on the polymers combined with different bioactive substances. At the end, we discuss their prospects for translation to clinical practice. Osteonecrosis is a disease caused by a temporary or permanent loss of blood supply to the bone. The causes of osteonecrosis are extensive, and the pathogenesis is still unclear . The potThe destruction of bone activates the self-repair response of bone tissue  [includiAt present, in both basic research on and clinical application of osteonecrosis treatments, there are a large number of studies that report various constructive methods. Systemic management may be unsuitable for osteonecrosis because the unavoidable problems of systemic treatment include insufficient local osteonecrosis concentration and systemic side effects. Recently, researchers to treat osteonecrosis locally through injection of stem cells , growth In clinical application, surgical treatment is the most important means. Surgical therapies, including core decompression, osteotomy, arthroplasty, and so forth, have been developed in clinical practice, but they are also subject to limitations, such as the narrow scope of application and repeated revision operations . At presThanks to the development of biotechnology and materials science, many biomaterials are available to make bone substitute materials to cope with the problems in bone grafting. Among them, polymers are widely used in the study of osteonecrosis because of their excellent biocompatibility and biodegradability. This article focuses on applying various polymers in osteonecrosis and elaborates and summarizes the current research. Then, the different functions of various polymers combined with different substances are discussed. Finally, the application of polymers in the treatment of osteonecrosis and future outlook are summarized. We aim to provide a comprehensive review of the application of polymers in the treatment of osteonecrosis and a meaningful theoretical basis further to advance the treatment of osteonecrosis with biomedical polymer materials.Biocompatibility, biodegradability, and certain mechanical properties are required for biomaterials used in osteonecrosis research . BiocompPolymers are mainly divided into two types, natural and synthetic . At presPolymers that are often used in the treatment of osteonecrosis are poly (lactide-co-glycolide) (PLGA), poly (ε-caprolactone) (PCL), polylactide (PLA), poly (propylene fumarate) (PPF) . VariousBecause natural polymers have the characteristics of biocompatibility and biodegradability—and the biological functional molecules on the surface of natural polymers are conducive to cell adhesion, aggregation, proliferation, and differentiation—natural polymers are widely used in tissue engineering. Various natural polymers such as chitosan, alginate, and peptide chain hydrogel have been made into bone substitute materials for osteonecrosis therapy .Chitosan is a linear polycationic polysaccharide polymer derivative of chitin. A large number of research reports show that chitosan has good biocompatibility, high biodegradability, low allergenicity, antibacterial properties, and wound healing activity. Chitosan can be easily extracted from shellfish and other seafood waste. However, the poor solubility of chitosan in neutral and alkaline media limits the direct application of chitosan in medicine and biomedicine . ChitosaAlginate is a frequently used biomedical material, often for drug delivery, cell embedding, tissue embedding, and cartilage tissue regeneration . Alginatin vitro experiments. The alginate beads embedded with synovial fluid MSCs (ABSMSCs) were implanted into the femoral head of the rabbit model of hormone-induced femoral head necrosis after core decompression surgery  is a Chinese medicine extracted from deer antlers, and it is a protein-polysaccharide complex. CCC contains 16 amino acids, including glycine, proline, glutamic acid, and so forth. . CCC haseoblasts .in vitro experiments confirmed that the composite hydrogel has good biocompatibility. The composite hydrogel material was also injected into the femoral skull tunnel of the ONFH rabbit model as the experimental group. The control group was injected with saline , a natural polysaccharide composed of D-glucuronic acid and D-N-acetyl glucosamine repeating units , is the h saline . At 1 moh saline , demonstSome peptide and protein nanofiber structures have also been extensively studied as biomaterials. As early as 2011, et al., used a peptide-based hydrogel called RADA16 to provide a solution to the BMP-2 leakage problem previously encountered by. They believe that this novel method may provide benefits for osteonecrosis therapy.Five years later, in vivo and in vitro experiments, RADA16 is a peptide-based hydrogel composed of 16 amino acids  and has The above findings support peptide-based hydrogel as an intraosseous carrier and provide a new solution to the leakage problem in osteonecrosis therapy. They also guide the next steps in studying peptide chain hydrogel in osteonecrosis model experiments.The bone tissue removes the mineralized components and retains the organic matrix and growth factors to obtain demineralized DBM. DBM has strong osteogenic properties because it contains many organic components and growth factors and is often used in bone repair research . BFGF caIn recent years, synthetic polymers have received more attention than natural polymers because of their desirable properties in bone engineering, such as porosity, degradation time, and mechanical properties. They have strong shaping abilities and can be made into various shapes according to need .co-glycolide) (PLGA) is currently one of the most successfully developed synthetic biodegradable polymers. Because of its excellent biocompatibility and biodegradability, it has been widely used in research on various human delivery systems  (PCL) is another polymer material that is widely used in bioengineering. The biocompatibility of PCL is excellent, and the surface chemistry of PCL is suitable for cell attachment, proliferation, and differentiation. Moreover, the degradation byproducts of PCL are non-toxic and can usually be metabolized and eliminated through the body’s natural metabolic pathways . A previLactic acid, the precursor of poly (lactic acid) (PLA), is non-toxic to humans. PLA is also one of the most widely used synthetic polymers approved by the FDA for biomedical purposes . Wang etIn recent years, polypropylene fumarate (PPF) has attracted widespread attention as a promising biodegradable, injectable, and non-toxic bone cement material . Chang eOsteonecrosis is a disease caused by the destruction of blood supply and decreased skeletal cell activity . The recin vivo, heterotopic ossification, and lack of effective support remain to be resolved  . Bone maeoblasts . Previoueoblasts .in vitro and promote the survival and proliferation of bone marrow mesenchymal stem cells in vitro.In the study of PCL/TCP FGS  construcSome investigators studied SMSC. These cells show the ability to differentiate into bone, cartilage, and fat and can be easily obtained from the joint fluid . Chen etGrowth factors can accelerate the differentiation of stem cells into osteoblasts and have been widely used in the study of osteonecrosis . Among tPrevious studies have shown that oral simvastatin (SIM) has the function of promoting new bone formation in the damaged bone tissue of the human body, but statins are easily degraded during the first liver metabolism . Tai et Sufficient angiogenesis is necessary for the long-term survival of osteoblasts in the necrotic area . VEGF isBFGF, because of its effect on gene expression and angiogenesis, is considered to be a critical factor in the process of bone repair . used BFSome small molecule drugs also promote angiogenesis. The active ingredient of ginseng, ginsenoside Rg1, regulates angiogenesis and stimulates blood vessel formation by up-regulating the expression of nitric oxide and VEGF . Chang eOsteogenesis and angiogenesis are the most critical functions of functionalized polymers, and most functionalized polymer bone substitutes are constructed with this goal. The combination of osteogenesis and angiogenesis is more advantageous in osteonecrosis therapy than either process alone. Osteogenesis and angiogenesis are complementary: the new blood vessels provide oxygen and nutrients for the new bone tissue and remove the metabolic waste from the new bone tissue. The pore structure of new bone tissue provides space and mechanical support for new blood vessels.in vivo experiments confirmed that the PTI scaffold group had the lowest incidence of femoral head collapse, better cartilage preservation, and more new bone formation in the bone tunnel. Deferoxamine is an iron chelator that stimulates the expression