Implementation of evidence-based cancer prevention and early detection in low- and middle-income countries (LMIC) is challenging. Limited and inappropriate introduction of novel alternatives results in an equity gap whereby low-income populations receive a lower benefit. Implementation research represents an opportunity to foster the adoption and expansion of evidence-based cancer control strategies; however, scientific development in high-income countries does not necessarily fulfill the particular needs of LMIC in the field. A review on the link between implementation research and practice, the tension between theory and pragmatism, the conflict around implementation research methods, and determinants of research priority definition was carried out by considering the perspective of cancer prevention and early detection implementers in LMIC. Basic principles and alternatives to overcome implementation research challenges in these settings are discussed. Cancer is a leading cause of morbidity and mortality worldwide , 2. AlthSeveral factors influence the successful implementation of novel cancer control alternatives, including health system organization as well as social and economic determinants. Accordingly, the ability and capacity to properly introduce new technologies and programmatic approaches in dissimilar contexts have become crucial in reducing disease burden disparities and in cancer control in general terms. During the last decade, implementation research has been proposed as a means to foster the adoption and expansion of evidence-based cancer control strategies; thus, it is currently a field of intensive activity with growing support by funding and governmental institutions .Several theoretical frameworks have been developed in the field aimed at providing structured guidance to practice; however, implementation research and practice are still facing relevant challenges such as the differential nature of health problems and control interventions and the variability in requirements for specific settings. Indeed, cancer biology (by tumor type), the natural history of the disease (preinvasive/invasive), and the diversity of interventions for cancer prevention and early detection significantly impact program organization and the economy of health systems, thus increasing the complexity of the implementation process and associated research.Theory and methods of implementation research have been extensively discussed and summarized , 6, but Most theoretical frameworks recognize the need of several steps for integrating evidence-based practices in a given scenario ; howeverThe decision (adoption or adaptation) to introduce new technologies or programs in the public health setting is shaped by several organizational and external factors where the availability of strong scientific evidence may be neither compulsory nor sufficient. From the perspective of the innovation decision process, attaining a proper level of knowledge (from scientific evidence) is the first step toward adoption, but the final decision is influenced by other considerations such as envisioned relative advantages, compatibility with current structures and processes, level of complexity, testability , and observability . Yet, seHence, decision-making in the public sector is complex, and, in many cases, research to help the adoption decision must be the initial step to foster implementation  found the majority to be oriented toward dissemination rather than implementation and focused on interventions at the institutional and community levels rather than focusing on public policy implementation . Ra. Ra42]. Cluster randomized interventions  have been used to surmount this limitation; however, these designs require larger sample sizes and constrain the use of mass media campaigns for educational or promotional purposes due to the risk of contamination in control groups. Consequently, individual randomized trials seem to be more appropriate to evaluate implementation strategies on a small scale within a given organization where contextual factors equally affect all groups under evaluation and are not a central component of the study. Anyway, using a control comparable with the subjects of the intervention has been questioned from ethical and technical perspectives in implementation research, since this is the last step in the research process for interventions with already proven efficacy. Alternatively, several options for comparison have been proposed, including step-wedge trials (delayed intervention for the control group), time-series analysis, and simulation by modelling , 45.In addition, a broad range of proposals for integrating research into routine practice has been developed, including traditional approaches such as quasi-experimental designs, community trials, natural experiments, case studies, and new developments like implementation effectiveness research, pragmatic trials, hybrid designs, participatory action research, and so forth , 19, 43.As noted, internal validity, external validity, and feasibility represent major driving forces for implementation research in low-resource settings ; the adeAn additional issue is the need for a larger spectrum of reliable outcome variables for a proper assessment of sustainability and scalability of cancer prevention. Research translation from clinical trials to public health programs usually leads to a reduction of intervention efficacy , 46; indUsing short-term outcomes of cancer prevention and early detection, such as disease stage at diagnosis, detection rates, or biological response, adds value to implementation research by integrating quality and other influential factors that are difficult to measure by other means . AlthougHarmonization between implementation research and practice may be in tension within the comprehensive approach envisioned. While research could help accelerate implementation, an excessive demand for it may possibly become a barrier for introducing new alternatives to cancer control, particularly in low-resource settings; therefore, identifying research needs and defining research priorities through the implementation process are crucial.Given their proximity to policy decision-making, the perceived needs of implementation research are highly subjective. In general terms, a higher availability of baseline data on the burden of disease and program performance favors identification of knowledge gaps and research needs, and it is usually associated with a higher scientific capacity in the implementation setting . InternaBesides scientific capacity and the availability of baseline data, other factors that could also influence the perceived needs of implementation research are the cost of innovations, strength of associated evidence, and level of innovation marketing . In cancInnovations supported by strong evidence may also create an independent dynamic in dissemination of innovations within the scientific community and, consequently, may reduce the perceived needs of implementation research as in the case of marketing ; neverthFor instance, individual weight management programs and surgical and pharmacological treatments for obesity control rely on strong evidence from randomized trials ; howeverPriority definition for implementation research could also be influenced by funding sources. Funding agencies establish internal objectives within their own theoretical frameworks that may or may not be aligned with implementation research priorities in LMIC; in consequence, the search for funding sources deserves careful attention in order to avoid deviation from primary needs. Furthermore, a large magnitude of external funding for implementation research might conflict with integration of innovations within health systems, because the implementation process should comprise financial sustainability and political commitment from the real setting.The development of implementation research and science represents a remarkable opportunity to reduce disparities in cancer control; however, particular conditions of underserved populations and scarcity of resources in most LMIC require a broad perspective within the whole implementation process not restricted to the delivery of innovations or programs.Informed and evidence-based decisions in public health are highly desirable; however, after the proof of concept, an excessive demand for intensive or complex implementation research could unnecessarily delay or hinder the introduction of new technological and programmatic alternatives given the frequent political uncertainty and lower technical skills in developing countries. Indeed, the diverse character of preventive interventions and the low frequency of short-term cancer-related outcomes increase the complexity of implementation and effectiveness research on cancer prevention and early detection strategies. Sustainability, coverage, and special outcomes required for population-based interventions in cancer control impose additional challenges to underserved communities.In this context, the role of funding agencies and international organizations becomes essential to harmonize the quality of research and implementation needs. Additionally, some basic principles should be considered to promote better integration between implementation research and practice in lower-resource settings, where flexibility of research methods is particularly relevant to properly responding to specific needs and research questions.


