Pilot introductions of the Standard Days Method (SDM) of family planning demonstrated its potential to meet unmet contraceptive needs in key populations, strengthen male involvement, and increase overall contraceptive uptake. Few countries had implemented national scale-up due to barriers, such as competing resource priorities and uneven stakeholder engagement. Demand-side user barriers, including insufficient fertility awareness knowledge, were also constraints. Policy makers should determine the SDM's added value to the contraceptive method mix and identify potential barriers to its implementation. Pilot introductions of the Standard Days Method (SDM) of family planning demonstrated its potential to meet unmet contraceptive needs in key populations, strengthen male involvement, and increase overall contraceptive uptake. Few countries had implemented national scale-up due to barriers, such as competing resource priorities and uneven stakeholder engagement. Demand-side user barriers, including insufficient fertility awareness knowledge, were also constraints. Policy makers should determine the SDM's added value to the contraceptive method mix and identify potential barriers to its implementation. The Standard Days Method (SDM), a modern fertility awareness-based family planning method, has been introduced in 30 countries since its development in 2001. It is still unclear to what extent the SDM was mainstreamed within the family planning method mix, particularly in low- and middle-income country (LMIC) settings, where the SDM had been introduced by donors and implementing partners. This review of implementation science publications on the SDM in LMICs first looked at community pilot studies of the SDM to determine the acceptability of the method; correct use and efficacy rates; demographics of users; and changes to contraceptive prevalence rates and family planning behaviors, especially among men and couples. Then, we examined the status of the SDM in the 16 countries that had attempted to scale up the method within national family planning protocols, training, and service delivery. At the community level, evidence demonstrated a high level of acceptability of the method; efficacy rates comparable to the initial clinical trials; diversity in demographic characteristics of users, including first-time or recently discontinued users of family planning; increased male engagement in family planning; and improved couple's communication. Nationally, few countries had scaled up the SDM due to uneven stakeholder engagement, lackluster political will, and competing resource priorities. Results of this review could help policy makers determine the added value of the SDM in the contraceptive method mix and identify potential barriers to its implementation moving forward. The Standard Days Method (SDM) is a fertility awareness-based family planning method that identifies a 12-day fertile window during which women with regular menstrual cycles (26–32 days long) should abstain from sex or use a barrier method to prevent pregnancy. SDM is limited to women with regular menstrual cycles of 26–32 days, which applies to an estimated 50%–60% of women of reproductive age, though contraindications, including recent pregnancy and breastfeeding, can also affect cycle regularity and eligibility for the method.First developed and tested in 2001 by the Institute for Reproductive Health (IRH), the SDM was introduced with “CycleBeads,” a string of different colored beads that each represent 1 day in the menstrual cycle, as a visual tracking tool to facilitate correct use of the method. Brown beads indicate nonfertile days, and white beads indicate fertile days when the user should abstain from sex or use a barrier method. The user moves a small rubber ring along the CycleBeads string each day to track their fertility. In 2012, the free iCycleBeads app was introduced and piloted as a digital version of the CycleBeads for download on a mobile device.The SDM is 95% effective in perfect use and 88% effective in typical use.Although the SDM was introduced largely in pilot programs by nongovernmental organizations (NGOs) and donor agencies that supported ministries of health (MOHs), it remains unclear to what extent the SDM was implemented or scaled up at the national level within health systems. Reported use of the SDM captured in Demographic and Health Surveys remained less than 1% across countries where it was introduced. Reported knowledge of the SDM also varied considerably in Demographic and Health Surveys, from less than 1% in India to 82% in Rwanda, with a median of 26% .What happened when the SDM was first introduced in low- and middle-income country (LMIC) settings?Was the SDM an effective and feasible method of family planning for users?What was the status of the SDM implementation and scale-up at national levels in LMICs?This landscape analysis of implementation studies of the SDM intended to answer the following key questions:This analysis focused on SDM implementation in low-resource settings and user-based outcomes, including users' approval of the method, continuation rates, and efficacy, as well as the impact of attempts to institutionalize the SDM within the family planning method mix at the national level. This landscaping review examined implementation science of the SDM specifically in LMIC settings from a user perspective and complemented other reviews on method efficacy.To complete the landscape analysis, we completed database searches in both PubMed and Google Scholar using the search terms “Standard Days Method + family planning + implementation.” We limited the search results to publications from 2000 to 2019 because of the SDM's recent development as a fertility awareness-based method.PubMed recovered 10,489 results, and Google Scholar found 16,300 results. After scrutinizing the titles of all 26,789 results, 165 studies were included for further screening of abstracts. All 165 studies addressed some aspect of the SDM of family planning, whereas the other search results were unrelated to the SDM specifically. Of these, 97 studies were duplicates in both PubMed and Google Scholar search results; therefore, 58 studies were selected for further review from Google Scholar and 10 from PubMed .In addition to conducting database searches, we searched for gray literature reports on the IRH website. Because of IRH's long history in developing and implementing the SDM, we understood that their program materials had significant evidence on the status of the SDM in LMICs, especially in terms of nationalization and scale-up. This search yielded an additional 25 gray literature reports, including annual reports, project briefs, and evaluation materials.We completed a full-text analysis of the 93 sources identified in both database and IRH searches. In completing this analysis, we excluded 58 studies that did not provide answers to our initial research questions on user-based outcomes of the SDM implementation and status in national family planning systems in LMICs. Ten studies were excluded because they did not explicitly study the SDM but merely mentioned the SDM in conjunction with other family planning methods. We excluded 12 studies that provided general commentary on the SDM as an addition to the family planning method mix but did not provide new evidence of the SDM's implementation. Five studies were excluded because they were efficacy studies of the SDM, so they relied on only 1 data point (pregnancy rate) in a clinical trial setting. We were interested in examining other outcomes of the SDM and its feasibility as a method when implemented in more routine family planning practice. Sixteen studies were excluded because they were not conducted in an LMIC setting. We excluded 9 studies on the social marketing and provider-side issues of the SDM implementation because these were outside the scope of our research questions. Studies that examined provider-based outcomes, including training, feasibility of counseling, and marketing methodologies, warrant a separate rigorous analysis and review. Lastly, 6 studies were excluded because they did not provide sufficient data on user-based outcomes of the SDM implementation. These studies did not study the SDM explicitly  and/or included only 1 data point  and included nothing about correct use, satisfaction with method, or other user-based outcomes. Many of the studies that were excluded from full data analysis informed the discussion section of our review.Using these exclusion criteria, 35 studies were included for final, in-depth analysis. We separated these studies into those that presented evidence from a pilot introduction of the SDM in an LMIC community (13) and those that examined results of national scale-up efforts of the SDM (22). In terms of study methodologies, all 13 pilot studies followed study cohorts for a period of 6–18 months, collecting user data at multiple points. None of the studies used a control or comparison group. The 22 national scale-up reports were cross-sectional implementation studies.For pilot studies, our analysis focused on the following factors: (1) number of participants in study, (2) demographics of participants, (3) reasons for discontinuation of method, (4) approval of method, (5) number of participants who would recommend method, (6) ability to understand and use the method correctly, (7) previous experience with family planning, (8) intent to continue using the SDM, (9) reasons for using the SDM, (10) change to modern contraceptive prevalence rate (mCPR), (11) number of pregnancies, and (12) other outcomes of the SDM