of angiogenic genes and promotes osteogenic differentiation of osteoblasts , Mg, and Li) also have dual functions of osteogenesis and angiogenesis, and they are often used in osteonecrosis research. Strontium has a chemical structure similar to calcium and stimulates bone formation, inhibits osteoclast differentiation, and promotes angiogenesis . Kang etMany studies have found that the osteogenesis and angiogenesis functions of various growth factors have a synergistic effect, and their combined application can achieve a better osteonecrosis repair effect than a single growth factor . Peng anin vitro biological activity. They implanted the scaffold into the femoral head of ONFH rabbits to evaluate the bone formation and angiogenesis ability of the stent in vivo and the effect in repairing bone defects. The results showed that the composite scaffold had good mechanical compressive strength. It could continuously release Li and EPO, enhance the formation of new bone and new blood vessel in ONFH rabbits, and had some effect in repairing femoral head necrosis (EPO is a pleiotropic cytokine that can enhance the function of VEGF and accelerate the differentiation of bone marrow mesenchymal stem cells into osteoblasts. necrosis , 12B.Many pathological changes occur during the development of osteonecrosis. It is challenging to achieve sufficient therapeutic effects with pure polymer materials. Therefore, functional polymer materials are being developed. The combination of polymers and biologically active substances achieves targeted therapy and maximizes the effectiveness of each, which is of great significance for the treatment of osteonecrosis.Osteonecrosis often affects the articular surface and is especially common in the femoral head. Osteonecrosis that has not been effectively treated will eventually cause the articular surface to collapse, leading to arthritis. The treatment of osteonecrosis has always attracted the attention of the medical community, and various methods have been explored to relieve and treat it. Treatment is mainly divided into two categories, surgical and nonsurgical treatments. At present, the primary clinical treatment is surgery. In the surgical treatment of osteonecrosis, joint replacement surgery is generally considered as a final intervention. Because the life of the artificial joint is limited, it may require multiple revision operations, which undoubtedly increase the pain and economic burden for the patient . TherefoA variety of organic and inorganic materials have been studied to treat osteonecrosis . BecauseThe relevant experiments mentioned in this review were all carried out in animal models. Animal models of osteonecrosis cannot fully simulate the process of human osteonecrosis. The vast majority of research is limited to animal experiments, and research results cannot soon be translated into clinical practice. Therefore, the development of more ideal animal models for osteonecrosis research is necessary for the future.The current composites cannot achieve the optimal coordination of various properties, such as the mutual influence between porosity, degradability, and mechanical properties . The comThe reconstruction of human bone tissue is a complex process that involves the synergy of many tissues, cells, and biological factors. We believe that the next step of functionalizing polymer materials should be to add more cells, growth factors, drugs, and other biologically active materials rather than just a few biologically active materials. The interaction between various biologically active factors related to osteonecrosis should also be studied more.In summary, the creation of various functionalized polymer biomaterials may improve the treatment of osteonecrosis. We believe that future scientific and technological innovations and research can eventually result in significantly better treatment of osteonecrosis.


Mental health is determined by a complex interplay between the Neurological Exposome and the Human Genome. Multiple genetic and non-genetic (exposome) factors interact early in life, modulating the risk of developing the most common complex neurodevelopmental disorders (NDDs), with potential long-term consequences on health. To date, the understating of the precise etiology underpinning these neurological alterations, and their clinical management pose a challenge. The crucial role played by diet and gut microbiota in brain development and functioning would indicate that modulating the gut-brain axis may help protect against the onset and progression of mental-health disorders. Some nutritional deficiencies and gut microbiota alterations have been linked to NDDs, suggesting their potential pathogenic implications. In addition, certain dietary interventions have emerged as promising alternatives or adjuvant strategies for improving the management of particular NDDs, at least in particular subsets of subjects. The gut microbiota can be a key to mediating the effects of other exposome factors such as diet on mental health, and ongoing research in Psychiatry and Neuropediatrics is developing Precision Nutrition Models to classify subjects according to a diet response prediction based on specific individual features, including microbiome signatures. Here, we review current scientific evidence for the impact of early life environmental factors, including diet, on gut microbiota and neuro-development, emphasizing the potential long-term consequences on health; and also summarize the state of the art regarding the mechanisms underlying diet and gut microbiota influence on the brain–gut axis. Furthermore, we describe the evidence supporting the key role played by gut microbiota, diet and nutrition in neurodevelopment, as well as the effectiveness of certain dietary and microbiome-based interventions aimed at preventing or treating NDDs. Finally, we emphasize the need for further research to gain greater insight into the complex interplay between diet, gut microbiome and brain development. Such knowledge would help towards achieving tailored integrative treatments, including personalized nutrition. Neurodevelopmental disorders (NDDs) are linked to the disruption of coordinated events leading to neurodevelopmental processes, and constitute a cluster of disorders characterized by the inability to reach cognitive, emotional, and motor developmental milestones . AlthougHuman genetics is a well-known key factor involved in the etiology of the most common NDDs; however, both environmental and gene-environment interactions appear to strongly influence their clinical manifestation, which would explain the lack of heritability of these disorders , 2. DespThe diagnosis of these conditions, based mainly on clinical symptoms, and their management is highly challenging. Pharmaceutical treatment, the first-line therapy of choice for clinical management, is often associated with several side effects, and other concerns about long-term effects and efficacy exist . TherefoThe bidirectional nature of the gut–brain axis is well-recognized, with gut microbiota emerging as a key player controlling this two-way communication system . ImportaSpecifically, studies using GF mice have established that the total absence of microbiota impairs social behavior , as wellDiet has been recognized as one of the main factors shaping the gut microbiota and consequently its modulation is considered one of the easiest ways to develop and maintain a healthy gut microbiome. In fact, gut microbiome modulation through dietary interventions has been widely suggested as a robust and attainable strategy to prevent disorders, including mental conditions –18, and In the context of NDDs, some dietary interventions, including dietary advice and specific diets or certain dietary components and supplements, may influence the onset and manifestation of neurodevelopmental impairments in childhood neurological disorders, at least in specific cohorts –27. HoweIn this context, we should highlight that the relationship between diet and mental health is complex and bidirectional, and studies report less healthy dietary choices among patients with NDDs , 31. In Here, we review the current scientific evidence for the impact of early life environmental factors on gut microbiota and neurodevelopment, and highlight the long-term consequences of early nutrition on physical and mental health. We also summarize the state of the art regarding the mechanisms by which gut microbiota influences the brain–gut axis. In addition, we describe the evidence supporting the key role played by gut microbiota, diet and nutrition in neurodevelopment, as well as the effectiveness of certain dietary and microbiome-based interventions aimed at preventing and treating NDDs. Finally, we highlight the need for further research to advance