CSVD might progress for many years during the early stage of the disease as it remains asymptomatic. Prevalent among elderly individuals, CSVD has been alarmingly reported as an important precursor of full-blown stroke and vascular dementia. Growing evidence has also shown a significant association between CSVD’s radiological manifestation with dementia and Alzheimer’s disease (AD) pathology. Although it remains contentious as to whether CSVD is a cause or sequelae of AD, it is not far-fetched to posit that effective therapeutic measures of CSVD would mitigate the overall burden of dementia. Nevertheless, the unifying theory on the pathomechanism of the disease remains elusive, hence the lack of effective therapeutic approaches. Thus, this chapter consolidates the contemporary insights from numerous experimental animal models of CSVD, to date: from the available experimental animal models of CSVD and its translational research value; the pathomechanical aspects of the disease; relevant aspects on systems biology; opportunities for early disease biomarkers; and finally, converging approaches for future therapeutic directions of CSVD.Cerebral small vessel disease (CSVD) refers to a spectrum of clinical and imaging findings resulting from pathological processes of various etiologies affecting cerebral arterioles, perforating arteries, capillaries, and venules. Unlike large vessels, it is a challenge to visualize small vessels  Cerebral small vessel disease (CSVD) refers to a diverse range of clinical and neuroimaging findings resulting from pathological changes of various etiologies affecting the cerebral small vessels, particularly small veins, venules, capillaries, arterioles, and small arteries . More prNotably, the inconsistency in terms of the definition, unstandardized neuroimaging reporting, and silent nature of the disease at the early stage hampers a deeper understanding of its pathogenesis and subsequent effective therapeutic measures . These cIn view of the social and healthcare burden it may incur, contemporary and collaborative efforts are necessary to generate and expand our current understanding of CSVD from the aspects of its pathomechanism, systems biology, opportunities for early disease biomarkers, and potential therapeutic approaches. This chapter summarizes these core topics from the perspectives of numerous experimental animal models of CSVD.One of the predominant types of strokes resulting from the occlusion (ischemia) of small blood vessels deep within the brain is an ischemic stroke . About 3The definition of CSVD remains contentious due to its complex and overlapping pathophysiological mechanism. However, it is generally accepted that CSVD is mainly due to the pathological consequences of small vessel disease on the brain parenchyma rather than the underlying diseases of the vessels .Therefore, the term CSVD is preferred to describe a brain parenchyma injury that is associated with distal leptomeningeal and intracerebral vessel pathology that resides in poorly collateralized subcortical gray and deep white matter. Moreover, it is mainly due to several vasculo-pathological processes that affect and cause occlusion to the small perforating cerebral capillaries (of sizes 50–400 μm), small arteries , arterioles, and venules that penetrate and supply the brain subcortical region  Figure . SeveralThere are several etiopathogenic classifications of CSVD. However, the most prevalent forms of CSVD are amyloidal CSVD  and non-amyloidal CSVD  . Other lIn general, the various pathological changes of CSVD not only resulted in cerebral parenchyma damage, that is, axonal injury, neuronal apoptosis, demyelination, and oligodendrocyte damage see  but alsoNonetheless, the underlying pathomechanism of CSVD remains contentious despite the growing insights from histopathological, epidemiological, and physiological studies. Moreover, there is increasing evidence that advanced age and the presence of chronic hypertension may reduce the ability to self-regulate cerebral blood flow (cBF) in response to various systemic blood pressure levels and increased arterial stiffness, hence the increased speed and flow pulsatility in cerebral arterioles . These hAnother key factor thought to contribute to the pathogenesis of CSVD is endothelial dysfunction, with elevated biomarkers being reported . In addiOn the other hand, hypoperfusion or reduced cBF in CSVD has been hypothesized to be involved with endothelial dysfunction . GeneralMoreover, a group of genetically inherited forms of CSVD with an increasing prevalence has been widely investigated for the past decade . AlthougNOTCH3 gene (a genetic determinant of CADASIL) in pericytes was found to contribute to CSVD pathogenesis due to abnormal cross-talk between ECs and pericytes  has been linked as a common disease pathomechanism between different types of monogenic CSVD, largely from proteomic and biochemical studies on postmortem monogenic CSVD in humans and animals. Moreover, increasing evidence from genetic studies supports the fact that CSVD can be highly heritable, especially among patients with early onset CSVD and young patients with stroke, and that common variants in monogenic CSVD genes may contribute to the disease pathomechanism in certain CSVD forms . In addiericytes .Further deliberation of the current various pathogenesis of CSVD as highlighted in the foregoing paragraphs will be discussed in the later section. Our current knowledge of the natural history of CSVD had been based largely on our neuroimaging findings, although it is limited. Recognizing the heterogeneous manifestations of CSVD, from silent to symptomatic, implies that our apparent detection of the disease is made possible through the imaging of the brain white matter. Therefore, neuroimaging remains the key modality in assessing and diagnosing CSVD.The ischemic consequences of several manifestations of CSVD, such as white matter hyperintensities (WMHs), lacunar strokes, cerebral microbleeds, enlarged perivascular spaces, and small subcortical infarcts, can be detected using magnetic resonance imaging (MRI) . WardlawIn addition, WMHs are also regarded as an ischemic white matter demyelination and can manifest as symptomatic or silent (asymptomatic) brain parenchyma lesions. Interestingly, this so-called “silent” manifestation of CSVD is frequently reported as an incidental finding from brain images of individuals who never experienced any symptom of stroke, which is more frequent among the elderly . It has About 95% of asymptomatic manifestations of CSVD are lacunar silent brain infarcts (SBIs) (as seen as WMHs on MRI) and are arguably more prevalent than symptomatic manifestations. The two major contributors to the onset and progression of SBI include age and hypertension . The keyIn addition, healthy white matter is more myelinated than white matter of patients with AD  and has Reduced cBF, endothelial dysfunction, oxidative stress, and focal neurological signs are related to cerebral lesions and have been found to correlate with imaging markers, that is, the number and volume of WMHs . FurtherInvestigations using animal models are becoming routine, involving rats and mice or even larger animals such as rabbits and non-human primates, to better understand the development and progression of CSVD. By using animal models, the pathological process of CSVD, such as ischemic white matter lesions following reduced BBB integrity and endothelial dysfunction, can be evaluated. However, as discussed in the previous section of this chapter, CSVD has several different and overlapping pathological features. So the models used ideally should have similar  CSVD characteristics, that is, diffuse white matter damage, small vessel arteriopathy, and small discrete infarcts, with and/or without cognitive impairment . MoreoveThe approach used most frequently is bilateral common carotid artery occlusion (BCCAO) or two-vessel occlusion, which reflects the hypoperfusion and/or ischemic injury aspect of CSVD . A previAlongside the BCCAO approach, there is another well-established and valid animal model for CSVD – the spontaneously hypertensive stroke prone (SHRSP) rat model . SelectiNOTCH3 gene that encodes transmembrane receptors may contribute to a rare monogenic CSVD such as CADASIL  that contributed to the arteriovenous malformations and white matter lesions as precursors of CADASIL  may lead to ischemic damage, causing WMHs, lacunae and microbleeds associated with CSVD . Hence, l damage . The majl damage .in silico computational approaches are used to study BBB-related pathology, hence lending support to the involvement of the BBB in CSVD. The first approach is MD, a method used at the molecular level of complexity, for example, a model to study the BBB, mutated or misfolded proteins and transporters, and small molecule permeation across the BBB. The MD approach enables the investigation of impaired protein structure and function and drug-like molecule cytotoxicity at the BBB. Besides MD, finite element methods and pharmacokinetics target the organ  as the level of complexity, opening a new window into investigations on cerebral injury, that is, BBB leakage and permeation  have demonstrated that the maturation of vascular smooth muscle cells (vSMCs) and arterial differentiation depend on the activity of cell signaling that involves the Notch family of cell signaling receptors, especially Notch3 . The steillaries .Although the exact pathomechanism involving mutant Notch3 aggregation still needs further investigation, previous studies have proposed that the co-aggregation of mutant Notch3 and other proteins suggest that additional proteins are recruited into Notch3 deposits . For exaNOTCH3 gene mutations can also cause damage in