introduction.For scale-up studies, our analysis used the following factors: (1) lead organizations in scale-up efforts, (2) whether the SDM was included in provider training, (3) if CycleBeads were in national procurement, (4) if the SDM was included in health management information systems or other national measurements and national family planning protocols, (5) number of service delivery points with the SDM, (6) number of service providers trained in the SDM, and (7) number of registered SDM users.A total of 13 pilot studies to introduce the SDM were conducted in 10 countries: Albania, Benin, Burkina Faso, the Democratic Republic of the Congo (DRC), El Salvador, Ethiopia, Guatemala, India, Rwanda, and Turkey. Apart from Ethiopia, Guatemala, and Turkey, the remaining 7 pilot introductions and studies of the SDM were conducted by IRH with U.S. Agency for International Development funding. Although study methodologies varied slightly, each of these pilot studies involved first training health workers of various cadres including community health workers, health agents, nurses, midwives, and physicians to teach the SDM to new users with the assistance of CycleBeads, job aids, and visual brochures. Health workers were trained to counsel potential SDM users on the menstrual cycle, including the period start date and fertile window, and how to move the rubber ring along the different colored CycleBeads to track their cycle. On days 8–19, indicated by the white beads, users were taught to either abstain from sex or use a barrier method during intercourse. Users were taught the SDM in both home and clinic settings, and the SDM was often introduced with a range of other contraceptive methods and in routine family planning outreach and clinic settings. To accept the SDM, users were to report having regular cycles of 26–32 days. Those who accepted the SDM were offered the chance to participate in a study ranging from 6–18 months to follow their progress and experience using the method. In each study, recruitment of study participants was part of a program to introduce the SDM through family planning service delivery at home or in the clinic. Participation was wholly optional, and participants could have left the study at any time. Users did not have to participate in the studies to receive family planning services.The pilot studies had sample sizes ranging from 76 to 767 users with a total of 2,906 users . There wOverall, the pregnancy rates among SDM users in the community studies ranged between 10% and 18% in each study population, which varied from the initial efficacy study that reported a 12% typical use pregnancy rate.The trend in pregnancy rates matched results on correct use of the SDM among study participants. In most pilot studies, users were asked at multiple intervals to describe the mechanism of the SDM use, including how to identify the start of a menstrual cycle and manage fertile days. Answers to these questions improved over time. After 6 months of use, between 85%–99% of respondents correctly described the SDM, including which were the fertile days and how to correctly use CycleBeads, compared to 65%–75% in the initial surveys. This demonstrates how familiarity and comfort with the SDM, similar to other family planning methods, improved with time and use. Among users who continued the SDM beyond an initial 3 cycles, approval rates were very high, between 90%–100% saying they enjoyed the method and would recommend it to others. However, this approval figure was likely biased possibly from a courtesy bias dependent on the relation between study subject and data collector. In addition, these figures often did not include those users who discontinued the method in the initial months.,The demographics of users varied across study populations. Two studies found higher education levels among the SDM users compared to other family planning methods and the general population: in TurkeyThree studies measured the implementation of the SDM specifically in underserved, lower- educated populations. The majority of users in these studies had lower schooling levels or had never attended school. In rural Jharkhand State, India, 59% of SDM users had no schooling,Both pregnancy rates and rates of correct use were similar between the higher-educated and lower-educated groups across all studies. Other demographic indicators, including parity, wealth, and place of residence, varied considerably and showed the wide range of users who were attracted to the SDM as a family planning method.A consistent finding across the studies was reason for uptake of the SDM. The majority of users cited no side effects or health effects as the primary reason for choosing the method, while others cited low cost, no need for health visits, convenience, or existing familiarity with periodic abstinence as a family planning method. Measurement of previous use of modern methods of contraception varied across studies. For those that asked about ever use of modern family planning, between 15%–96% of SDM users said this was the first time they were using a modern method of family planning. Other studies asked about contraceptive use in the 2 months before SDM uptake, and answers varied between 21%–62% of users stating they were not using contraception in the immediate past. Common methods used recently included withdrawal, condoms, rhythm, and periodic abstinence.The majority of users chose SDM because it has no side effects or health effects.,,Only 3 studies measured change to overall mCPR in target communities after the introduction of the SDM. In El Salvador, the mCPR increased from 45% to 58%, with 4% of new contraceptive users using the SDM.–,,Lastly, many users in the community studies cited improved couple's communication, increased male involvement in family planning, and more consistent condom use as additional benefits of using the SDM. A study from Bihar, India, demonstrated that “couple-based fertility awareness education is effective in increasing demand for contraception and improving knowledge of fertility overall.”Many users cited improved couple's communication and increased male involvement in family planning among the added benefits of using the SDM.Sixteen countries had conducted some level of national standardization and institutionalization effort for the SDM . Nationa,,,,,,,,,,Although IRH led the process for institutionalization of the SDM in all 16 countries, local civil society groups helped lead efforts in Latin American countries, including Bolivia,The extent of the SDM scale-up varied considerably across the different country contexts. Some countries, including Bolivia, Haiti, Nicaragua, and Senegal, id not complete the full national scale-up because of lack of interest or capacity of both local MOHs and civil society partners. In Senegal, efforts were limited to only 2 years of pilot activities in training and initial service provision with the NGO, Tostan, but the MOH chose not to continue programming for the SDM after the pilot. The situation in Haiti was similar; although the government supported a 2-year pilot introduction, they did not continue supporting the method in national protocols, reporting mechanisms, or training manuals beyond the initial pilot. Reasons for discontinuing support of the SDM were limited capacity and resources at the level of the MOH, competing priorities in family planning/reproductive health, and limited political will within the MOH.Some countries discontinued support of the SDM because of limited capacity and resources at the level of the MOH, competing priorities, and limited political will.In Latin America, the SDM was first introduced in key target areas with low modern contraception uptake and high numbers of users of traditional family planning methods. Bolivia and Nicaragua limited the SDM to these targeted populations with high demand for the method, and Ecuador, Guatemala, Honduras, and Peru continued to expand the method. All of the Latin countries had included the SDM in national health worker training, measurements, and protocols and policies. Decisions to take the SDM beyond initial pilots were made based on both the capacity and the will of local partners and country MOHs.Aside from Senegal, every other African country included in scale-up efforts had the SDM included in national training, measurements, and family planning protocols. The SDM had the greatest institutional reach in the DRC. IRH partnered with 26 local organizations in the DRC and included considerable investment in social marketing for the method through Population Services International and Catholic Relief Services. The role of faith-based providers in the DRC was critical to expanded uptake of the method, and the national MOH also recognized both the local demand for and added value of the method.A study in Rwanda demonstrated that 87% of trained community health workers correctly screened clients for eligibility to use the SDM based on cycle lengths/history and 92% accurately explained how to use CycleBeads. Further, 89% of clients reported knowledge of all key steps in the SDM after being counseled by the community health worker.IRH used an approach in Madagascar that was similar to efforts in the DRC, forging partnerships with faith-based organizations to promote the SDM nationally. The MOH in Mali recognized the demand for natural methods in the country and had consistent MOH advocates for the method who promoted family planning programming. Mali's MOH also encouraged the strategy of task shifting in SDM provision, training 13,000 community health workers in SDM teaching and promotion in areas with low uptake and accessibility to other modern methods of family planning.Due to the decentralized nature of health policy and service provision in India, IRH partnered directly with the of Jharkhand State MOH in promoting the SDM, concentrating first on half of the state's districts with the greatest need for family planning services. Jharkhand included the SDM in state training, measurement, and family planning policies, and within 11 years, 6% of registered family planning users in Jharkhand were using the SDM, and half of the state population had heard of the SDM as a method of family planning.No country managed to include CycleBeads in national commodity procurements as it was considered an unconventional medical commodity and supplied by only 1 U.S.