towards achieving essential tailored integrative treatments, including personalized nutrition.One of the main promises of the Human Genome Project (HGP) was to increase our understanding of the mechanisms underlying the etiology of complex diseases, thereby furthering their prevention and treatment. However, after HGP completion, human genetics was found to explain merely 20–30% of the etiology of these traits, with the rest owing to environmental factors and their interactions with the human genome .The exposome can be defined as the measure of all types of exposure an individual is subjected to in a lifetime and include insults from the external environment, which interact with the internal environment  impacting on health , 34. TheRemarkably, the critical gut microbiota developmental period occurs in parallel with brain development  and, altWell-documented factors associated with the risk of NDD onset and contributors to the individual's microbiota are those related to maternal health   and manyBifidobacterium breve strain, or with a dietary prebiotic mixture that promotes bifidobacterial growth, reverses selective behavioral alterations in C-section mice. These results strongly suggest that adjunctive microbiota-targeted therapies may be developed to help avert the long-term negative behavioral consequences associated with C-section. In consistency with this, very recently in a human prospective study it has been reported the impact of breastfeeding on the modulation of the longitudinal impact of delivery mode on the gut microbiota composition, with an observed increase in the relative abundance of Bacteroides fragilis and Lactobacillus in Cesarean-delivered infants with longer duration of breastfeeding  mice have revealed that gut microbiota modulate the development of the HPA axis, impacting stress response. In this respect, some studies have proven the effectiveness of microbiota-based interventions in increasing stress resilience in healthy subjects . Other sResearch has also revealed that the gut microbiota largely impacts host gene expression by modulating epigenetic modifications, such as methylation, histone acetylation or non-coding RNAs (ncRNAs), which are involved in neurogenesis, neuronal plasticity, learning and memory . Thus, mThe gut microbiota is well-known to play a central role in modulating oxidative stress as well as immune system development and function , 64. TheThrough the effect of SCFAs, the microbiota has also been shown to modulate the levels of brain-derived neurotrophic factor (BDNF), a neurotrophin with important effects on brain development and plasticity, which is dysregulated in patients with NDDs . TherefoNowadays, it is clear that the human gut is inhabited not only by bacteria but also by less explored gut prokaryotic and eukaryotic viruses. With the growth of next-generation sequencing technologies, our knowledge about the role of gut bacterial microbiome in health and disease has rapidly expanded . By contIn studying the role of viruses, researchers have traditionally focused on eukaryotic viruses due to their well-known impact on human health. A few years ago they began to realize the relevance of gut bacteriophages for gut microbiome dynamics, and to pay attention to the previously ignored relationship between bacteriophages and human diseases. In fact, cumulative evidence has started to suggest that gut bacteriophages known as phages, which are prokaryotic viruses that dominate over other viruses in the gut ecosystem and infect gut bacteria, can also strongly impact human health, either beneficially or detrimentally . In factF. prausnitzii in their gut microbiota than healthy controls, the higher abundance of some of phages infecting major human gut commensal bacteria, such as F. prausnitzii, may indicate the potential role of these phages in IBD pathophysiology  is associated with a lowered abundance of gut Bifidobacteria in infancy, and a decreased risk of developing ADHD (Attention deficit hyperactivity disorder (ADHD) is currently the most prevalent neurodevelopmental complaint. It is characterized by inappropriate levels of hyperactivity, impulsivity and/or attention difficulties . Currenting ADHD .Research into the effect of food on ADHD started  40 yearsMore recently, meta-analyses have evaluated the efficacy of dietary interventions on children with ADHD. They showed that the clinical effects of PUFA supplementation and food additive elimination were small to modest, while the effects of the FFD on ADHD were substantial, pointing to the existence of a food-induced subtype of ADHD . Indeed,Unhealthy dietary patterns and ADHD show a positive correlation , suggestBesides the reported ADHD-diet association, there is also scientific evidence for an association between other lifestyle factors and ADHD. According to research, children with ADHD are almost twice as likely to demonstrate less healthy behavior, which leads to the previously described association between ADHD and obesity, even after adjustment for other multiple parameters such as age, sex, medication and comorbidities . Given tObservational studies have also demonstrated some associations between specific micronutrient levels in subjects with ADHD and the presence or severity of symptoms; however, these studies do not allow conclusions to be drawn on causal relationships. In addition, as demonstrated in omega-3 PUFAs supplementation, the therapeutic benefits of supplementation may depend on baseline nutrient status and thus may likely be narrowed to individuals with specific micronutrient deficiencies . Furtheret al. also reported that mice with an autism-like condition showed lower levels of Bifidobacteria and Blautia gut bacteria, and their guts produced fewer compounds, such as tryptophan and bile acid, needed to produce serotonin (Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by the presence of stereotypical behavior, exhibiting communication and social interaction deficits. Although the precise ASD etiology remains unknown, both genetic and environmental factors are recognized to play a key role in its pathogenesis. Many environmental factors linked to the risk of developing ASDs have been associated with gut microbiota shifts (dysbiosis) as dysbiosis-related gastrointestinal alterations are often associated with ASDs. Furthermore, a strong positive correlation has been demonstrated between ASD severity and the severity of the comorbid gastrointestinal dysfunction linked to gut dysbiosis . Regardierotonin . It is iBacteroides fragilis  in ASD children with gastrointestinal pain  in autistic children, together with low levels of SCFAs detected in patients' fecal samples , and suggests that the infant gut microbiome may be associated with subsequent development of communication, personal and social, and fine motor skills in 3-year-old children and with delays. In fact, the main finding was the potential association between e skills . Consistformance . One smaformance . ChildreLactobacillus Plantarum PS128 on ASD symptoms, a psychobiotic strain with beneficial effects on anxiety, and demonstrated that a 28-days intervention with the probiotic significantly ameliorated certain behavior, specifically opposition/defiance, in boys with ASD  and fructo-oligosaccharides (FOS) increases social interaction in chronically stressed mice, positively influencing the relative abundance of the key bacterial genera Akkermansia, Bacteroides, and Desulfovibrio  diet, which has gained popularity in recent years for ASD treatment . The ratBifidobacterium) have shown particularly high dipeptidyl peptidase IV activity, the primary degrading enzyme of BCM7, suggesting they may limit BCM7 activity during early development. Taking into account the reported evidence and despite the need for further studies, gut microbiota might be considered to positively impact peptidases levels in the context of neurodevelopment and, thus, on ASD. Selected strains of B. longum subsp. Infantis, and B. bifidum, among others with high degradative capabilities, might be potential probiotic microorganisms able to abolish food-derived opioid peptides and, thereby, contribute to host health  is the dietary intervention with the most proven therapeutic effect in Nutritional Psychiatry, especially for the treatment of refractory pediatric epilepsy and with a high therapeutic potential for many mental health and metabolic disorders. The KD has recently been proposed as a promising metabolism-based dietary intervention for the prevention and treatment of ASD. In this respect, a recent systematic review of the literature examining the interplay between KD and ASDs revealed encouraging findings, particularly from animal studies, which support the potential to improve core behavioral symptoms of ASD by using KD or