the BBB  up to the cellular level had suggested that TGF-β signaling pathways were significantly involved in the pathomechanism of monogenic CSVD. Due to its vast expression, TGF-β has multiple biological functions including a regulatory role in vascular development . The TGFHTRA1 gene may lead to fragility of the vascular wall in CARASIL. The HTRA1 gene encodes an evolutionarily conserved serine protease. Mutations in CARASIL generally due to loss of HtrA1 activity that impaired substrate processing, hence, serve as primary disease mechanism. HtrA1 is primarily located and functions in the ECM; hence, it helps to degrade certain substrates located in extracellular compartments  protein accumulation in cerebral capillaries has been widely studied and shown to affect BBB integrity, which leads to a loss of tight junction proteins and thus to increased BBB permeability. The progressive deposition of Aβ in the walls of cortical and leptomeningeal small arteries can lead to vessel dysfunction and brain parenchymal injury, thus causing vascular occlusion and rupture see . On the APOE ε4 alleles was related with the presence of lacunae. Additionally, this finding suggested that there is a crucial involvement of Aβ clearance in the pathogenesis of lacunae. Moreover, it is widely accepted that APOE is associated with aging; hence, it serves as a risk factor that influences CSVD  gene, and damage of the BBB due to aberrations and mutations of the FOXC1 gene may permit the entry of pathogens or immune cells and disrupt brain function, thus leading to the onset and progression of CSVD  and CSVD, and both patients with PITX2 gene mutations and murine Pitx2–/– mutants displayed brain vascular phenotypes. Together, these results extend the genetic etiology of stroke and demonstrate an increasing developmental basis for human cerebrovascular disease , single photon emission computed tomography (SPECT), or optical imaging  to knockout and transgenic  animals. With the development of these animal models, non-invasive techniques to assess functional, biochemical, and anatomical disease-related changes have become indispensable, and a variety of small animal models have been developed for the imaging scanners with high sensitivity, specification, and resolution. Furthermore, the findings in mouse models obtained by small animal PET/SPECT and MRI scanners can be compared directly to the human situation with clinical scanners and represent true translational research from bench-to-bedside and back to the bench again.On the other hand, cerebral perfusion, cerebrovascular reactivity, BBB permeability, and white matter microarchitecture are accessible through MRI; these pathologies are altered in CSVD. Cerebrovascular reactivity may occur at early stages of CSVD and is correlated with future development of WMHs, while reduced cBF may predict the future risk of dementia. Newer approaches, such as diffusion tensor imaging (DTI) , had received more attention for the assessment of CSVD . DTI is Diffusion tensor imaging studies in mouse models that exhibit specific types of white matter abnormalities may become a guide for information on the root cause of signal changes. One study in the shiverer (shi) mouse model of dys-myelination and demyelination using cuprizone treatment suggests that reductions in the myelination of the corpus callosum increase radial diffusivity  . In moreIn summary, the new and advanced quantitative neuroimaging techniques are not ready for routine radiological practice, but are already being employed as monitoring biomarkers in the newest generation of trials for CSVD .CAA is a common amyloidal form of CSVD, and its incidence is mostly related to advanced age . Based oA study on SHRSP rats, as a valid model of non-amyloid CSVD, found the mutual occurrence of non-amyloid CSVD and CAA, as is commonly found in the aging brain . SpontanIn addition, recent evidence suggested that through the use of a novel cerebrospinal fluid biomarker of BBB-related soluble platelet-derived growth factor receptor-β and capillary mural cell pericytes, BBB damage can serve as an early biomarker for human cognitive decline that is independent of Aβ, and it has been supported by a study on regional BBB permeability using dynamic contrast-enhanced MRI .Genetics might play a crucial role in elucidating the cellular and molecular mechanisms of CSVD, and thus the pathophysiology of its hereditary forms. CADASIL, CARASIL, and several other forms of CSVD have been discussed with regard to the genetic factors and their pathways. Therefore, cellular, molecular, and biochemical changes underlying CSVD can easily be assessed using animal models of these rare single-gene disorders. Increasing the number and variety of transgenic, induced mutants and naturally occurring animal models of genetic disease are vital to identifying new genes that are the root cause of the disease; then, allow better understanding of the cellular and molecular mechanisms of genetic diseases and elucidating the genes involved in such diseases with complex inheritance patterns.NOTCH3 gene  prevents the CSVD phenotype in both mouse models of CADASIL and NOTCH3 knockout mice , interleukin-6 (IL-6), intracellular adhesion molecule-1 (ICAM1), and l models . The prol models . In addil models . TherefoThe second type are serum neurofilament (NfL) markers. Measuring the NfL level has been reported to be a direct approach of measuring the extent of neuronal damage . Since NThe next type of biomarkers are serum albumin (SA) and albuminuria markers. The leakage of albumin during BBB dysfunction is associated with increased BBB permeability, especially in the aging brain. Previous studies found that increased SA levels and the CSF/SA ratio are associated with the presence of WMHs in CSVD and vascular dementia, which serve as surrogate markers for BBB breakdown . On the Another type of widely studied biomarkers of endothelial dysfunction are coagulation and hyperhomocysteinemia markers. One of the most crucial coagulation factors in circulation system is fibrinogen, which has been widely associated with endothelial dysfunction, followed by BBB damage, and is a beneficial marker for the disease . FibrinoMPs are non-nucleated, small, and membrane-enclosed extracellular microvesicles . Their sMPs can serve as a procoagulant because they bear functionally bioactive phospholipids and cyto-adhesion molecules, such as phosphatidylserine and procoagulant protein tissue factor, that play major roles as cellular activators of the clotting cascade . MoreoveApart from endothelial dysfunction, Finally, a major problem relates to the fact that CSVD has multiple features and measuring the MPs of blood samples does not necessarily correspond to what happens to all CSVD features; different MP subpopulations may have different microthrombogenic effects on the progression of CSVD, but it is clearly stated that the MP level increased gradually prior to CSVD. In conclusion, considerable evidence suggests that MPs may play an important role in CSVD, although many molecular details still need to be clarified. The use of comprehensive panels of circulating MP biomarkers exploring the functioning of the different biological pathways may be useful to study CSVD.In animal models, plasma and cerebrospinal fluid biomarkers can assist in the development and implementation of similar approaches in clinical populations. These biomarkers may also be helpful in decisions for an advance treatment to human testing. Longitudinal studies in animal models can determine the initial presentation and progression of biomarkers that will be used to assess the disease-modifying efficacy of drugs. The refinement of biomarker approaches in preclinical systems will not only aid in drug development but may also facilitate diagnosis and disease monitoring .Furthermore, relationships in animal models can be investigated between peripheral biomarkers and readily available neuropathology; these can be translated into human studies where biomarkers are accessible, but neuropathology is often not. MicroRNAs (miRNAs) have also been implicated in disease pathogenesis and recommended as a putative biomarker  , 2012. IIn addition, since hypertension is one of the main risk factors for the development of CSVD, is a major contributor to stroke, and the most common cause of vascular dementia, chronic hypertensive rat models have been shown to bear similarities to most key features of CSVD. According to findings by a previous study, the mouse model of angiotensin II (AngII)-induced hypertension was an appropriate animal model for early onset CSVD and therefore, vascular cognitive impairment, pathologies commonly preceding vascular dementia .To date, a unifying pathomechanism of CSVD remains elusive, and hence contributes to the current lack of effective therapeutic strategies in preventing and treating CSVD . Indeed,Thus far, targeting the risk factors of diseases such as hypertension and hypercholesterolemia remains the focus of therapeutic approaches in CSVD despite its controversial long-term outcomes . Here, wIn line with human studies, SHRSP rats demonstrate similar histopathological changes such as arteriosclerosis and lipohyalinosis of small vessels . TherefoIn clinical studies, available data suggest conflicting results in terms of the efficacy of anti-hypertensive treatment in reducing the rate of WMH progression in patients with stroke – ranging from a significant reduction to no effects . NeverthStatin, an HMG-CoA reductase inhibitor, is prescribed principally as an anti-hyperlipidemic agent in CSVD. Research evidence suggests that statin treatment might be beneficial in terms of preventing stroke recurrence in patients with small vessel stroke . Linear In