-based company. Supplies of CycleBeads were purchased through international NGOs, faith-based organizations, or donor bilateral funding and were then distributed within private and public sector clinics. The lack of national procurement of CycleBeads limited the continued implementation of the SDM and remained the most common barrier to national institutionalization of the method. The free digital versions of CycleBeads, in the form of mobile device apps, may help countries overcome this barrier in the future.No country managed to include CycleBeads in national commodity procurements.This analysis showed various enablers and barriers to the SDM's community-level introduction and national-level scale-up. Pilot introductions were largely successful in generating demand for and correct use of the SDM, especially among new users of family planning. At the national level, the scale-up of the SDM were predicated on strong levels of government cooperation and broad-based coalitions of partners and advocates for the method. As in the cases of Bolivia, Haiti, Nicaragua, and Senegal, even after a successful pilot introduction of the SDM, without sufficient levels of advocacy and cooperation from national actors, the SDM will not be scaled up beyond the pilot intervention sites. Other countries with a more robust institutionalization of the SDM, including Burkina Faso and the DRC, had both strong levels of support from national stakeholders and an active coalition of partners invested in its implementation.The low percentage of SDM acceptors in comparison to other contraceptive methods may have been a barrier to stakeholders' investment in national implementation of the method. Although community pilots demonstrated a level of demand for the SDM across numerous demographic indicators, in those studies that measured the percentage of SDM users within the broader contraceptive method mix, the percentage of family planning acceptors who chose the SDM did not move beyond 1%–5%. Worldwide, about 4% of all couples of reproductive age have used fertility awareness-based methods.Results from this analysis demonstrated that demand for the SDM was especially pronounced in communities already practicing fertility awareness-based methods of family planning, including less effective methods like periodic abstinence and withdrawal. High acceptance rates in Burkina Faso, the DRC, and among Mayan communities in Guatemala were all due to existing traditions of periodic abstinence and demonstrated the potential to improve the efficacy of these methods in teaching the SDM. The higher demand for the SDM in certain populations may have been a reason that national governments chose a more limited implementation of the SDM among targeted groups, rather than a national, system-wide scale-up.Results also demonstrated other community benefits to the SDM introduction, including improved couple's communication, dispelled myths on modern contraception, and strengthened family planning use more broadly. For many couples, the introduction of the SDM was the first opportunity to discuss family planning jointly and involve men in decision making on both sexual activity and contraceptive use.To achieve these results, pilot introductions of the SDM relied on direct training of frontline health workers and often employed an aspect of social marketing in the community to encourage conversations and improve knowledge of family planning overall. The importance of high-quality health worker training was especially evident when examining both the results on discontinuation of the SDM as a family planning method and failure rate in the initial 3 months of use. Although the majority of discontinuation occurred in the first 3 months of method use, either due to irregular cycles or unintended pregnancy, discontinuation rates varied considerably across study locations, likely demonstrating variants in teaching the method and appropriately screening eligible users. It also underscored the need for accompanying social and behavior change communication programming, particularly around body literacy and fertility awareness, to ensure both health care providers and clients understand the cycle requirements for eligibility and to better prevent unintended pregnancies in the initial months of use.Although there was skepticism that teaching the SDM was overly complicated and cumbersome for service providers, evidence from studies in this analysis demonstrated the opposite. There was evidence that various cadres of health workers, including at the community level, had the capacity to adequately screen potential users for method eligibility. If properly trained, followed with supportive supervision, and equipped with job aids and guidelines, multiple levels of health providers taught the SDM effectively, which allowed users to understand the mechanisms of use quickly, and correct use improved over time. However, health workers were known to underutilize evidence-based practice guidelines.If properly trained, health providers taught the SDM effectively, and correct use improved over time.The SDM was never more popular than other family planning methods, but there was still a demand for the method and other clear benefits to its introduction to improve client satisfaction and prevent unintended pregnancy. Those most attracted to the method were often first-time or discontinued users of modern family planning methods, and there was potential to improve contraceptive use within these populations by introducing the SDM. Further, inclusion of the SDM in family planning programming had potential to improve couple's empowerment in reproductive decision making, sexual negotiation, and consistent condom use.Including the SDM in family planning programming had potential to improve couple's empowerment in reproductive decision making, sexual negotiation, and consistent condom use.Moving the SDM away from donor-supported pilots required both method champions at the national MOH level and buy-in from health care providers within the clinic and community. This proved challenging as some family planning/reproductive health commentators argued against promoting the SDM in family planning programming, stating that there wasn't sufficient evidence on the efficacy of the SDM to merit its promotion as a modern method of family planning.,In reviewing the published literature available to complete this landscape review, 2 main limitations on the data arose: the preponderance of gray literature and high level of influence of IRH on the SDM research. The majority of literature on the implementation of the SDM were not peer reviewed, gray literature reports from foreign assistance programs. These reports were also all published by IRH. Researchers at IRH had also published 5 of the 9 peer-reviewed articles included in the study; the 4 others were published by non-IRH-affiliated researchers in Ethiopia,Pilot introductions of the SDM demonstrated that the method was acceptable, especially to users of other fertility awareness-based methods of family planning or those concerned about side effects of hormonal contraception. Many SDM acceptors were first-time users of modern family planning. Other community benefits of the SDM's introduction included improved couple's communication, male involvement in family planning, and increased contraceptive uptake overall. Both discontinuation and method failure rates varied across study sites, highlighting the importance of high-quality health worker training in teaching the method and screening potential users. Tendency to experience unintended pregnancies in the first 3 months of use also demonstrated a need for more demand-side interventions to teach fertility awareness and body literacy when introducing the method to users.At the national level, multiple barriers to the SDM's implementation and scale-up remained. Although the SDM had been piloted in over 30 countries worldwide, 16 countries had undergone rigorous scale-up processes to mainstream the SDM within the broader family planning method mix. Twelve of those countries had included the SDM in national family planning protocols, measurement tools, and health worker training, but no country managed to get CycleBeads into national procurement.National implementation of the SDM was predicated on strong local political will and a broad-based coalition of local advocacy partners coordinating the method's implementation. There was little evidence of national scale-up of the SDM beyond the 16 countries included in this study. Although pilot studies demonstrated the potential for the SDM to match unmet contraceptive needs in key populations, strengthen male involvement, and increase overall family planning uptake, both demand-side and institutional barriers to include the SDM in the family planning method mix persisted.