analogous metabolic strategies . In factExtensive scientific evidence advocates that unhealthy dietary patterns may increase the risk of developing depression or anxiety, while a healthy dietary pattern and some specific dietary components may do the opposite. This would suggest that dietary interventions could help to prevent, or be an alternative or adjunct therapy for depression and anxiety. However, the relationship between diet and depression and anxiety is complex and further studies are essential to understand the nature of this relationship, especially in individuals vulnerable to these conditions . Regardiet al. demonstrated that the administration of the lactic acid bacteria Lactobacillus rhamnosus in mouse models modulated GABA receptor expression and induced anxiolytic behavioral effects via a vagus nerve-dependent pathway , the abnormal trajectory of brain development linked to this disorder is established during gestation and early life, long before the onset of the clinical symptoms of disease, which often occur in early adult life. SZ is a chronic mental illness characterized by positive symptoms , negative symptoms  and cognitive alterations . The disease typically progresses gradually, with early warning signs  developing before the first severe episode (psychosis) when positive symptoms started to be experienced. Interestingly, the shortened life expectancy observed in patients with SZ has been attributed to many other medical disorders often comorbid to the disease, such as cardiovascular diseases and diabetes.It is well-established that different early life environmental factors, many of which are linked to gut microbiota shifts, might trigger the onset of this psychotic disorder in genetically susceptible individuals. Indeed, preclinical studies have shown that maternal stress and maternal immune activation (MIA) during pregnancy result in SZ-like behavior in offspring . In addiSuccinivibrio and Corynebacterium, has been associated with severe symptoms of SZ , piroxidine (vitamin B6), and cobalamine (vitamin B12) deficiencies have been reported common in SZ patients. Total plasma homocysteine (Hcy) level is considered as a sensitive measure of these deficiencies and elevated Hcy levels have been widely associated with the etiology of numerous health impairments, especially cardiovascular diseases and several mental health disorders such as Alzheimer's disease and SZ  and someIn this regard, several randomized double-blind placebo-controlled trials have shown the effectiveness of homocysteine-reducing strategies, with folic acid and vitamin B supplementation improving both positive and negative symptoms, mostly related to attention/vigilance, and especially in chronic SZ patients with hyperhomocysteinemia .Additionally, low serum levels of vitamin D have also been observed in SZ patients having a negative correlation with psychosis severity . LikewisOther studies highlight the association between SZ and celiac disease  and therproteobacteria  and potentially harmful bacteria (proteobacteria). By contrast, in a recent study published by Lindefeld et al., the authors draw attention to the potential negative effects of KD on gut microbiota, describing a decrease in Bifidobacteria and an increase in E. coli  could be recommended to replace KD for refractory epilepsy treatment. Although KD is highly valued to treat epilepsy and has therapeutic potential for the prevention and treatment of other mental health and metabolic disorders  in PTZ-kindled rats, reduced seizure severity and epileptic activity when compared to seizures in controls  often associated to mental health disorders, researchers few years ago reported the role of the gut microbiota in modulating the relationship between red meat consumption and atherosclerosis and other cardiovascular disorders. In particular, several studies in mice and humans have reported increased fasting plasma levels of trimethylamine (TMA), a compound produced by the gut microbiota metabolism, and its proatherogenic metabolite trimethylamine-N-oxide (TMAO), concomitant with an increased risk of atherosclerosis, after oral intake of L-carnitine and phosphatidylcholine depending on the gut microbiota profile . AdditioBifidobacterium abundance  gene, which modulates MTHFR enzyme activity, and other factors such as age, gender, smoking and certain medications have been associated with Hcy levels  located in the methylenetetrahydrofolate reductase  regime as therapeutic approach for ASD, a recent systematic review of four randomized controlled trials on GFCF diets found a 50% efficacy rate of treatment, and reported that the GFCF diet may provide more substantial clinical benefits in individuals with low GSH levels and in those with preexisting GI symptoms . ResearcCurrently, preclinical and cross-sectional studies have strongly established that the gut microbiota influences cognition, mood, and behavior. In this regard, research highlights that early life perturbations of gut microbiota function can profoundly impact neurodevelopment, with potentially crucial long-term consequences on health. However, there is still a critical need for population-based prospective cohort studies to provide a comprehensive understanding of the early temporal variability in the host-microbe dynamic interactions, which determine the shift from mental health to mental disorder, and vice versa. In this regard, gut microbiota profiles and determinants of those profiles linked to the onset of NDDs should be extensively investigated, and further studies are essential to design gut microbiome-targeted intervention strategies to promote the development and maintenance of a healthy brain. Thus, to develop more effective microbiome-based interventions and innovative dietary supplements targeting NDDs, we require a greater understanding of the beneficial gut microbiota members for mental health. These would include bacteria as well as bacteriophages, which are active against particular bacteria, and the underlying mechanisms by which they act, including bioactive molecules (postbiotics). In the near future, such potential novel intervention strategies could pave the way toward preventing the development of NDDs in subjects with risk indicators, and provide new alternatives to improve the clinical management of subjects diagnosed with NDD.Diet is also considered as an amendable factor that can help to protect against the onset and manifestation of mental health disorders by controlling the gut-brain axis. To date, studies have reported a prominent inter-individual variation in the clinical response of NDDs to beneficial dietary interventions, and consequently a major challenge currently faced by nutritional interventions is to identify biomarkers that can accurately predict the efficacy of the response.The gut microbiota may be a key mediator of dietary effects on mental health, although diet is also known to be involved in brain functioning through other microbiota-independent mechanisms. In this respect, exhaustive studies are needed to decipher the precise mechanisms by which certain dietary interventions exert their effects, with the main goal of designing safer and easy-to-implement targeted strategies, based on those underlying mechanisms. Finally, it is also important to note that although diet is a major component of an individual's lifestyle, data on other lifestyle factors and the Human Genome provide fundamental information that should also be taken into account when studying the determinants of mental health, besides the bases of dietary effects on mental health. In fact, scientific evidence has indicated that the effects of diet on the host may be modulated by variations in the human genome as well as by other lifestyle factors that may, likewise, influence gut microbiota and human genome expression. Therefore, in the current -omics era, further studies based on multi-omics data integration are greatly needed in the field of Nutritional Psychiatry in order to identify baseline molecular signatures and/ lifestyle determinants (diet and other lifestyle factors) that may (co)determine or predict the specific effects of dietary interventions. The results provided by these studies will likely lead to refined future dietary strategies to prevent or improve the treatment of NDDs, and, in this way, help Psychiatry progress towards tailored nutrition and personalized medicine.MC and AL wrote the first draft of the manuscript. JP, PC-F, and MC have contributed substantially to the writing and revising of the manuscript. MC designed the aim of the editorial. All authors have made substantial intellectual contributions, took responsibility to the manuscript, and give final approval of the version to be submitted.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.