another study involving a similar stroke-prone model, rosuvastatin treatment was found to attenuate renal inflammatory processes and to delay the onset of brain damage . In hypeClinical evidence suggested that pre-stroke statin administration reduces WMH progression, improves executive function , and proThe use of anti-platelet agents remains one of the strategies in secondary stroke prevention after lacunar stroke . In geneA pooled analysis of randomized trials had supported the use of single anti-platelet agents as a secondary prevention modality following lacunar stroke . NonetheThere has been a recent proposition to view CSVD as a dynamic whole-brain disease to guide on new direction of therapeutic approaches in CSVD . NeverthRecently, compelling evidence from experimental models suggests that oxidative stress might be one of the key players involved in the development of arteriopathy in CSVD  and cereSeveral authors had found that natural antioxidants, such as vitamin E, ascorbic acid, L-carnitine, astaxanthin, and nigella sativa supplementation, reduce oxidative stress in SHRSP and CCH rat models, as depicted by increased activities of superoxide dismutase, catalase, and glutathione in the brain , plasma Together with the oxidative stress–lowering effect, vitamin E or its compounds as supplements have been found to prevent neuronal death , preservOn the other hand, a combination of α-tocopherol and lovastatin treatment in SHRSP had led to similar findings in terms of reduced oxidative stress, preservation of hippocampal structure, and improved cognition . It is tL-carnitine supplements in CCH rats significantly reduced the pathological hallmarks of ischemic white matter disease by enhancing the myelin sheath thickness and oligodendrocyte marker expression , an antioxidant enzyme, alleviates oxidative stress in the SHRSP, as measured by the increased plasma total antioxidant status and reduced vascular superoxide anions . These cConsidering the role of oxidative stress in the pathomechanism of CSVD, combating oxidative stress might be a promising therapeutic approach. Lessons from vascular disease and/or stroke trials indicated that antioxidant treatment might fail to show benefits in these settings in view of the limitation of the study design and failure of the relevant antioxidant to adequately reverse oxidative stress, which might be particularly true in advanced stages of the disease . In futuCilostazol is a specific phosphodiesterase III inhibitor that has been shown to prevent platelet aggregation, reduce the oxidative stress level, and exert vasodilatory effects by increasing the intracellular level of CAMP and endothelial NO-synthase activity . CilostaThe reduction of oligodendrocyte death and regeneration of white matter that were observed in the cilostazol-treated group diminished upon the inhibition of protein A/K, which modulates the phosphodiesterase inhibition . This suIndeed, the pleiotropic effects of cilostazol had attracted several researchers to investigate its practicality in the clinical setting of CSVD. In a multicenter, randomized, double-blind, placebo-controlled trial, cilostazol treatment in patients with acute lacunar infarction had resulted in a favorable decrease in the pulsatility index in comparison to the placebo-treated group . SubgrouThe role of cerebrolysin as a neuroprotective and neurotrophic compound has been investigated in various experimental animal models and clinical studies of stroke and neurodegenerative disease . HoweverOther potential therapeutic approaches, such as smoking cessation, reduced salt intake, fasting, and increased physical activity, might be of benefit in the modification of CSVD risk factors, which are common to most non-communicable cardio-cerebrovascular diseases. In the CCH rat model, physical exercise had been shown to confer protection against BBB impairment , reduce Besides, intermittent fasting pretreatment prior to BCCAO in the CCH rat model has been shown to alleviate oxidative stress in the hippocampus, as evidenced by decreased malondialdehyde concentrations, increased glutathione concentrations, higher gene expression of antioxidative enzymes, and enhanced superoxide dismutase activity as compared to the non-fasting group . In factIn addition, the role of dietary salt restriction in CSVD should be further investigated in view of the evidence that high dietary salt intake in SHRSP rats exacerbated hypertension and increased the mortality rate . The neeAll in all, it is critical to carefully evaluate the risk and benefits of each treatment based on each patient. The apparent disparity in terms of the findings might be a reflection of the dynamicity and complexity of the disease in which different pathomechanisms are involved in different disease subtypes. Indeed, more studies are required to find a novel approach in CSVD treatment as a step toward establishing clinical practice guidelines of CSVD management. Therefore, several experimental animal models of CSVD should be used to discern the treatment effects on different pathological features of the disease. Large-scale randomized control trials that accurately identify the subtypes and stages of CSVD are required to assess the effectiveness of these treatments in preventing CSVD development in high-risk subject as well as in halting disease progression. Further studies should also be conducted to elucidate the impact of systematically incorporating non-pharmacological therapeutic strategies in the current management of CSVD. Nonetheless, it should be kept in mind that a safe, tolerable, and non-invasive treatment would be critical to increase the compliance rate in patients, which is one of the keys to successful treatment.Cerebral small vessel disease is a relatively heterogenous disease process and an important precursor to cognitive decline, stroke, and age-related functional decline. Despite the increasing number of research studies on CSVD, the pathomechanism in terms of its vascular pathology and brain injury remain elusive with various contentions on management and prevention. However, current technological advances in elucidating the disease pathomechanism may increase our understanding of the natural history of CSVD up to the molecular level. The main hurdle in exploring the natural history of CSVD is the fact that there is a coexistence of multiple forms, such as WMHs, lacunar infarcts, and microbleeds. Therefore, more attention and targeted efforts are needed to better disentangle the clinical consequences of CSVD. Meanwhile, advanced experimental and clinical trials are crucial to better elucidate the diagnostic criteria of CSVD and provide better therapeutic and preventive measures to halt and reduce the burden of disability, AD, or dementia caused by CSVD; the establishment of correct animal models to study the specific pathogenesis and mechanism of multiple forms of CSVD is highly beneficial.MM conceived, reviewed, and revised the final content of the manuscript. CN drafted the initial and original content of the manuscript and revised it. NA, AS, and MG contributed equally to drafting the initial and original content of the manuscript. All authors have jointly agreed on the final draft for submission.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.


Psychopathy continues to be a challenge in forensic contexts, and evidence of its association with destructive behaviors, such as aggressive antisocial behaviors, is extensive. However, the potential role of intelligence as moderator of the well-established association between psychopathy and aggressive antisocial behaviors has largely been neglected, despite intelligence having been independently related to both concepts. Increased knowledge of whether intelligence is relevant to this association is needed because of its possible implications on the assessment and treatment of individuals with psychopathic traits and aggressive antisocial behaviors. This study aimed to investigate the association between psychopathic traits, aggressive antisocial behaviors, and intelligence in young violent offenders and to test whether intelligence moderates the relationship between psychopathic traits and aggressive antisocial behaviors. Participants were 269 male violent offenders aged 18–25 years, assessed on the Psychopathy Checklist-Revised (PCL-R), the Life History of Aggression (LHA), and the General Ability Index from the Wechsler Adult Intelligence Scale, 3rd edition. Associations were tested with Spearman’s rho, and moderation analysis was performed through ordinary least squares regressions. The PCL-R four-facet structure was used for the analyses. We found a positive association between psychopathic traits and aggressive antisocial behaviors, and a small negative association between the Affective PCL-R facet and intelligence. In the moderation analyses, a small yet statistically significant moderation effect of intelligence on the association between the Interpersonal facet and LHA total scores was demonstrated. However, the amount of variance in the LHA total score explained by the model was very small: 2.9%. We suggest that intelligence, however, important for rehabilitation strategies and everyday functioning, is not necessarily pertinent to understanding aggressive antisocial behaviors in young offenders with psychopathic traits. People with highly psychopathic traits are a resource-intensive group in the criminal justice system, and they often return to crime despite extensive rehabilitative efforts . CliniciPsychopathy is considered the most important clinical construct in the criminal justice system  due to iOne factor previously related to both aggressive antisocial behaviors and psychopathy is intelligence. Research has shown that