Invasomes are novel vesicular systems that exhibit improved transdermal penetration compared to conventional liposomes. These vesicles contain phospholipids, ethanol, and terpene in their structures; these components confer suitable transdermal penetration properties to the soft vesicles. The main advantages of these nanovesicles lie in their ability to increase the permeability of the drug into the skin and decrease absorption into the systemic circulation, thus, limiting the activity of various drugs within the skin layer. In this paper, several features of invasomes, including their structure, mechanism of penetration, applications, characterization, and potential advantages in dermal drug delivery, are highlighted. Overall, this review suggests that enhanced transdermal penetration of drugs using invasomes provides an appropriate opportunity for the development of lipid vesicular carriers. These vesicles are composed of phospholipids and edge activators, such as polysorbate or sodium cholate, producing elastic carriers for improved transdermal drug delivery [® led to the development of other novel elastic vesicles via alterations in the vesicular composition. In previous examinations, elastic vesicles such as niosome (prepared mostly by non-ionic surfactant and cholesterol) [The transdermal route is an important pathway for localized or systemic effects . The strdelivery ,18,19,20esterol)  and ethoesterol)  have disesterol) ,24,25,26esterol) . Althougesterol)  and liteesterol) , this reLiposomes are phospholipid-based vesicular structures composed of anionic, cationic, and neutral lipids and cholesterol that improve the encapsulation of lipophilic, hydrophilic, and amphiphilic drugs. Lipophilic drugs are placed in the inner part of the lipid bilayer, hydrophilic drugs in the aqueous core, and amphiphilic types in the interlayer of the vesicles ,31. ContTerpenes and ethanol in the invasomes cause deformability of the vesicles, disrupt the SC bilayer skeleton, and act as penetration enhancers, improving the permeability of the invasomes . AccordiThe addition of ethanol in the formulation of lipid nanovesicles is an effective strategy to increase the fluidity of the lipid bilayer of the skin ,40. The X-ray diffraction and differential scanning calorimetry (DSC) results showed that terpenes lead to increased drug penetration by disrupting the tight bilayers and lipid packing in the SC . FurtherDragicevic-Curic et al. revealed that various types of terpenes have a synergistic effect on the permeation of temoporfin. Invasomes containing a 1% mixture of three types of terpenes  demonstrated higher temoporfin permeability than invasomes containing 1% citral alone . In anotExamination of particle size demonstrated that the size of the invasomes is directly correlated to the amount of terpenes; the size of the invasomes increases as the amount of terpene increases. The size of vesicles containing 1% terpenes was 124 nm, whereas the size of vesicles with 0.5% terpenes was 93.0 nm . PrasantThe results of cryo-transmission electron microscopy (cryo-TEM) were in agreement with the DSC and ESR results, indicating the influence of terpenes on the shape of the invasomes, i.e., in addition to spherical vesicles, malformed vesicles of varied shapes also existed in invasomal dispersions . DragiceA synergistic effect between phospholipids, ethanol, and terpenes on dermal absorption has been visibly observed . DragiceThe storage temperature has a significant effect on the physical stability of invasomes, i.e., the size of the particles and the polydispersity index (PDI) value. During storage at room temperature, all invasomes show an increase in the particles size and the PDI value, demonstrating physical instability, i.e., aggregation or fusion of the vesicles ,52. In tDifferent approaches have been examined to progress the transdermal permeation of drugs. Among them, use of effective and safe classes of penetration enhancers such as natural terpenes are the most popular methodology. Despite proper performance of penetration enhancers in transdermal delivery, few of them have been approved for clinical application due to their skin irritation and toxicity. In general, there is balance between the potency of penetration enhancers and their toxicity. Terpenes present high penetration potency for both hydrophilic and lipophilic compounds even at small concentrations. The strategic mechanism for terpene penetration occurs through interaction with SC intercellular lipids . TerpeneIn this section, we have enumerated several applications of invasomes. An overview of various studies on the therapeutic applications and skin permeability enhancement of invasomes is given in Hypertension is a global series health problem because of its association with cardiovascular disease. Advances in the treatment of hypertension have played a major role in decrease of stroke mortality and coronary heart diseases . IsradipHyperpigmentation disorders arise because of melanin overproduction, leading to unusual distribution of melanin in specific portions of the skin. Control of tyrosinase activity is the rate limiting step for melanin production. Phenylethyl resorcinol is a novel skin whitening agent, which prevents the tyrosinase activity. Lower stability and poor water solubility are the major limitations of phenylethyl resorcinol for cosmetic products. Amnuaikit et al. prepared topical formulation of phenylethyl resorcinol loaded invasomes and transfersomes and compared them with conventional liposome. In vitro assessment demonstrated better melanin content reduction and tyrosinase inhibition activity for invasomes and transfersomes in comparison with liposome .Acne is a prevalent chronic inflammatory infection of the skin that has various negative effects on young adults. It creates emotional stress, discomfort, and long-lasting scarring to the skin . DapsonePhotodynamic therapy is one of the interesting approaches, including the use of photosensitizing compound, which concentrates in the target cells and then locally irritates by visible light. Finally target cell will be impaired by apoptosis or necrosis . DragiceBenign prostatic hyperplasia is a common disease which occurs in elderly mans. The development of the prostate leads to pathological change in the urine and kidney . In the ® (a new microneedle device), which further improved drug permeation and penetration [Studies have shown that the invasome is one of the successful drug delivery systems for hydrophilic drugs. According to an in vitro study by Badran et al., invasomes containing a 1% mixture of terpenes were more efficient in the dermal delivery of hydrophilic compounds than an aqueous solution. These vesicles were also efficient in combination with a Dermarolleretration .Invasomes are non-toxic vesicular carriers that have been used for transdermal delivery. They can also assist in the penetration of the incorporated agent, while incorporating both lipophilic and hydrophilic drugs. Phospholipids, ethanol, and terpenes are the main units of the invasome structure. Furthermore, the penetration of these vesicles can be simply modulated by modifications of their composition. Based on the available studies, we emphasize the high potential of invasomal formulations in topical therapeutic applications. These systems expand the opportunities for dermatology research in the future. Nevertheless, additional studies are necessary to demonstrate the clinical efficacy of invasomes. With regard to the mentioned ability of invasomes as drug carriers, we also suggest a focus on the development of appropriate technology for the industrial production of invasomes as will be necessary for the application of invasomes in the treatment and prevention of diseases in future dermatology research.


In February 2020, Nigeria faced a potentially catastrophic COVID-19 outbreak due to multiple introductions, high population density in urban slums, prevalence of other infectious diseases and poor health infrastructure. As in other countries, Nigerian policymakers had to make rapid and consequential decisions with limited understanding of transmission dynamics and the efficacy of available control measures. We present an account of the Nigerian COVID-19 response based on co-production of evidence between political decision-makers, health policymakers and academics from Nigerian and foreign institutions, an approach that allowed a multidisciplinary group to collaborate on issues arising in real time. Key aspects of the process were the central role of policymakers in determining priority areas and the coordination of multiple, sometime conflicting inputs from stakeholders to write briefing papers and inform effective national decision making. However, the co-production approach met with some challenges, including limited transparency, bureaucratic obstacles and an overly epidemiological focus on numbers of cases and deaths, arguably to the detriment of addressing social and economic effects of response measures. Larger systemic obstacles included a complex multitiered health system, fragmented decision-making structures and limited funding for implementation. Going forward, Nigeria should strengthen the integration of the national response within existing health decision bodies and implement strategies to mitigate the social and economic impact, particularly on the poorest Nigerians. The co-production of evidence examining the broader public health impact, with synthesis by multidisciplinary teams, is essential to meeting the social and public health challenges posed by the COVID-19 pandemic in Nigeria and other countries. In Nigeria, policymakers used a co-production model linking political decision-makers, health policymakers and academics from diverse disciplines to maximise the speed, relevancy and impact of scientific data and evidence to respond to COVID-19.This model allowed a multidisciplinary group to collaborate on issues arising in real time, with demonstrated impact on national decision making and apparently limiting the virus’ spread.Challenges of the co-production model included limited transparency, bureaucratic obstacles and an overly epidemiological focus on direct impacts of the disease compared with the social and economic effects of response measures.Integration of epidemiological, social science and economic analyses by multidisciplinary teams, in concert with policymakers, provides a strong path to meeting the twinned social and public health challenges created by COVID-19.National responses to the COVID-19 pandemic have varied considerably.This practice paper describes policy responses taken to mitigate the COVID-19 pandemic in real time, along with potential explanations for observed trends in Nigeria. We present a model for the co-production of evidence between political decision-makers, health policymakers and academics, which was conceived in order to maximise the speed, relevancy and impact of data and scientific evidence brought to bear on far-reaching policy decisions. We examine the benefits and limitations of the evidence generation and decision-making process, discuss potential consequences and draw lessons for the way forward in Nigeria and other countries in sub-Saharan Africa and