A 60-year-old male patient presented to our outpatient clinic complaining of a 12-month history of a progressively enlarging painful ulcer on his right calf. For the past 6 months, with no previous confirmed diagnosis, he had been on varying doses of systemic and topical antibiotics that resulted unsuccessfully. On examination, a well-defined moderate severity violaceous verrucous plaque with raised edges [Dermoscopy of the inferior portion of the lesion  showed white scales, black dots, hemorrhagic spots, and yellow crusts at the periphery. The center of the lesion had a distinct shiny white blotches and strands and polymorphic vessels surrounding the yellowish-orange ovoid areas .On in vivo reflectance confocal microscopy examination , the presence of small rounded hyperreflective bodies, 0.4 μm in size, in the epidermis suggested the transepidermal elimination of fungal cells .Ultrasonography was performed on the same area with a linear transducer using a 22-MHz frequency . There was epidermal thickening, and 2 well-defined hyperechogenic round structures were seen in the epidermis and in the superficial dermis. Color Doppler sonography detected an irregular increase in echogenicity and vascularization giving the dermis a disorganized appearance .Histopathology of a 5-mm punch biopsy from the same area showed a flattened epidermis and a granulomatous infiltrate in the dermis, with giant cells surrounding pigmented spherical fungal structures, besides an increased number of dermal capillaries and dermal fibrosis .Fonsecaea sp. was isolated from tissue culture, consequently confirming the diagnosis of chromoblastomycosis.Direct mycological examination of specimens treated with KOH 20% + DMSO exhibited septate brownish muriform cells, and The patient in this manuscript has given written informed consent to the publication of the case details.Chromoblastomycosis is a neglected and chronic infectious disease that has a peculiar characteristic, the transepidermal elimination of fungal structures in its early stages. Considered one of the implantation mycoses, the disease is present in several countries especially in developing countries; chromoblastomycosis is relatively common in Brazil . The etiDermoscopy is a helpful semiological dermatologic tool in the diagnosis of cutaneous and subcutaneous mycoses such as chromoblastomycosis. More commonly, the disease presents as verrucous slow-growing plaques with deep brown to black dots, crusts, scales, and yellow-orange characteristic structures on dermoscopy. The most important dermoscopic findings are the presence of multiple and irregular black dots, which are attributed to the elimination process of inflammatory cells, fungal elements, and hemorrhage through the epidermis –7. It caThere are currently several techniques of high-frequency ultrasound with many applications in the field of dermatology. Studies are underway to refine ultrasound technology and equipment, for both diagnostic and therapeutic purposes . The ultIn vivo reflectance confocal microscopy is an emerging technique that cuts optically the living tissue of the skin and appendages at various depths in horizontal layers with cellular-level resolution and no change in tissue surface. This is a noninvasive imaging method; initially focused on the diagnosis of benign and malignant skin lesions, its use in basic and clinical dermatology is wide . It is aThe authors suggest that imaging exams allow real-time, high-quality noninvasive assessment of the transepidermal elimination of fungal structures, contributing to the diagnosis and follow-up of chromoblastomycosis, notwithstanding that direct microscopy, histopathology, and the isolation of the etiological agent remains the gold standard.➢ We propose the use of imaging as new propaedeutical tools in chromoblastomycosis.➢ Dermoscopy correlated to clinical and histopathology findings and may be used as an aid to follow treatment response.➢ In vivo reflectance confocal microscopy is a fast, real-time, and useful method to approach a suspected skin lesion of chromoblastomycosis.➢ Dermoscopy, high-frequency ultrasonography, in vivo reflectance confocal microscopy, and histopathology evidenced the transepidermal elimination of fungal structures seen as black dots clinically. The contribution of these processes to a better understanding of diagnosis and therapeutic follow-up needs to be validated.


Traumatic orbital apex syndrome (TOAS) is an uncommon but severe ocular complication of craniomaxillofacial fracture. The optimal surgical strategy for TOAS has not been determined. To investigate the endoscopic anatomy of the orbital apex region, propose a protocol for simultaneous endoscopic endonasal decompression of the optic canal, superior orbital fissure, and proper orbital apex (EEDCFA) for TOAS and report its use in two patients.An endoscopic endonasal approach was utilized to dissect the orbital apex region in two silicon-injected adult cadaveric heads. The details of the procedure used for decompression of the orbital apex were determined. The effects of this procedure were determined in two patients with TOAS who underwent simultaneous decompression of the optic canal, superior orbital fissure, and proper orbital apex.The orbital apex consisted of three portions, the contents of the optic canal superomedially; the contents of the superior orbital fissure inferolaterally; and the converging portion, or proper orbital apex, anteriorly. From an endoscopic endonasal approach, the optic nerve, superior orbital fissure, and orbital apex convergence prominences were found to form a π-shaped configuration. This π-shaped configuration was indicative of the orbital apex and was an important landmark for decompression of the orbital apex. Endonasal decompression of the orbital apex in the two patients resulted in the satisfactory recovery of extraocular mobility, with no surgical complications.EEDCFA is feasible, effective, and safe for patients with TOAS caused by direct compression of displaced fracture segments. The π-shaped configuration is a valuable landmark for EEDCFA. Traumatic orbital apex syndrome (TOAS) is an uncommon but severe ocular complication of craniomaxillofacial fracture, characterized by injuries to cranial nerves II, III, IV, V, and VI. From an anatomic perspective, trauma usually involves both the superior orbital fissure and the optic canal. Although, surgical decompression is a treatment of choice. The optimal surgical strategy for TOAS has not yet been determined. Methods described to date for patients with TOAS include endoscopic endonasal decompression of both the optic canal and proper orbital apex  and an oThis study was, therefore, designed to investigate the endoscopic anatomy of the orbital apex region, focusing on the interrelationships of the superior orbital fissure, optic nerve, and proper orbital apex. Based on these anatomic findings, a protocol was designed for the simultaneous endoscopic endonasal decompression of the optic canal, superior orbital fissure, and proper orbital apex (EEDCFA) and the benefits of this protocol were tested in two patients with TOAS.via the endoscopic endonasal transethmoidal transsphenoidal route combined with the trans-septo-transsphenoidal route. The orbital apex was dissected and its detailed anatomy was determined using the nasal endoscope.The orbital apex in two silicon-injected adult cadaveric heads (four sides) was approached In addition, two patients with TOAS caused by direct compression from the displaced fracture segments were evaluated. The orbital apex in each was evaluated pre-operatively by CT scanning. The two patients underwent EEDCFA. Recovery was evaluated post-operatively by determining extraocular motility and visual acuity.Institution Review Board ethics approval was obtained and patients consented to publication of their images.The apex of the orbit is located in the orbit posteriorly, thus forming a transition zone between the orbit and intracranial structures. The orbital apex consists of three portions: the contents of the optic canal superomedially; the contents of the superior orbital fissure inferolaterally; and the convergence portion, or proper orbital apex, anteriorly, in which the contents of the optic canal and the superior orbital fissure converge into the orbit. The superior orbital fissure and the optic canal form the posterior osseous orbital apex . The supThe optic canal is bounded by the superior root of the lesser wing of the sphenoid bone superiorly, the optic strut inferolaterally, and the body of the sphenoid bone medially .The convergence portion  is attached to a circular fibrous ring, called the common annular tendon, which serves as the tendinous origin of the rectus muscles. The common annular tendon divides the superior orbital fissure into three compartments: superolateral, central, and inferior.Understanding the anatomy of the lateral wall of the sphenoid sinus remains crucial in EEDCFA . From suThe patient was placed under general anesthesia and orotracheal intubation. The nasal vestibules were prepped with an iodine solution. The draping left both eyes exposed in the operative field allowing intraoperative evaluation of the globes if required. Following decongestion of the nasal cavity with cotton pledgets soaked with 1:10,000 adrenaline, the landmarks of the nasal cavity on the right side were identified . The ipsA total of two patients with TOAS underwent EEDCFA. The extraocular mobility functions and visual acuity of these two patients improved following decompression procedures. No surgical complications occurred. Demographic and pre- and post-operative visual and extraocular mobility functions of two cases with TOAS were listed in A 31-year-old male was struck by a falling steel plate at his workplace on the right side of his head. He was taken to a local clinic, where his wound was debrided and sutured. However, the bone fracture was not treated. Two weeks later, he was admitted to the ophthalmology department of our hospital. His main complaint was a complete loss of vision in his right eye and diplopia. Ophthalmologic examination revealed no perception of light, direct and indirect light reflex defects, and complete ophthalmoplegia of his right eye . AdminisThe concept of the orbital apex was controversial. It has been defined as the most posterior orbit, not including the contents of the superior orbital fissure and optic canal , 11, 13.Conservative management and close observation without surgical intervention may be sufficient , 17. Megvia an open microsurgical approach. The visual and extraocular mobility function of the patient improved to various extents. Imaizumi et al. .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.