offenders, including violent offenders, tend to score lower on measures of intelligence than non-offenders, especially in terms of verbal abilities . HoweverAlthough previous research provided evidence of some relation between psychopathy and intelligence, the role of intelligence as a possible moderator of the well-established relationship between psychopathy and aggressive antisocial behaviors is largely unknown. The only known published study of this demonstrated that intelligence and psychopathy interact, with higher levels of psychopathy and intelligence linked to higher levels of crime among young offenders . HoweverThe aim of the current study was to investigate whether the relationship between psychopathic traits and aggressive antisocial behaviors is moderated by intelligence in a well-described, nationally representative cohort of young violent offenders in Sweden, with the following specific research questions: (1) Which associations can be found between psychopathic traits, aggressive antisocial behaviors, and intelligence? and (2) Does intelligence moderate the relationship between psychopathic traits and aggressive antisocial behaviors?M = 22.3, SD = 1.9) violent offenders, recruited from nine correctional facilities in the western region of the Swedish Prison and Probation Service. In total, 269 young violent offenders participated in the DAABS, with a participation rate of 71%. The DAABS cohort has been assessed as nationally representative for young violent offenders in Sweden.The present study analyzed data from the Development of Aggressive Antisocial Behavior Study (DAABS). The DAABS collected baseline data from March 2010 to July 2012  regressions were used to determine whether intelligence (WAIS-III GAI) moderated the relationship between the four PCL-R facets and aggressive antisocial behaviors  in separate analyses for each facet. Prior to analysis, residuals were checked and determined to be normally distributed. In order to decrease multicollinearity within the models, all independent variables were centered prior to analysis and creation of the moderator variable, in accordance with The study was approved by the Regional Ethics Review Board in Lund, Dnr 2009/405, as part of the DAABS project, and executed in accordance with the Declaration of Helsinki. Participation was voluntary, and all participants provided written informed consent before participation. After completing participation, each participant received 200 SEK as compensation for the time they spent in the study instead of working in the Swedish Prison and Probation Service. Participants who demonstrated current mental illness were offered referral to prison doctors, and psychiatrists if available, for further assessments.sr = -0.16, P = 0.010) and the WAIS POI , while no significant correlations to the WAIS VCI were found for any of the PCL-R facets.Psychopathic traits were positively associated with aggressive antisocial behaviors for all facets except for the Interpersonal facet . The AffIn the moderation analyses , the onlThe present study investigated whether intelligence, which is generally important for rehabilitation strategies and everyday functioning in forensic contexts, is relevant in the association between psychopathic traits and aggressive antisocial behaviors. The aims were to identify associations between the four facets of psychopathy according to the PCL-R, aggressive antisocial behaviors according to the LHA, and intelligence as measured by the WAIS-III GAI, and to test whether intelligence moderated the associations between psychopathic traits and aggressive antisocial behaviors. Our analyses yielded two main findings. First, our results indicated differing positive associations (weak to strong) between psychopathic traits and aggressive antisocial behaviors in young violent offenders depending on facet examined, with the strongest associations with the Lifestyle and Antisocial facets and the PCL-R total score and no significant associations to the Interpersonal facet scores. Only the Affective facet was weakly, negatively correlated to measures of intelligence. In the moderation analyses, a small yet statistically significant moderation effect of intelligence on the association between the Interpersonal facet and LHA total scores was demonstrated. However, the amount of variance in the LHA total scores explained by the model was very small: 2.9% see .The results from the moderation analyses, with a small but statistically significant moderation effect of WAIS-III GAI on the relation between Interpersonal facet scores and LHA total scores, are interesting but must be interpreted with caution. First, the Interpersonal facet scores were highly skewed in our sample of young violent offenders, with the majority of the participants scoring “0” see . That isp-values rather than as evidence of an effect that holds clinical value. In summary, we could not confirm the findings of The results of the moderation analyses for the other PCL-R facets were in line with what could be expected from the results already described, with intelligence not being a significant moderator of the association between psychopathy and aggressive antisocial behaviors. However, WAIS-III GAI scores were a statistically significant, independent predictor in the multivariate regression analysis. When compared to the correlations reported in Our findings of associations between psychopathic traits and aggressive antisocial behaviors are in line with previous research demonstrating strong relations between these concepts . Howeverrs ≤ 0.53) with aggressive antisocial behaviors, with a pattern of somewhat stronger correlations to antisocial than to aggressive behaviors. The results of a moderate-to-strong correlation between the PCL-R total score and aggressive antisocial behaviors should be interpreted in light of the associations with the Lifestyle and Antisocial facets, and the fact that behaviors in these facets were more common in the group than the behaviors in the Interpersonal and Affective facets  was significantly, negatively, albeit weakly, correlated to both general and perceptual dimensions of intelligence. Due to the weak correlation, interpretations should be made with caution. Yet, the results are in line with previous findings by It should also be noted that we found no associations between the PCL-R facets and the verbal dimensions of intelligence in our study. As recently pointed out by Unfortunately, the research evidence of an association between psychopathic traits and intelligence is still ambiguous and hampered by differences in study designs. That said, self-control  and tolerance of others  have been demonstrated to be protective against aggression and antisocial behaviors . Self-diBased on the, so far, contradictory findings about whether intelligence is a moderator of the association between different facets of psychopathy and aggressive antisocial behaviors, we suggest replications of our work and further studies on this subject. Continued research needs to consider the different contributions of the PCL-R facets, and also to expand the investigations to other samples, especially samples where higher scores on the Interpersonal facet can be expected. In this, researchers need to choose measures with care, and preferably use different measures of the same condition, e.g., psychopathy, intelligence, and aggressive antisocial behaviors, to provide a clearer picture of the constructs of interest . It is cThis study is limited by its cross-sectional design. However, the current sample was large and nationally representative for Sweden, and the data were derived from thorough clinical investigations considering not only self-reports but also official information on aggressive antisocial behaviors. Based on previous findings, investigations into whether different patterns may be distinguished between groups with low-to-moderate versus highly psychopathic traits could be recommended. This, however, was not possible in this study due to the low prevalence of highly psychopathic traits in our sample, which might be explained by the relative youth of the participating offenders whose psychopathic traits might not yet have been fully established. Another possible explanation is maybe because offenders in European settings generally score lower on the PCL-R compared to their North American counterparts . A furthThe present study examined the association between psychopathic traits, aggressive antisocial behaviors, and intelligence in young violent offenders and tested whether intelligence moderates the presumed relationship between psychopathy and aggressive antisocial behaviors. We demonstrated that both bivariate and multivariate associations and moderation effects varied depending on which facet that was investigated, and that the Interpersonal and Affective facets had very low impact on the explained variance in aggressive antisocial behaviors in young violent offenders. We suggest that intelligence, although important for rehabilitation strategies and everyday functioning, is not necessarily pertinent to understand aggressive antisocial or psychopathic behaviors in young violent offenders.This study was carried out in accordance with the recommendations of the Regional Ethics Review Board in Lund, with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Regional Ethics Review Board in Lund, Dnr 2009/405.FGM, MW, and DG contributed to the conception and design of the study. EB collected the data. FGM, MW, and DG performed the statistical analysis. FGM wrote the first draft of the manuscript. All authors wrote the sections of the manuscript and contributed to manuscript revision, read, 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.