beyond.On 26 January, Nigeria Centre for Disease Control (NCDC) established a national emergency response system with multiple workstreams and close liaison with state-level centres.Between meetings, working groups met regularly to advance three work areas: epidemiological modelling and projections, health systems issues, and social and economic aspects of the response. A range of epidemiological and health systems data were provided from NCDC and other Nigerian government agencies; geospatial data and data on population mobility, food security and wages were also made available to the group. First, the modelling working group, used the data to parametrise a range of deterministic, agent-based and stochastic models to provide short-term projections on the course of the epidemic at national and state level , beginning when states hit the threshold of 100 cases. The models were used to compare different scenarios with respect to extending national and community lockdowns, testing and isolation strategies, imposing or lifting travel restrictions, opening borders and a variety of other non-pharmaceutical interventions (NPIs). Second, on a parallel track, the health systems working group studied the same questions from the perspective of the impact on health systems, with the goal of maintaining health services to the greatest extent possible. Finally, the socioeconomic working group looked at the wider societal impact of the disease, and particularly of response measures such as lockdowns and bans on mass gatherings, using survey data on how these measures affected living standards, small businesses and entrepreneurs, and learnings from other countries around the world.Policy questions were fed from the PTF directly to the chair of the coordinating group via evening calls and communications. Policy questions guided the analyses of the three working groups, with different strands brought together and discussed during the Tuesday evening calls. Findings were combined into short, synthetic position papers limited to 1–2 pages, usually with much longer annexes to provide further detail as needed by policymakers.Position papers were provided first on a weekly or biweekly basis (often with accompanying PowerPoint slides) to feed into fast-moving decisions by the PTF. The PTF reported these outputs monthly to the president of Nigeria, through face-to-face meetings summarising position papers. The pace slowed as the epidemic was controlled and transmission rates began to wane in July and August. A total of some 20 position papers were provided, in addition to 25 state-specific papers describing epidemic projections and implications for the application of NPIs in each state. Position papers fed into major policy decisions taken by the Nigerian president, the PTF and other high-level decision-makers, including the extension of the cessation of movement (lockdown) order to more states (2 April) and in time (23 April); the gradual lifting of the lockdown order (4 May); orders on mandatory mask wearing, bans on interstate travel and mass gatherings, and curfews (4 May); precision lockdowns in states and specific local areas (18 May and 29 June); decisions to increase testing and create new laboratories 10.1136/bmjgh-2020-004793.supp1Supplementary dataFollowing the implementation of public health measures, case numbers declined but remained at a stable level . Contrary to initial projections,13A number of hypotheses have been advanced to explain the less-than-expected spread and severity of the pandemic in Nigeria and other sub-Saharan African countries. First, the much lower age structure of the continent’s population has surely played a role, given that COVID-19 mortality is considerably lower among young people.17There is emerging evidence that prior widespread exposure to other coronaviruses has led to cross immunity in Africa, as evidenced by high prevalence of serological cross-reactivity against SARS-CoV-2 in pre-COVID-19 pandemic plasma samples from sub-Sahara Africa.Similar to other African countries, Nigeria likely benefited from the early initiation of public health interventions, guided by the advice and action of the PTF. The prompt action to institute movement restrictions and introduce NPIs, just a few weeks after the first confirmed case, potentially truncated the peak of the epidemic, thus allowing some immunity to develop in subsections of the population at a modest peak infection level.3Many countries in sub-Saharan Africa have faced outbreaks in recent years, with lessons learnt, however, subsequent preparedness has been variable. At the end of 2019, Nigeria and almost all African countries had undertaken a Joint External Evaluation of the International Health Regulations, which showed gaps in several key technical areas needed for countries to address outbreaks in a coordinated manner, but also highlighted improving competencies in real-time surveillance and immunisation.3Importantly, although the spread and severity of the disease appears to have been limited by policy, these decisions had trade-offs, especially in terms of the socioeconomic well-being of the poorest segments of the population. Lockdowns, compounded by self-imposed distancing, the closing of markets and businesses and travel restrictions led to skyrocketing food and transport prices, hoarding and post-harvest food loss at both farm and market levels, resulting in a ‘hidden’ food security crisis among the country’s most vulnerable populations.21Palliative measures introduced by the Nigerian government to mitigate the socioeconomic impact of the pandemic and response measures, such as distribution of food items and conditional cash transfers, have been criticised as being inadequate,Nigeria’s COVID-19 evidence co-production model was in many ways beneficial to the response, as it resulted in responsive evidence gathering and synthesis, drawing from diverse expertise, with a demonstrable impact on policy decisions. Open daily communication between the PTF Advisory Group (the Tuesday Evening Group) and the PTF ensured that position papers were directly relevant to the most pressing policy questions, and that evidence and recommendations were delivered in time to inform decisions. As a result, the position papers and other support provided valuable inputs into consequential early decisions on lockdown and the combinations of NPIs likely to be most effective in limiting transmission. Subsequent position papers directly influenced the approach taken for more targeted policy questions, including optimal test, treat and isolation strategies; restrictions on inter-state movement; the contribution of asymptomatic cases to transmission; precision lockdown; the need for cash transfers to mitigate the impact on socioeconomic well-being; school closures; and international border re-opening. The group’s diverse expertise, organised into topical work areas, allowed for substantive input on this broad range of policy questions. Furthermore, the academic leadership of the group and primary accountability to the PTF limited the influence of any single donor or technical partner despite the utilisation of funding and resources from multiple organisations and governments. This structure ensured government action was not overwhelmed by the strategic agendas of powerful outside actors, as can occur in low-resource settings .Box 1Establishment of a presidential taskforce bringing together key policy decisions-makersTimely provision of relevant information and analysisMulti-disciplinary team with diverse approaches, allowing for triangulation between different models and analysis tacticsLinkage with Nigerian and non-Nigerian academics and expertsAcademic leadership of evidence co-production group limited influence of any single donor or financial partnerLimited ability for researchers to initiate position papers on topics they found relevantLack of transparency in content of position papers and inputs into decision-making processPredominance of epidemiologists with relatively lesser participation of social scientists, economists, risk communication specialists, and other specialistsBureaucratic red-tape hindered important serological and contact tracing studiesFractured governance, with lack of coordination between multiple tiers with responsibility for implementationPolitical dynamics and interests hampering response in some statesPublic distrust of public health system and in political leadership due to chronic lack of performanceEconomic impact of lockdown and COVID-19 resulting in fewer resources to spend on healthInsecurity due to terrorism and other security risks hampered response in some parts of the countryHealth system weaknesses including limited testing capacity and ability to manage critically ill patientsThis policymaking approach had some weaknesses (Panel). First, the directive nature of the PTF’s involvement meant that research teams were limited in their ability to initiate briefing topics, restricting the breadth of subjects for position papers and potential scope of useful advice. Second, the position papers initially had a limited circulation list. Although these papers have now been made widely available,Bureaucratic red tape was unfortunately a significant obstacle when it came to producing Nigeria-specific evidence needed to parametrise models and understand the course of the pandemic in country. Two planned studies, a serological survey and a contact tracing study, were severely hampered by slowdowns in funding and administrative arrangements caused by lockdowns and other challenges, where the relevant grants were being processed. While these two studies are currently underway, the data they will generate would have been much more useful in the early days of the response. Contractual processes between multiple organisations, while complex, can and must be expedited in the context of pandemics and other emergencies, and in the future all measures should be taken to ensure the relevant arrangements are in place in advance. On the Nigerian side, red tape was less of a barrier, as the creation of the PTF allowed policymakers to overcome ministerial divisions and make high-level decisions with relative ease.The impact of the evidence co-production model was also constrained by limitations inherent to the Nigerian public health system, political system and economy. First, although the PTF led the national multisectoral response, Nigeria’s federal structure means that individual state governments led local implementation despite varying capacity. Decisions made at federal level were not always effectively translated into action for communities on the ground. In other instances, states were overly dependent on federal institutions. Other limitations were found in historical aspects of Nigeria’s political economy, such as its weak public health funding, particularly at primary healthcare level; a small and shrinking share of resources available for public health, including for the COVID-19 response; public distrust of government authorities and insecurity due to terrorism and other security risks.Contrary to long-standing narratives in global health, the COVID-19 response in many poor countries suggests that wealth is not the sole determinant of success.