L-Asparaginase and Superoxide dismutase, following their association with liposomes will be extensively discussed.The drugs concept has changed during the last few decades, meaning the acceptance of not only low molecular weight entities but also macromolecules as bioagent constituents of pharmaceutics. This has opened a new era for a different class of molecules, namely proteins in general and enzymes in particular. The use of enzymes as therapeutics has posed new challenges in terms of delivery and the need for appropriate carrier systems. In this review, we will focus on enzymes with therapeutic properties and their applications, listing some that reached the pharmaceutical market. Problems associated with their clinical use and nanotechnological strategies to solve some of their drawbacks  will be addressed. Drug delivery systems will be discussed, with special attention being paid to liposomes, the most well-studied and suitable nanosystem for enzyme delivery in vivo. Examples of liposomal enzymatic formulations under development will be described and successful pre-clinical results of two enzymes,  The so-called “change in paradigm” of molecules as drugs, from almost exclusively low molecular weight molecules to bioactive agents was due to research and biotechnological advances ,2. NowadEnzymes are widely distributed in all animal and vegetal cells, playing a crucial role in all cellular metabolisms by being involved in critical reactions essential for the existence of life ,4,5. TheEnzyme application as therapeutic agents, namely as digestive auxiliaries  has been reported since the 19th century ,8. LaterThe enzymatic therapeutic strategy became more realistic after the establishment and increment of genetic engineering technologies that made possible the production of enzymes with the needed characteristics of purity, selectivity and amounts compatible with the clinical use . The theEnzymes, as a particular class of proteins, can be distinguished due to the specific binding and action on their targets with great affinity and specificity. They can be from vegetal, animal and antimicrobial origin ,11,23. DOne of the reasons for that discrepancy is probably related to problems arising from the behavior of exogenous enzymes when administered in living organisms. In some cases, it can result in mild or even acute allergic reactions, including anaphylaxis and death ,8,12. MoEarly efforts with intravenous administration of therapeutic enzymes based on passive uptake by target cells and tissues resulted in poor therapeutic activity. Improved activity, reduced immunogenicity and clearance were achieved with enzyme–nanocarrier association, the topic of extensive and fruitful research work ,22. NanoAs one of the most-studied DDS of bioactive agents, liposomes have given rise to several commercialized formulations and many others in advanced stages of clinical trials. They present several advantages over other nanocarriers, such as structural versatility, biocompatibility, biodegradability, non-toxic and non-immunogenicity nature as well as the mild conditions for their preparation. They are spherical structures, consisting primarily of amphiphilic molecules (phospholipids), organized in bilayers and were the first lipid vesicles introduced by Bangham and Horne in 1964 . The hydThe physicochemical properties of liposomes are directly related to their lipid composition and preparation method. Lipid molecules such as phospholipids and cholesterol are the major components of the vesicular carriers. Their composition can be widely varied, through the choice and combination of their constituents, lipids and others. This allows the diversity of their physicochemical properties, depending on the following variables: charge of phospholipid polar head groups, saturation and length of the phospholipid acyl chains, presence of cholesterol or other non-lipid-charged molecules and proportion of the various constituents (lipidic or not). The environmental pH also influences drug–vesicle interactions . The encConventional liposomes A fail toLiposome characteristics depend on the lipid composition selected for their preparation. Accordingly, they can present different surface charges: neutral, positive or negative. Non-charged and non-coated liposomes tend to be less stable and higher aggregation is expected. On the opposite, charged liposomal formulations give rise to an increase in the intermembrane repulsion and reduction in the propensity of liposomes to aggregate.Negatively charged vesicles present enhanced interaction with the MPS and were used in pathologies localized in the liver and spleen . CationiAnother targeting strategy that has been developed is the preparation of stimuli-responsive liposomes, i.e., liposomes can be designed to release the incorporated drugs in the presence of specific stimuli, such as an in vivo pathological trigger. The stimuli can be tissue-generated  or generated from external sources  .The phospholipids traditionally used for liposomes preparation are phosphatidyl choline from egg yolk or soybean, hydrogenated phosphatidyl choline, phosphatidyl ethanolamine, phosphatidyl glycerol, phosphatidyl inositol, phosphatidyl serine and phosphatidic acid . The modThere are several types of liposome classifications, the most common according to the structural parameters, method of preparation or with their behavior in vivo. Liposomes are typically classified by the number of lipid bilayers (lamellae) . Vesicles are characterized by the diameter (which may vary from a few nanometers to a few micrometers) and distribution of vesicle populations (assessed by the polydispersion index); captured volume (aqueous volume sequestered by amount of lipid); drug loading or drug incorporated per amount of lipid in liposomal form; incorporation/encapsulation efficiency, expressed as a percentage and corresponds to the quotient between the final and initial ratios of incorporated substance/lipid in liposomal form; surface charge; and morphology ,48.The classic method of preparing liposomes is extremely simple, consisting of dissolution of the mixture of the lipid constituents (containing the bioactive agent if hydrophobic) in compatible organic solvent, followed by drying in a round bottom flask, under reduced pressure or under a flow of nitrogen, to form a lipid film. The addition, under stirring, of an aqueous solution (containing the bioactive agent in the case of being hydrophilic) leads to the formation of liposomes in suspension. This method generates multilamellar liposomes containing the incorporated agent, commonly referred to as multilamellar vesicles (MLV). Despite its simplicity, this method of preparation has some drawbacks, as resulting liposomes present great heterogeneity in terms of mean size and low incorporation efficiencies. Small unilamellar vesicles, commonly referred to as SUV can be obtained by submitting large liposomes, such as MLV, to the action of ultrasound or extrusion. Large unilamellar vesicles (LUV), can be achieved after solubilization of the lipid mixture and of the bioactive agent in detergent and its slow removal by dialysis. All these types of liposomes, MLV, LUV and SUV, are named as conventional or from the first generation, and were progressively being replaced by more sophisticated ones that allowed the incorporation of higher percentages of solutes. One of these preparation strategies involves a lyophilization step of liposomes, containing the incorporated material, and rehydration, under controlled conditions. This kind of liposomes, called dehydration–rehydration vesicles (DRV) represent one of the first important stages in liposome technology, and allows the incorporation efficiency to increase from around 10% in classical liposomes up to 90% . A complThe encapsulation of enzymes in liposomes is a dual strategy aiming to protect enzymes from degradation and to target them in vivo. In the recent years, enzyme entrapment methods have been based on kinetic specifications of the enzyme, and optimum pH and temperature in a way to guarantee that both an enzyme-loaded liposome