Frailty is a common and clinically significant condition in geriatric populations, associated with adverse health outcomes such as hospitalisation, disability and mortality. Although there are systematic reviews/meta-analyses assessing the prevalence of frailty in community-dwelling older adults, nursing home residents, and cancer and general surgery patients, there are none assessing the overall prevalence of frailty in geriatric hospital inpatients.2 test performed to assess its magnitude.This review will systematically search and analyse the prevalence of frailty within geriatric hospital inpatients within the literature. A search will be employed on the platforms of Ovid, Web of Science and databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, SCOPUS and the Cochrane Library. Any observational or experimental study design which utilises a validated operational definition of frailty, reports the prevalence of frailty, has a minimum age ≥65 years, attempts to assess the whole ward/clinical population and occurs in hospital inpatients, will be included. Title and abstract and full-text screenings will be conducted by three reviewers. Methodological quality of eligible studies will be assessed using the Joanna Briggs Institute critical appraisal tool. Data extraction will be performed by two reviewers. If sufficient data are available, a meta-analysis synthesising pooled estimates of the prevalence of frailty and pre-frailty, as well as the prevalence of frailty stratified by age, sex, operational frailty definition, prevalent morbidities, ward type and location, among older hospitalised inpatients will be conducted. Clinical heterogeneity will be assessed by two reviewers. Statistical heterogeneity will be assessed through a Cochran Q test, and an IEthical approval was not required as primary data will not be collected. Findings will be disseminated through publication in peer reviewed open access scientific journals, public engagement events, conference presentations and social media.79202. First review to systematically or exclusively assess the overall prevalence of frailty in geriatric hospital inpatients.Will seek to provide stratified analysis of the prevalence of frailty based on age, sex, operational frailty definition, prevalent morbidities, ward type and location.Three independent reviewers during screening phase; ensuring high internal reliability and consistency of included studies.Will include only studies for which the full text is available in English, therefore will likely be relatively over-representative of Western nations ; although this is true of scientific publications in general.Frailty is a common and clinically significant condition within geriatric populations,The aim of this review is to systematically search and analyse the prevalence of frailty among geriatric populations (aged ≥65 years) within inpatient hospital settings within the literature. If a meta-analysis proves possible, the aim of this study is also to synthesise pooled estimates of the prevalence of frailty and pre-frailty, as well as the prevalence of frailty stratified by age, sex, operational frailty definition, prevalent morbidities, ward type and location (country and continent), among hospital inpatients.To identify and compare studies reporting the prevalence of frailty within hospital ward settings.To combine the extracted data to calculate the pooled overall prevalence of frailty in hospitalised geriatric inpatients.To perform stratified analysis of the prevalence of frailty based on age, sex, operational frailty definition, prevalent morbidity and ward type in order to assess the relationship between frailty and these factors.Inclusion criteria: all studies must have a minimum age of ≥65 years, use a clearly defined and validated operational definition for the classification of frailty , either assess (or attempt to assess) the whole ward, department, unit, hospital or specific clinical population, or employ some form of randomised selection of participants, occur within a hospital setting, in, or including, hospital inpatients , report the prevalence of frailty or provide sufficient data to allow the calculation of the prevalence of frailty. If a study examines a mixed cohort, only data relating to hospital inpatients will be included in the review.Exclusion criteria: all studies not written in English, studies where the sample are not hospital inpatients .Searches will be conducted on the platforms of Ovid  and Web of Science (incorporating the databases of Science Citation Index Expanded (SCI-Expanded), Conference Proceedings Citation Index—Science (CRI-S), and Emerging Sources Citation Index (ESCI)), and the databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, SCOPUS and the Cochrane Library databases (the Cochrane Database of Systematic Reviews (CDSR), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Methodology Register (CMR), the Database of Abstracts of Reviews of Effect (DARE), Health Technology Assessment database (HTA), and the NHS Economic Evaluation Database (EED)).Any form of observational or experimental study design which assesses the prevalence of frailty and meets the above eligibility criteria. For longitudinal observational studies, and experimental studies, frailty scores and additional data will be extracted from baseline data, provided baseline data meets the above eligibility criteria.The search strategy will be conducted on the two platforms of Ovid and Web of Science, as well as the databases of SCOPUS, CINAHL Plus and the Cochrane Library databases . These s10.1136/bmjopen-2019-030147.supp1Supplementary dataPrior to the commencement of title and abstract screening by the three independent reviewers, duplicates will be removed using EndNote V.X8.2. The reduced list of studies will be manually screened for the removal of any remaining duplicates. All reviewers will be provided with an instructional screening form , and a .10.1136/bmjopen-2019-030147.supp2Supplementary dataThe title and abstract of all studies will then be independently screened by the three reviewers, with each reviewer placing potentially eligible studies into a separate folder. On completion, potentially eligible studies from all three reviewers will be placed into a ‘master folder’ and the results collated. Duplicates will be removed, leaving the final combined list of studies for the full text screening phase. All reviewers will then independently screen the full text of remaining studies utilising the screening form and maintain separate files for included and excluded studies (including reasons), as well as for studies for which the reviewer feels the need to contact the authors for clarification or additional information.On completion, a full text screening master file  will be 10.1136/bmjopen-2019-030147.supp3Supplementary dataManual screening will also be employed by reviewers and include the reference lists of all included studies, as well as excluded but potentially relevant studies or systematic reviews captured within the screening. As part of the grey literature search of this review, in process publications will also be searched and conference abstracts will be followed up with authors to ascertain if a full text relating to the data is available. Studies of the same cohort will be included only once, using the study which provides the most information about the cohort relevant to this review.The quality of eligible studies from full text screening will be assessed by two reviewers independently using the Joanna Briggs Institute critical appraisal tool for studies reporting prevalence dataData extraction will be performed by two reviewers independently. In the event of any discrepancies between the two reviewers, a consensus will be attempted to be reached by discussion. In the event that a full consensus cannot be reached between the two reviewers after an exhaustive discussion, the opinion of a third reviewer will be obtained and the proceeding majority consensus will be taken.The following data, where available, will be extracted from all eligible studies ), sex , country/continent, sample size, diagnosis/prevalent morbidity (if applicable), any other relevant characteristics), criteria utilised for the operational definition of frailty. Results: Number of frail participants, number of ‘pre-frail’ participants, number of robust/non-frail participants, prevalence of frailty, prevalence of pre-frailty, prevalence of robustness/non-frailty, number of male participants, number of frail male participants, number of pre-frail male participants, number of non-frail/robust male participants, prevalence of frailty in male participants, prevalence of pre-frailty in male participants, prevalence of non-frailty/robustness in male participants, number of female participants, number of frail female participants, number of pre-frail female participants, number of non-frail/robust female participants, prevalence of frailty in female participants, prevalence of pre-frailty in female participants, prevalence of non-frailty/robustness in female participants, and finally authors comments and reviewers’ comments.External to the studies, data will also be extracted with regard to the 5-year average gross domestic product (GDP) per capita purchasing power parity (PPP)  of the country in which each study takes place, incorporating the 5 years directly preceding the commencement of recruitment to the study.2 test will be performed in order to assess the magnitude of this heterogeneity, with I2 values of 25%, 50% and 75% being considered low, moderate and high, respectively. If the Cochrane Q statistic test detected statistically significant heterogeneity, combined with the researcher’s assessment, a randomised-effects model will be used. Given the nature of this review and in particular its overall aim, combined with the eligible studies identified in preliminary searches, it is likely the initial quantitative synthesis will use a random-effects model.Quantitative synthesis : if a sufficient quantity of identified studies are comparable, a meta-analysis, pooling the aggregated data from each study, will be performed. Clinical heterogeneity will be assessed by two reviewers based on their judgement of the available data and any disagreements will be discussed thoroughly with the aim of reaching a unanimous consensus. If a unanimous consensus cannot be reached, the opinion of a third reviewer will be sought, and the proceeding majority consensus will be taken. Statistical heterogeneity will be assessed through the utilisation of a Cochran Q test and considered present at p<0.05. An IStratified analysis will also be conducted according to age , sex, operational frailty definition, ward type, prevalent morbidity and location (country and continent) where possible. These variables have been specifically chosen for stratified analysis predominantly due to an enhanced knowledge of these areas being of practical utility to researchers and clinicians; stemming from empirical evidence persistently showing alterations in these factors to impact on the prevalence of frailty.2 test will be performed in order to assess the magnitude of this heterogeneity, with I2 values of 25%, 50% and 75% being considered low, moderate and high, respectively.Clinical heterogeneity for stratified analysis will be assessed by two reviewers based on their judgement of the available data. Any disagreements will be discussed thoroughly with the aim of reaching a unanimous consensus. If a unanimous consensus cannot