Ananya program is a highly ambitious and courageous effort to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide in Bihar, India, across a population of approximately 120 million people [Ananya was initiated, Bihar was emerging from decades of political upheaval and weak governance and leadership; faced crippling shortfalls of health infrastructure, commodities, management and staffing, and was among the lowest performing of Indian states for RMNCHN indicators. Ananya was launched by the Government of Bihar (GoB) and the Bill and Melinda Gates Foundation (BMGF) with strong political will and commitment to health sector performance improvement. The GoB and BMGF set ambitious goals focused on reducing maternal, neonatal, infant and under-five child mortality and childhood malnutrition. BMGF made grants to multiple organisations for supply and demand-side interventions and attempted to unify these activities under a common theory of change [The The first phase of the program included intensive ancillary support by non-governmental organisations (NGOs) to governmental implementation in a sizeable population of about 28 million in eight focus districts -5. AfterAnanya partners, bringing together policy, programmatic and research expertise – including the BMGF India Country Office, CARE India, BBC Media Action, Project Concern International, Population Council, Mathematica, Johns Hopkins University, the University of California San Francisco, and George Washington University – to capture learning from the two-year pilot (2012-2013) and the first four-years of statewide scale-up (2014-2017) of Ananya technical and managerial innovations, interventions and delivery approaches across the RMNCHN continuum of care. Sixteen manuscripts in addition to this commentary have resulted from this comprehensive analysis, twelve of which appear as a special collection in the Journal of Global Health: “Ananya : Lessons from Primary Health Care Performance Improvement.”Stanford University led an effort with the A focus of the pilot phase was on experimentation with innovations to vexing challenges in advancing RMNCHN at scale. During this period, CARE India designed and rigorously tested team-based incentives, non-monetary incentives and promotion of team-based performance improvement which showed promise as an approach for improving frontline worker (FLW) coordination and teamwork and the quality and quantity of FLW-beneficiary interactions . For insAnanya partners. A quasi-experimental independent evaluation by Mathematica of overall impacts of the first phase of Ananya revealed that secular changes were under way in nearly half of RMNCHN indicators, unrelated to Ananya [Ananya program were found for about 10% of indicators and were most prominent for mothers’ decisions around contraceptive utilisation. However, the evaluation was not powered to observe statistically significant differences in RMNCHN indicators within two years, and could not measure changes due to specific interventions, but rather was aimed to help inform program improvements and scale-up.The pilot phase was also an intensive period of intervention development, piloting and testing by all o Ananya . AdditioAnanya from building capacity of the FLW platform to developing innovations and addressing fundamentals of health system strengthening and quality improvement in health facilities.A key learning of the eight-district pilot phase was that deep structural constraints in health system organisation and delivery of interventions posed substantial limitations on behaviour change among health care providers and beneficiaries. Qualitative research suggested that while Accredited Social Health Activists  are deeply engaged in community service, they face pervasive delays in incentive payments, increased workload, lack of training and integration with the rest of the health system, and punishing managerial and supervisory practices which fuel job dissatisfaction . CARE InAnanya was no longer possible.These early results provided a signal that large-scale change was possible under conditions of intensive support to implementation, bolstered by innovative solutions identified through rigorous, expansive experimentation. The GoB forged ahead with scale-up efforts across the rest of the thirty districts in the state, assuming full ownership for program implementation. Going forward, however, it became impossible to maintain a control group or a quasi-experimental evaluation. Thus, evaluation of impact became dependent primarily on a series of Community-based Household Surveys conducted by CARE India primarily for the purpose of program monitoring rather than impact evaluation. Without a control group, full attribution of change to Ananya partners was pulled back during statewide scale-up and they focused on providing techno-managerial support to the government, gains in RMNCHN that had been achieved in the pilot phase rapidly fell back to baseline for the majority of RMNCHN indicators [Ananya.When ancillary, on-the-ground experimentation and presence of dicators . In geneAs implementation was scaled up statewide by the GoB, changes in RMNCHN indicators measured statewide were mixed with increases in some indicators balanced by decreases in others . Most noAnanya partners engaged in intensive efforts to inform approaches to achieve impact at scale through health systems strengthening. CARE India partnered with the GoB to develop and scale-up a wide array of managerial and technical solutions, including improvements in infrastructure, human resources management, supply chains, data systems and ultimately the quality of care in health facilities [During the scale-up phase, cilities , with sicilities ,12. EarlBBC Media Action experimented with the development and deployment of mHealth-based mass media and interpersonal communications in stimulating changes in RMNCHN knowledge and health-related behaviours. Overall reach of the Mobile Kunji tool, which facilitated knowledge transfer from FLWs to women, was low  . Use of Innovations in self-help groups by Project Concern International to layer health interventions into groups originally conceived for promoting livelihoods and access to credit was shown in independent evaluations by Population Council and CARE India to be a scalable and highly effective model for broadly improving RMNCHN knowledge and behaviours ,15. The These interventions may be especially important considering that our equity analysis revealed that changes in RMNCHN indicators were driven largely by changes in the least marginalised subgroup  of the population . EssentiAnanya by BMGF, with high-level commitment by the GoB, created fertile ground for the development of numerous innovations in primary health care delivery at scale. Innovations included processes and tools for improving the effectiveness of FLWs in reaching and engaging with families in improving RMNCHN knowledge and behaviours, mHealth tools, health-layered SHGs, and facility quality improvement approaches such as nurse mentoring, team-building and use of simulations to improve intrapartum and newborn care. Insights into best practices for evaluation of complex global health programs in low- and middle-income countries emerged [Investment in  emerged . which mAnanya pilot demonstrated that with intensive ancillary support by NGOs to governmental implementation of primary health care interventions, substantial improvement in RMNCHN is possible. With continued governmental political will and commitment of resources, and with techno-managerial support from NGOs, GoB goals for health improvement are within reach.The In order to ensure these improvements reach across the population, there is a need to balance community and facility-based interventions. In the era of the Sustainable Development Goals, it is critical to take an equity lens in evaluations and to monitor for changes across socio-demographic groups to ensure that reach and impact are equitably distributed. Reach to the most marginalised with interventions targeted to address their needs must be intentional. Otherwise, an unintended consequence of universal primary health care programming, particularly if focused exclusively on facility-based processes and care, could be an accentuation of inequality, leaving the most marginalised further behind.Ananya were set, they were set at a higher level  than could be effectively tracked by the evaluations. The various partners had theories of change, but these were not necessarily aligned with each other or with a common set of measurable goals. Secular trends in health improvement in Bihar were strong, and without an ongoing ability to take this into account, including contextual factors and effects of other programs, attribution of change to Ananya program implementation was not possible, which may limit the strength of evidence for ongoing investment and policy change. Geospatial data on implementation progress was lacking and is important for associating implementation strength and the impacts of overlapping/intersecting interventions with changes in indicators over time. In the absence of a quasi-experimental evaluation design, the inability to calculate a dose response relating implementation to changes in indicators may further hinder the strength of evidence for influencing future policy change. It is also essential to measure