and a free enzyme showed a typical Michaelis–Menten profile . AdditioAs already mentioned, the encapsulation of enzymes in DDS has been extensively investigated aiming to improve their therapeutic performance. Liposomes are one of the most versatile nanosystems for the delivery of therapeutic enzymes, either by their ability to modulate the characteristics according to the membrane composition and size or by the technological approaches used for their production. Moreover, the development of liposomal formulations with native or chemically modified forms, their performances, the different routes of administration and lipid compositions have been extensively reviewed ,52,53,54L-Asparaginase and Superoxide Dismutase, liposomal formulation details and the most important outcomes of pre-clinical assays are presented in Relevant examples of therapeutic enzymes associated with liposomes, particularly, for the most well-studied, L-asparaginase is a component of the chemotherapy cocktail for the treatment of acute lymphoblastic leukemia (ALL) since the 1960s, acting by depletion of the circulating substrate, L-asparagine [L-Asparaginase liposomes (~150 nm) demonstrated to enhance half-life in the bloodstream (up to 10 times) in comparison to the non-incorporated enzyme. In addition, the incorporation in liposomes was responsible by the increased therapeutic effect observed in a tumor P1534-induced mice model, as well as the absence of acute toxicity [L-Asparaginase nanoformulations were accomplished by including in the lipid composition of liposomal membrane certain kind of phospholipids such as monosialogangliosides or phosphatidyl inositol. These lipids present at the liposomal surface are responsible for the decrease in plasmatic protein adsorption and consequent uptake by the MPS [paragine . This giparagine . The maiparagine . As the paragine . Nanosiztoxicity . Similartoxicity  after intoxicity . The lon the MPS ,58. More the MPS .Catalase is an oxyreductase enzyme with antioxidant activity acting by degrading hydrogen peroxide produced in inflammatory processes. After being co-loaded in liposomes with a cytotoxic drug, cisplatin, the nanoformulation was able to induce tumor hypoxia, resulting in a synergistic therapeutic effect . In anotSuperoxide dismutases are a family of metalloenzymes, able to scavenge superoxide radicals thus acting as antioxidants for the treatment of reactive oxygen species-mediate diseases. For more than 30 years, superoxide dismutase has been studied as a therapeutic tool in many animal models as well as in few clinical trials with positive results ,78,79,80Aiming to further improve the therapeutic effect of superoxide dismutase, the conjunction of enzyme chemical modification followed by incorporation in liposomal lipid bilayer was studied ,78,85,86Another combined approach consists of covalent linkage of superoxide dismutase to the terminus of the lipid component (DSPE-PEG), achieving long circulating properties of liposomes, while evidencing superoxide dismutase activity at the outer surface of the nanosystem . The preBesides parenteral administration of superoxide dismutase nanoformulations, non-invasive routes of administration have also been studied. One of these examples refers the epicutaneous application of a superoxide dismutase lipid-based nanoformulation on the back of adjuvant-induced arthritis rats. In this case, enzyme-loaded deformable lipid vesicles, Transfersomes, especially designed for transdermal delivery, were able to improve the disease symptoms of the animals in comparison to induced and non-treated animals, namely paw edema and inflammatory hematological and biochemical parameters. It was also shown that superoxide dismutase-loaded Transfersomes, epicutaneously applied, were able to reach blood circulation in a therapeutic dose and accumulate at inflamed paw .In an experimental colitis model, a recombinant form of superoxide dismutase was loaded in negatively charged liposomes and exhibited a reduction in inflammation of the colon . AdditioThe anti-inflammatory activity of superoxide dismutase-loaded, catalase-loaded and co-encapsulated superoxide dismutase/catalase in ultradeformable vesicles was measured after topical application on the arachidonic acid-induced mouse ear oedema model. The biological activity was compared to enzyme-loaded conventional vesicles and enzyme solutions. The co-association of both enzymes to deformable vesicles resulted in an improvement in enzyme penetration across the intact skin barrier to exert their therapeutic effect .Streptokinase is a fibrinolytic protein and urokinase is a serine protease. They are enzymes widely used for the treatment of several thrombosis disorders namely myocardial infarction, acute cerebral infarction and pulmonary embolism. Streptokinase activates bond cleavage to produce plasmin and urokinase acts by catalyzing the production of plasmin, leading to the breakdown of the fibrin mesh structure in blood clots. Their reduced biological half-lives constitute important drawbacks limiting the clinical use. Pharmacokinetic studies using streptokinase loaded in long circulating liposomes resulted in an increase in the half-life of the enzyme (16-fold higher) in comparison to the respective free form , and a hUricase is an enzyme that catalyzes the degradation of uric acid being then by-products easily eliminated by renal excretion. As observed for other therapeutic enzymes, the clinical application of uricase has been limited by unsuitable biological properties namely premature degradation and inactivation by endogenous proteases, among others . FollowiWhile enzymes as therapeutic agents have been applied for more than one century, their use as biopharmaceutics is still far from the expected for such a potent class of molecules. This fact has been correlated with side effects and low residence time in the living organisms, drawbacks that need to be solved. Fortunately, on the one hand, the DNA technology advancements allow enzyme production with necessary quantities and appropriated characteristics for clinical use. On the other hand, pharmaceutical nanotechnologies made possible the modulation of enzyme presentation to the human organisms, by its association with DDS namely liposomes, thus improving their therapeutic activity. Besides all the benefits from incorporating therapeutic enzymes in liposomes, the translation from the laboratory to the clinic always needs to address important challenges. One main challenge concerning enzymes is related to the preservation of the protein 3D structures, not only to avoid immunogenic responses but to maintain their biological function. During nanoformulation development, for each enzyme, the lipid composition needs to be adequately selected aiming to maximize the loading and to maintain the enzyme integrity. Furthermore, liposomal membrane compositions must be designed to deliver the enzyme with the suitable biodistribution profile according to the specific organ or tissue that it is intended to target. Another challenge deals with the chemical and physical stability of the liposomal membrane. In fact, liposome stability issues, observed for conventional liposomes, mostly used in the 1980s and 1990s decades, have been overcome due to intense academic efforts, resulting in the accomplishment of several methodologies to achieve stable liposomes. Moreover, the large-scale production of liposomal formulations is a well-established process that has already given rise to several commercialized products. Successful examples in clinical use are more than a dozen liposomal nanoformulations. The continuous evolution and sophistication of liposome technology as well as the increased fields of application are expected to enlarge this clinical offer. Nowadays, the liposome technology is mature, and these DDS will continue to play a leading role in bringing new enzymatic nanomedicines to the market. We truly believe that enzymatic therapy after appropriate formulation in DDS, such as liposomes, will fulfil its due place within the battery of the new generation of biomedicines.