be reached, the opinion of a third reviewer will be sought. Statistical heterogeneity for sub-analysis will similarly be assessed through the utilisation of a Cochran Q test and considered present at p<0.05. An ISimilarly, it is likely a random-effects model will be utilised to synthesise pooled estimates of the prevalence of frailty stratified by these criteria .Correlation analysis will also be employed to examine the relationship between the prevalence of frailty of geriatric inpatients and economic prosperity (GDP per capita PPP) , and healthcare expenditure (per capita PPP) . In addition, multi-linear regression analysis will examine the predictive value between economic prosperity and healthcare expenditure and the prevalence of frailty of geriatric inpatients. Preliminary research into these areas have shown frailty in the community to be correlated with economic indicators (GDP per capita PPP),Qualitative synthesis: if a meta-analysis is not possible based on the nature of the studies and the data available, a more thorough systematic narrative analysis will be conducted, with findings presented in both textual and tabular formats.All authors are strong proponents of patient and public involvement and engagement with research and believe the finding of this review will be important to aid the facilitation of improvements in the planning and orientation of organisation structures and resources within this setting to meet the needs of service users; specifically relating to the enhanced care of older adults in inpatient hospital settings. However, given the nature of this study (systematic review), it was not possible to involve the public. However, the findings will be disseminated to our patient and public involvement groups.Formal ethical approval was not required for this review as primary data will not be collected. The findings of this study will be disseminated through publication in the form of scientific papers in peer reviewed open access scientific journals, public engagement events within the UK and Europe, online via social media  and the PANINI project website,


Chronic inflammation is one of the main determinants of atherogenesis. The traditional medications for treatment of atherosclerosis are not very efficient in targeting atherosclerotic inflammation. Most of these drugs are non-selective, anti-inflammatory and immunosuppressive agents that have adverse effects and very limited anti-atherosclerotic effects, which limits their systemic administration. New approaches using nanoparticles have been investigated to specifically deliver therapeutic agents directly on atherosclerotic lesions. The use of drug delivery systems, such as polymeric nanoparticles, liposomes, and carbon nanotubes are attractive strategies, but some limitations exist. For instance, nanoparticles may alter the drug kinetics, based on the pathophysiological mechanisms of the diseases. In this review, we will update pathophysiological evidence for the use of nanoparticles to reduce inflammation and potentially prevent atherogenesis in different experimental models. Atherosclerosis is a largely-investigated multifactorial disease. The pathophysiology of the disease has partially been attributed to changed immune system functions. Immune cells, including lymphocytes, macrophages and neutrophils, found in atherosclerotic lesions suggest an important role of inflammation in the development of atherosclerosis ,2. FurthAccording to the “classical” pathophysiological view, atherosclerosis occurs because of lipid accumulation in the vessel wall. Nonetheless, according to the current view, atherosclerosis is a low-grade chronic inflammatory disease, in which the immune system plays a central role in the initiation, progress and stability of lesions ,6,7. TheTherefore, statins can act against cholesterol and non-specific atherosclerotic inflammation at the same time. Recently, some studies have indicated that the IL-1 signaling pathway can be a potential target of more selective anti-inflammatory drugs. In a clinical trial, treatment inhibiting this pathway with a monoclonal antibody against IL-1β (canakinumab) was investigated with promising results ,18. AnotAlthough anti-inflammatory drugs have been associated with beneficial effects, systemic use of such drugs is limited because of their adverse effects, such as neutropenia, bone marrow suppression, and immunosuppression. Stimulation or inhibition of the inflammatory process may be beneficial but also harmful depending upon the phase of the atherosclerosis development . It seemIn order to reduce adverse effects and improve comfortability of administration, researchers designed well-organized and targeted delivery approaches for anti-inflammatory agents, such as those that can be encapsulated into nanoparticles . VariousAfter the administration of nanoparticles in vivo, a protein corona coats the nanoparticles, causing changes in their biological characteristics. Development of coating by protein corona is usually considered as the first phase in the nanoparticle sequestration by the RES. Different strategies have been developed to inhibit this event. Currently available approaches are based upon controlling the stiffness of nanoparticles, since deformable particles are less susceptible of being internalized by macrophages in RES in off-target sites ,44. AnotNanoparticles can be also activated via radiofrequency or photothermal energy. For instance, a potential application for inhibiting macrophages was represented by laser pulse excitation of iron oxide nanoparticles layered with dextran and gold within cells. Nanoparticles were investigated also for potential photothermolysis as well as MRI . The sam−/− mice, there was a downregulation of the tissue inhibitor of metalloproteinase 3 (TIMP3) gene. The administration of the nanoparticles resulted in slowing down of the plaque progression [The gene regulation approach has also been hypothesized to be useful in the prevention and therapy of atherosclerosis when using nanoparticles. In a study, small interfering RNA (siRNA)-loaded nanoparticles were used to downregulate the expression of C–C chemokine receptor type 2 (CCR-2), which is involved in the infiltration of inflammatory monocytes to the sites of both atherosclerotic plaque and ischemic myocardial injury ,52. Photgression . Similargression .−/− mice on a high fat diet (HFD) and treated with angiotensin II, leading to a monocyte-mediated inflammation. Two days after administration of nanoparticles, the balance of non- and pro-inflammatory monocytes was favorably changed—mainly towards non-inflammatory macrophages. Atherosclerotic plaques were more stable and the rupture risk was decreased [−/− mice fed with HFD diet and to whom MTX-conjugated nanoparticles were administered, there were much less atherosclerotic lesions in the aortic arch and even more effective was the treatment when MTX was combined with etoposide [Another approach could be inhibiting the infiltration of monocytes to the site of the atherosclerotic plaques as well as blocking their transformation into macrophages. Nanoparticles conjugated with pioglitazone, which is an agonist of the peroxisome proliferator-activated receptor (PPARγ) and is involved in the regulation of the fatty acids, could modulate the differentiation of macrophages. Such nanoparticles were evaluated in the ApoEecreased ,56. The ecreased . Nanopartoposide ,57. The toposide . There wtoposide ,59,60. INonetheless, such drugs are burdened by a non-specific systemic decrease of macrophage with consequent risk of infections. Non-ablation approaches targeting macrophage functionality have then developed to reduce side effects. Magnetic microbubbles conjugated with P-selectin are effective in the early phase of atherosclerosis, when the shear stress generates fatty streaks . SimilarThe use of nanoparticles to deliver anti-inflammatory substances has been recently investigated, suggesting promising results. A number of clinical trials is evaluating the application of nanoparticles and anti-inflammatory substances to reduce the number and size of atherosclerotic plaques or to stabilize them. Nevertheless, further basic research seems to be necessary to learn more about the underlying functional mechanisms of the nanoparticles. This is necessary to encourage more well-designed clinical trials, which would use anti-inflammatory drugs and nanoparticles to prevent or treat atherosclerosis. Novel strategies that look promising are those on mechanisms of interaction between immune cells and nanoparticles, especially with respect to the fate of nanoparticles as well as their components after deposition at site of atherosclerotic lesions and the effects on immune cells. Such studies will hopefully help constructing nanoparticles tailored for specific accumulation and controlled activation of the delivered substance. On the other side, the exact quality and quantity of nanoparticles absorption by immune cells has not been fully understood. There are various absorption pathways in similar phenotypes of immune cells , and theAtherosclerosis is a disease which cannot be easily detected with the available imaging techniques in the initial steps of development. Currently available therapeutic strategies are aimed at the systemic, but not local and targeted, prevention and treatment of atherosclerosis. All of them have limited efficacy and some adverse effects. Targeted delivery of diagnostic contrast substances or therapeutic drugs by nanoparticles to sites of incipient atherosclerotic lesions is considered to be a sophisticated strategy for the diagnosis as well as prevention and therapy of atherosclerosis. Targeted delivering approach using nanoparticles can promote the stability and bioavailability of the drugs, improve the detection sensitivity, enhance the therapeutic efficacy, improve the pharmacokinetics of the drugs, and reduce the adverse systemic side effects. Nevertheless, there are still a number of drawbacks in such nanoparticles with respect to stability, structure design, toxicity, targeting efficacy, and production, requiring optimization to devise nanoparticle-based therapeutic/diagnostic approaches for atherosclerosis that are clinically favorable. Application of porous compounds combined with imaging agents is an interesting option and studies in the future need to concentrate on enhancing its stability and efficacy in vitro and in-vivo. It has to be emphasized that possible beneficial effects of nanoparticles have largely been obtained from the in vitro experiments and experiments using animal models. Therefore, it will be a challenging effort to translate the results of these studies into possible clinical use. Current nanoparticle-based strategies have mainly focused on the anti-inflammatory effects by targeting the development of macrophages/foam cells as well as the recruitment of monocytes to the atherosclerotic plaques. However, gene-therapy, monoclonal antibodies, and combination therapies can be promising if merged with the potential beneficial use of nanoparticles. Moreover, multifunctional nanoparticles can be developed that could facilitate the imaging and targeted delivery of drugs in humans, i.e., in a clinical setting. Although the application of nanoparticle technology in the prevention and treatment of atherosclerosis is an emerging field, the progresses and the results obtained so far have been promising. This might open new horizons in the therapy of atherosclerotic cardiovascular diseases.