change at the lowest possible implementation unit. Summary measures at district level, for example, may or may not provide insight into the contextual or programmatic factors associated with progress or lack thereof. Greater precision is needed in linking implementation factors and contextual factors to health measures, in order to gain insights into facilitating factors and barriers in improvement, or alternatively in decline, in health indicators. This would also enable analysis of outliers, seldom examined, but which may hold important insights into conditions which mediate change.While clear health goals for Ananya NGOs, and others to advance RMNCHN and adolescent health at scale. Ananya revealed massive structural challenges in primary health care delivery in Bihar, but also demonstrated that with investments in technical and managerial innovations and use of data to guide performance improvement, accelerated change is possible if evidence-based programs are implemented with sufficient intensity. Going forward, it will be critical to balance investments across the facility-community continuum; to measure impacts at local  level, disaggregated across intersecting aspects of marginalisation such as wealth, caste and gender; to maintain focus on the achievement of shared goals through a unifying, measurable theory of change; and to keep alive the Ananya spirit of optimism, urgency, innovation, and flexibility to evolve in response to ever-emerging quantitative and qualitative evidence of what is being achieved, for whom, where, and why or why not.The GoB continues to partner with BMGF, CARE India, several of the


The neurodegenerative process is characterized by the progressive ultrastructural alterations of selected classes of neurons accompanied by imbalanced cellular homeostasis, a process which culminates, in the later stages, in cell death and the loss of specific neurological functions. Apart from the neuronal cell impairment in selected areas of the central nervous system which characterizes many neurodegenerative diseases , some alterations may be found in the early stages including gliosis and the misfolding or unfolding accumulation of proteins. On the other hand, several common pathophysiological mechanisms can be found early in the course of the disease including altered oxidative metabolism, the loss of cross-talk among the cellular organelles and increased neuroinflammation. Thus, antioxidant compounds have been suggested, in recent years, as a potential strategy for preventing or counteracting neuronal cell death and nutraceutical supplementation has been studied in approaching the early phases of neurodegenerative diseases. The present review will deal with the pathophysiological mechanisms underlying the early stages of the neurodegenerative process. In addition, the potential of nutraceutical supplementation in counteracting these diseases will be assessed. In partA representative cartoon, which displays these mechanisms, is provided in Although the contribution of oxidative stress, inflammation and the imbalance occurring in mitochondria and endoplasmic reticulum appear to play a crucial role in the development of the neurodegenerative process, relatively poor information exists on the potential benefit that occurs when antioxidant product supplementation is carried out in patients undergoing neurodegenerative diseases . SeveralOn the other hand, the use of relatively safe antioxidant compounds found in the diet as a form of treatment in these disorders is attractive but limited by the difficulty in reaching an active concentration in the brain . Thus, tThe present review article will deal with the potential of using nutraceuticals in neurodegeneration. This will be assessed on the basis of identification, in the early stages of neurodegenerative diseases, of pathophysiological mechanisms which may be counteracted, at this stage, by means of supplementation with natural antioxidants.In eukaryotic cells, 90% of the reactive oxygen species (ROS) is generated in the mitochondria, although a small percentage can be found in the other cellular compartments, such as cytosol, peroxisomes and the endoplasmic reticulum . MitochoROS and RNS largely contribute to neuronal degeneration due to the induced alteration of macromolecules such as DNA, RNA, proteins and lipids .The blood–brain barrier (BBB) neuro vascular unit (NVU), made up of neurons, astrocytes, pericytes, microglia and endothelial cells, can counteract the effects of oxidation when the amount of ROS is limited and when the activity of antioxidant enzymes is preserved. Any imbalance in the NVU functioning may alter the brain homeostasis, resulting in high oxidative stress and the impairment of the integrity of the BBB ,15.The endoplasmic reticulum is an organelle which preserves many functions at the cellular level; more specifically, it is involved in the protein biosynthesis as well as in the protein folding and translocation, post-translational modifications of proteins including glycosylation reactions, the formation of disulphide bridges and the correct chaperone-dependent folding. Furthermore, the endoplasmic reticulum also regulates the homeostasis of the calcium ion and the synthesis of phospholipids. When these functions cannot be preserved, the cell enters into a stressful condition and the endoplasmic reticulum triggers a sequence of reactions making up the unfolded protein response (UPR). Many neurodegenerative diseases involve the accumulation of protein aggregates and the endoplasmic reticulum stress triggers the activation of an adaptive reaction that restores cellular protein homeostasis, known as proteostasis. Chronic ER stress results in neuronal loss, repressing the synthesis of synaptic proteins . If the An inflammatory process is started by the cells of the immune system, which activate an inflammatory cascade to protect the body from any damage. However, under some pathological conditions, inflammation is present even in the absence of any specific damage. Recently, a close correlation has been highlighted between inflammation and neurodegenerative diseases. In some cases, in fact, the chronic activation of innate immunity in the central nervous system (CNS) is triggered while, in other cases, peripheral immune cells pass through the BBB, as happens with multiple sclerosis .Microglia and astrocytes are the first cell lines that trigger an immune response by promoting the expression of pro-inflammatory cytokines leading to neurodegeneration, the phagocytosis of synapses and a lower neuronal function . Tumour Oligodendrocytes and macrophages are also involved in the CNS immune responses; in particular, oligodendrocytes are involved in regenerative processes as well as in the replacement of damaged myelin. There is a specific cross-talk among oligodendrocytes and microglia, which is able to select pro-inflammatory responses . The rolOver time, cells have developed endogenous mechanisms capable of reducing all substances whose accumulation produces cellular alterations.The molecules able of switching off all or even one of the following pathways can, to various extents, protect the body and slow down the progression of the disease. Some of these compounds represent the golden standard for studies carried out in the early stages of neurodegenerative disorders.Coenzyme Q10 (Co-Q10) (a benzoquinone ring with a side chain composed of 10 isoprene units) is synthesized in the body and does not derive from the intake of food. Co-Q10 has important functions, such as the involvement in mitochondrial oxidative phosphorylation for the production of adenosine triphosphate (ATP), the regulation of cell signalling, the modulation of gene expression, a strong antioxidant action and the stabilization of biological membranes ,27. Co-QGlutathione (GSH) is a tripeptide (glycine–glutamine–cysteine) with a thiol group, which preserves the cellular redox state through detoxification reactions. GSH is used by cells to defend themselves against oxidative stress through its GSH–peroxidase and GSH–reductase enzymes. The body reproduces GSH through the recycling of its amino acids and the intake of food rich in sulphur . The excVitamin E is a fat-soluble antioxidant that protects the biological membranes from oxidation and regulates many enzymes responsible for the reduction of ROS/RNS build-ups. The main sources of vitamin E are vegetable oils and foods rich in vegetable oils. Vitamin E includes four isoforms of tocopherols  and four tocotrienols . These isoforms cannot be mutually converted and only α-tocopherol meets the need for vitamin E of the human body . The antNumerous studies have shown that polyunsaturated fatty acids (PUFAs) are involved in neuronal development and growth, therefore their possible therapeutic effects on neurodegenerative diseases are being tested . As prev2, CO3−· and its slower interaction with the superoxide anion (·O2−), the hydrogen peroxide (H2O2) and peroxynitrite (ONOO−). NAC is able to modulate many neurotransmitters such as glutamate. The latter is involved in various neurological disorders. In fact, different forms of neuronal damage and degeneration are associated with the excitotoxic damage caused by an altered activation of the N-methyl d-aspartate receptor (NMDAr) [N-acetylcysteine (NAC) is a precursor of cysteine which promotes the production