Exosomes are lipid bilayer vesicles released by multiple cell types. These bioactive vesicles are gradually becoming a leading star in intercellular communication involving in various pathological and physiological process. Exosomes convey specific and bioactive transporting cargos, including lipids, nucleic acids and proteins which can be reflective of their parent cells, rendering them attractive in cell-free therapeutics. Numerous findings have confirmed the crucial role of exosomes in restraining scars, burning, senescence and wound recovery. Moreover, the biology research of exosomes in cutting-edge studies are emerging, allowing for the development of particular guidelines and quality control methodology, which favor their possible application in the future. In this review, we discussed therapeutic potential of exosomes in different relevant mode of dermatologic diseases, as well as the various molecular mechanisms. Furthermore, given the advantages of favorable biocompatibility and transporting capacity, the bioengineering modification of exosomes is also involved. The skin is composed of hair, sweat glands, sebaceous glands and other accessory structures, as well as enriched blood vessels, nerve muscles and lymphatics . The dirNumerous cells types release exosomes into the extracellular environment after fusing with the cytomembrane. Exosomes are membrane vesicle with a size of 30-150 nm. . GeneralHowever, after exosomes released, the nomenclature and characterization still not come into a consensus. According to the Minimal Information for studies of Extracellular Vesicles (MISEV), three key areas were addressed: EV isolation/purification, EV characterization and EV functional studies . RegardiThe secretion of exosomes is a process in which MVB fusing with the plasma membrane and different mechanisms are involved . Several2+ and activation of protein kinase C promotes both the generation and delivery of exosomes  effectively promote wound angiogenesis and epidermal regeneration et genes . Proteinet genes . Bone maet genes . Adiposeet genes . Additioet genes .Burns is a common injury in daily life, which occurs in 50 to 100 cases per 10,000 people annually . At presin vivo  is one of the most common and major complications of diabetes. At present, the pathogenesis of DFU is considered to be the result of the interaction between peripheral blood vessels and peripheral neuropathy. The complexity of the pathogenesis and the difficulty of wound healing make it one of the problems that threaten the life and health of diabetic patients . Our prein vitro . In diabin vitro . The plain vitro . iPSC exin vitro . The ginin vitro .+T cells function and facilitates tumor growth , exosomes also serve as an important vehicle for tumor and microenvironment communication, and reactivate tumor-associated signals such as TGF-β in order to promote metabolism and growth of cancer cells .Scleroderma is characterized by inflammatory, degeneration, thickening, and fibrosis, which in turn is hardened and atrophied, thus causing multiple system damage. Studies have reported a significant reduction in exosome levels in peripheral blood serum from patients with scleroderma, which is highly likely to be associated with impaired exosome transport system caused by vascular abnormalities . This dePsoriasis is an autoimmune disease of the skin, often accompanied by excessive proliferation of keratinocytes, while iron reserves often affect the working state of the patient’s immune system. Some researchers have found that important proteins regulating iron reserve such as hepcidin and soluble transferrin receptor are at low expression levels in serum exosome of patients with psoriasis, presumably affects immune function and thus affects the course of the disease .Exosomes can be extracted from saliva, mononuclear macrophages, and platelet secretions. After skin trauma, obstruction of coagulation function affects the repair time of wounds, and the blocked coagulation function is relevant to the change of tissue factor (TF) conformation or the presence of TF inhibitory molecules. Saliva-derived exosomes can shorten wound clotting time by transporting active TF in combination with factor VII. At the same time, these different sources of exosomes secreted into the intracellular space can also activate coagulation by transmitting TF, for example, exosome secreted by monocytes can bind to platelets and release their own TF into platelets to activate downstream cascades to promote thrombin and fibrin clot formation .de novo affect itself.Proliferation of skin cells plays a vital role in skin damage repair. At present, exosomes from various tissue and cell regulate the proliferation of skin cells, such as MSC exosomes , mouse EProliferation and migration of cells are pivotal for wound healing. With the onset of the clotting period, immunoinflammatory cells such as macrophages and neutrophils are first recruited to the damaged site to get rid of necrotic tissue fragments as well as phagocytose infected microbe. Subsequently, epidermal cells and dermal fibroblasts begin to migrate to the injured sites to fill the vacancies and promote wound healing . In thisAngiogenesis provides oxygen for repairing tissues and supply nutrients. The proliferation of vascular endothelial cells is an essential constituent of it. Moreover, it also requires interaction with angiogenic, endothelial cells and the surrounding extracellular matrix environment . The wouStem cells are the important reason to explain the super self-repair ability of skin. Epidermal stem/progenitor cells generally locate in the basal layer of the epidermis to meet the daily keratin renewal metabolism or the need to fulfill new cells after skin damage. The proliferation and differentiation of skin stem cells are affected by multiple factors, and finally achieve the balance between proliferation and differentiation . In the After skin trauma and infection, a great quantity of immune cells are recruited to the lesion region, Exosomes transport pathological nucleic acids, proteins and lipids, and take part in antigen-promoting, immune response-related receptors activation, and defense induction, which therefore arouse interests to consider exosomes as good immune-based therapeutics and vaccine candidates .in vitro to promote wound healing by facilitating neovascularization, collagen deposition as well as re-epithelialization  The scalability of exosomes is a major challenge currently. The future clinical use for exosomes depends on a mass-produced and GMP-compliant production process. New approaches like tangential flow filtration can concentrate large quantities of cell-conditioned media for exosome enrichment . (2) TheUltimately, although we have already acquired certain stock of knowledge on exosomes and their functions on skin biology, there still much room for exploration on the potential of exosomes in dermatologic disease is diagnose and treatment.HS did the conceptualization. HS and YS wrote. MW and DY collected the data. HQ and WX reviewed and edited. 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.


A human ovarian carcinoma, IGROV-1, was xenografted into different sites  in nude athymic female mice to investigate the pattern of antitumour efficacy of FAA and compare it to that of doxorubicin and cisplatin, two established cytotoxic drugs. Ascitic and lung-growing tumours totally failed to respond to FAA, whereas s.c. and liver-growing tumours were significantly growth inhibited. This pattern of activity differs from that achieved by the two conventional cytotoxic drugs, which were active against the IGROV-1 tumour growing in all of the tested sites. These studies indicate that cytotoxicity is not the major determinant of FAA antitumour efficacy even against human tumour xenografts. Moreover, the dramatic difference between the sensitivity of lung and liver tumour colonies demonstrates the great importance of the site of tumour growth for FAA efficacy.


The Indium-labelled somatostatin analogue pentetreotide has been successfully developed for imaging of somatostatin receptor positive tumours. However there is significant renal tubular uptake of the radiolabelled peptide, which can obscure upper abdominal tumours and would preclude its use for targeted radiotherapy. The aim of this study was to determine whether amino acid infusion, which has been shown to block renal tubular peptide reabsorption, diminishes renal parenchymal uptake of this radiolabelled analogue. Eight patients being scanned with the 111In-labelled somatostatin analogue, pentetreotide, for localisation of gastroenteropancreatic tumours received an infusion of synthetic amino acids. The ratio of isotope uptake in kidney to that in spleen was assessed, and compared to the ratio for matched control patients, to determine if amino acid infusion reduced renal parenchymal uptake of the radiopharmaceutical. The amount of isotope in the urine was determined to ensure that any effect of the amino acid infusion was unrelated to changes in clearance. Infusion of amino acids significantly reduced renal parenchymal uptake of isotope at 4 h. There was a non-significant increase in urinary clearance of isotope over the 4 h, consistent with reduced reuptake and a lack of effect on glomerular filtration rate. This technique, by preventing renal damage, may allow the use of this somatostatin analogue for local radiotherapy, and could be of wider value in blocking tubular re-uptake of potentially nephrotoxic agents, such as radiolabelled Fab fragments.