Nanoremediation, which is the use of nanoparticles and nanomaterials for environmental remediation, is widely explored and proposed for preservation of ecosystems that suffer from the increase in human population, pollution, and urbanization. We herein report a critical analysis of nanotechnologies for water remediation by assessing their sustainability in terms of efficient removal of pollutants, appropriate methods for monitoring their effectiveness, and protocols for the evaluation of any potential environmental risks. Our purpose is to furnish fruitful guidelines for sustainable water management, able to promote nanoremediation also at European level. In this context, we describe new nanostructured polysaccharide-based materials obtained from renewable resources as alternative efficient and ecosafe solutions for water nano-treatment. We also provide eco-design indications to improve the sustainability of the production of these materials, based on life-cycle assessment methodology. The increasing and rapid deterioration and degradation of the water quality is one of the most challenging issues facing the 21st century. It can be ascribed to a variety of factors such as population growth, the effects of climate change on the hydrologic cycle and increasing pollution. Globally, extensive research has been performed to address such urgent environmental issues and new technologies have been developed to remediate water pollution by both organic and inorganic contaminants. However, the cost and challenge associated with the treatment of both groundwater and wastewater and the increasing awareness of environmental risks calls for continued improvement and innovation. Nanotechnology has significantly contributed to remarkable industrial and societal changes over recent decades. Among the wide variety of fields of application of nanotechnology, considerable efforts have been devoted to exploiting the potential of engineered nanomaterials (ENMs) for environmental remediation, commonly referred to as “nanoremediation” ,4. IndeeDespite such promising expectations, environmental and human risk assessment associated with the use of ENMs is still a matter of debate and nanoremediation is seen still as an emerging technology . It has We herein report a critical analysis on the use of the ENMs for water remediation, with the aim of sharing the strategy developed within the NanoBonD project , funded in the framework POR CReO FESR Tuscany 2014–2020, whose objective is the development of innovative, ecofriendly and ecosafe polysaccharide-based nanotechnologies for the remediation of contaminated sediments and waters.The particularly desirable ENMs characteristics, which make them suitable for environmental remediation, can negatively rebound of the safety of application of such materials in water remediation . The curTrojan horse by increasing the uptake of contaminants to be remediated in exposed organisms . T. T145]. N-(3-dimethylamino)propyl)-N′-ethylcarbodiimide hydrochloride (EDC) and N-hydroxysuccinimide (NHS), with TOUS-CNCs: EDC and TOUS-CNCs: NHS 1:1 ratios (w/w). Moreover, according to this procedure, oxidation was conducted onto pre-formed and commercially available CNCs, while the purification step required cycles of dialysis. Compared to these procedures, in our protocol cellulose pulp oxidation represents the unique chemical step of the entire process, rendering this approach commercially appealing and easily scalable. Moreover, we have demonstrated that this synthetic approach could be conducted using pre-functionalized bPEI, without affecting the sponge-like morphology and the chemical stability of the composite but introducing additional properties to the adsorbent. As proof of concept we reported the cross-linking of TOUS-CNFs with bPEI grafted with pNO2-phenyl urea, achieving an aerogel which was successfully used for the heterogeneous sensing of fluoride anions in DMSO solution [Since our first report, several approaches have been reported for promoting the cross-linking between NC and bPEI, with the aim of synthesizing efficient composite adsorbents for heavy metal ions, all of them requiring chemical co-cross-linkers and/or activators. In 2016, Ge et al.  suggestesolution . More resolution .Although the choice of a renewable starting material, the selection of a cheap and scalable synthetic process, and the high efficiency in the removal of contaminants and pollutants from water are crucial criteria toward the full-scale implementation, all these aspects are not sufficient by themselves the for validation of this new nanotechnology which, due to its final application, also requires high standards of ecosafety. To reach this goal, within the NanoBonD project both the formulation and the synthetic process have been further modified and optimized, following an eco-design approach and the guideline of a detailed life-cycle assessment analysis.Moreover, in a long-term perspective, since most water and soil remediation applications are likely to require large quantities of ENMs, the cost, feasibility, and life-cycle considerations of manufacturing these materials on a large scale must be considered, as also evidenced by Carpenter et al. .LCA was applied since the early stage of the development of the synthetic process of the CNFs nanosponges, analyzing the inputs and outputs of each process step, regarding energy and material flows, emissions, and waste .The specific purpose was to identify the environmental hotspots and provide basis for environmental improvement actions. Starting from the lab scale process, the main hotspots were found in the energy and water consuming steps, the raw materials and the solvents used in the washing steps, which impact not only in the resource consumption but also in the waste disposal stage. Therefore, actions to decrease the impacts of these categories were undertaken and an optimized synthetic strategy was proposed regarding mostly (i) the change of formulation ratio among cellulose, bPEI and citric acid, favoring higher yields in CNS; (ii) the change of washing solvents from organic (methanol) to aqueous; and (iii) the conduction of the purification step under milder conditions, lowering energy consumption. The optimized process was again evaluated with LCA and the analysis showed interesting improvements on most of the environmental impact categories assessed . However, the results confirmed that major improvements will be achieved with the optimization of the energy consuming steps, likely to be achieved in a scale-up configuration.This approach made the overall synthetic protocol suitable for further scale-up. Indeed, the TEMPO/KBr/NaClO system is widely used for different industrial processes and, within the NanoBonD project, it has been possible to apply this oxidative approach in the conversion of different sources of cellulose at pilot scale, managing production of final CNS material in the order of kilograms for in-field demonstrative treatments on real matrices. However, implementation of the synthetic protocol is still under way to reduce the energy costs mainly associated to the lyophilization step.A critical comparison of the proposed approach with the most consolidated technologies for wastewater treatment allows the outlining of advantages and limits in the use of CNS for water remediation, over the choice of a renewable and recyclable starting material. Among these we mention chemical precipitation , the use of ion exchange resins or activated carbon, membrane filtration and electrochemical treatments ,155,156.−1) is at least an order of magnitude lower than that usually required by using standard adsorbents  or membranes, and an increment in the adsorbent concentration might lead to further improvements in decontamination efficiency.In this context, the heavy metal removal efficiency of CNS is comparable to that obtained with different approaches for some analytes, while for other ones it must be still considered insufficient. However, the amount of adsorbent used per unit volume of water  require a careful pH control and/or a specific pH to work at their optimum. On the contrary, CNS have been purposely designed to exploit their adsorption efficiency at pH = 7.6, also acting as buffer in different water matrices, so that pH adjustment is not required in field application.Similar to activated carbons and ion exchange resins, CNS can be regenerated several times by counter-current washing with acidic solutions, maintaining good to excellent adsorption performances. However, being constituted by a bio-organic matrix, in this case the adsorbent material can eventually be disposed by combustion, while other technologies generate waste. Finally, further strengths of the use of CNS as adsorbent units for wastewater treatment are (i) their bifunctional action toward both organic and inorganic contaminants, while with standard approaches the coupling of different technologies is usually required; and (ii) their versatility for application in different water matrices, including marine water.Nanoremediation can provide enormous benefits and with appropriate strategies and (nano)solutions allowing reduction of uncertainties and environmental and human risks, they will satisfy regulatory requirements, boost circular economy, and support a fully effective deployment of the sector. Main recommendations are that ecosafety obtained by an eco-design approach should be recognized as a priority feature. Ecotoxicity testing should be more ecologically grounded and include more realistic environmental scenarios. Research and innovation should focus on greener, sustainable, and smart (nano)solutions with the aim of providing a more ecofriendly nanoremediation.Regarding the environmental sustainability assessment of ENMs, it is acknowledged that LCA is a valuable tool to implement the LCT strategy. However, the full implementation is far from being feasible due to many unsolved methodological issues, which will very likely progress in parallel with the ecotoxicological characterization.Nevertheless, at present, LCA can provide sound support for the eco-design of emerging ENMs, which is very important already at the early stage of their development, at the lab scale, and can guide usefully the transition to the scale-up phase. The experience carried out in the NanoBonD project confirms the validity of this approach.