of the endogenous antioxidant GSH responsible for the balance of the cellular redox state . The bio (NMDAr) . Patient (NMDAr) . The adm (NMDAr) . Many st (NMDAr) . NAC als (NMDAr) . At the  (NMDAr) . The pro (NMDAr) . Again,  (NMDAr) . In mult (NMDAr) . Finally (NMDAr) .Supplementation with natural compounds, including plant extracts and nutraceuticals, have recently been studied for their potential in approaching the prevention and/or the management of neurodegenerative disorders, mainly in the early stages of the disease. Here, will be identified the principal candidates which have been studied in recent years.Polyphenols are the largest group of phytochemical compounds and in the last twenty years, have been largely investigated by researchers, scientists and nutritionists thanks to their impact on health: polyphenols, in fact, play an important role in degenerative diseases such as cancer, cardiovascular alterations, chronic inflammation and neurodegenerative diseases . Fruits,Among the countless polyphenols, we will investigate two plants containing many polyphenols (turmeric and blueberry) and the use of a phenolic compound resveratrol.Curcuma longa L. plant and belongs to the Zingiberaceae family. It consists of essential oils, polyphenols, carbohydrates, proteins, fats, minerals and water. The main component of the turmeric plant is curcumin, a polyphenolic compound with strong antioxidant, anti-inflammatory, antiviral and antibacterial properties; recently, some studies have proved its potential in neurodegenerative diseases [Turmeric comes from the rhizome of the diseases . For exadiseases , reducesdiseases , which, diseases . The antdiseases . Althougdiseases . These adiseases . Modern diseases .Resveratrol is a polyphenolic compound present in fruits , roots, cereals, seeds, flowers, vegetables, tea (green and black tea), peanuts and above all, in wine. The presence of high concentrations of resveratrol in wine and its positive effects were confirmed by the “French Paradox” which states that the moderate daily consumption of red wine may protect the body against the increase in triglycerides and cholesterol levels. Many scientific studies have emphasized the important therapeutic effects of resveratrol, focusing on its antioxidant, anti-inflammatory, anti-tumour and cardio-protective properties. Precisely for this reason, the intake of resveratrol is recommended for many diseases . The eleEricaceae are a plant family with a high content of polyphenols and strong antioxidant properties. The fruits present in our diet are blueberries, cranberries and bearberries. According to experimental evidence, the intake of these fruits has protective effects on the CNS . A studyA representative cartoon which displays the protective mechanisms  is provided in The incidence of neurodegenerative disorders  is increasing exponentially. Early stages of neurodegenerative process are characterized by common mechanisms: oxidative stress, loss of cross-talk among the cell organelles and increased neuroinflammation culminating in cell death. A correct maintenance of the endogenous antioxidants and supplementation with natural nutraceuticals have been suggested to counteract the oxidative damage and inflammation in brain tissues occurring in patients undergoing neurodegenerative processes. Since it is known that the accumulation of all these compounds can cause toxicity, further clinical trials are required to support an extensive use of the right quantities to hire/produce, mainly in the early stages of neurodegenerative diseases.


The pathogenesis of PDR is complex and involves vascular, inflammatory, and neuronal mechanisms. Several structural and molecular alterations associated to PDR are related to the presence of inflammation that appears to play a non-redundant role in the neovascular response that characterizes the retina of PDR patients. Vascular endothelial growth factor (VEGF) blockers have evolved over time for the treatment of retinal neovascularization. However, several limitations to anti-VEGF interventions exist. Indeed, the production of other angiogenic factors and pro-inflammatory mediators may nullify and/or cause resistance to anti-VEGF therapies. Thus, appropriate experimental models are crucial for dissecting the mechanisms leading to retinal neovascularization and for the discovery of more efficacious anti-angiogenic/anti-inflammatory therapies for PDR patients. This review focuses on the tight cross talk between angiogenesis and inflammation during PDR and describe how the chick embryo chorioallantoic membrane (CAM) assay may represent a cost-effective and rapid  Retinal and choroidal neovascularization are the leading causes of visual impairment in various ocular pathologies, including retinal vein occlusion, age-related macular-degeneration, retinopathy of prematurity and diabetic retinopathy (DR).DR is one of the main complications of diabetes mellitus and it represents the major cause of vision loss in the working-age population . At presvice versa [see . Furthermore, a large percentage of patients do not respond to anti-VEGF drugs or exhibit a poor response. Supposedly, this limited efficacy may depend on the activation of other pathways promoting ocular angiogenesis as a consequence of the local production of various pro-angiogenic and pro-inflammatory factors [reviewed in  has been proposed as a valid alternative animal model for the investigation of the mechanisms underlying physiological and pathological angiogenesis . This reAngiogenesis is a complex multi-step process. Various events are necessary for angiogenesis to occur, including the interaction between cell surface receptors, soluble factors, and extracellular matrix components. Several cell types are also required, with endothelial cells playing a major role .The formation of neovessels has been thoroughly investigated and described in several insightful reviews –28. BrieDuring diabetes, hyperglycemia acts on retinal endotelium, promoting the activation of interconnected biochemical pathways, including the polyol   and hexoThese hyperglycemia-induced alterations are considered one of the primary events in the pathogenesis of DR and they are followed by other dysfunctions, such as retinal hyperpermeability, thickening of the basal endothelial membrane, and activation of a strong inflammatory response.Another hallmark of DR is the presence of micro-occlusions in the retinal microvasculature . EndotheHIF-1α gene expression via the activation of the canonical nuclear factor κB (NF-κB) pathway, a key regulator of innate immune, inflammatory and angiogenic responses , mesoderm , and endoderm  . The mid2 on day 6, increases to 65 cm2 by day 14 , its disadvantages being represented by a limited area for manipulation and observation , and gene expression analysis by quantitative RT-PCR.The immune system of the chick begins to develop during the embryonic life . ClassicThe first line of defense against bacterial pathogens in the chick embryo is represented by heterophils . These rin ovo and to be expressed also by other cells with phagocytic activity, such as dendritic cells, after hatching  have shown that the vascular reaction is also due, at least in part, to an inflammatory reaction induced by the presence of such foreign materials . The read repair . This mod repair . Histolod repair . The CAMd repair . Hyalurod repair .in vivo effects of the sequential delivery of dexamethasone followed by VEGF on the immune response and vascular network formation in the CAM assay. Cross-section images of control CAMs showed very few inflammatory cells, mostly macrophages and heterophils. In contrast, an abundant presence of inflammatory cells, fibroblast encapsulation, and swelling (edema) were found in the tissue surrounding the VEGF implant that were inhibited by dexamethasone -treated CAMs and responsible, at least in part, for the neovascular response triggered by this cytokine . Mononucethasone .Together, these data indicate that the chick embryo CAM represents a platform suitable for the study of the cross talk between angiogenesis and inflammation.The use of the chick embryo CAM for the study of retinal vascular pathologies dates back to the early' 80s. Glaser and colleagues utilized the CAM to investigate the vasoproliferative activities of several mammalian tissue extracts . They observed a potent vasoproliferative response when pellets containing retinal extracts were applied on the top of the CAM, while other adult tissues resulted ineffective . With a pars plana vitrectomy from PDR patients has been shown to exert significant biological responses when delivered in vitro and in vivo to different cell types in various pre-clinical experimental models [reviewed in  belong to a class of pattern recognition receptors that are involved in controlling inflammation, angiogenesis, tissue repair, and innate immune responses , characterized by different ligand properties, biological function and cellular distribution . Among t binders . Thus, cNotably, unlike the anti-inflammatory agents hydrocortisone and UPARANT, the anti-VEGF drug bevacizumab induces only a moderate inhibition of neovascularization and inflammatory cell recruitment promoted in the CAM assay by PDR vitreous-loaded beads [see Taken together, these data suggest that the pro-angiogenic and pro-inflammatory activity of PDR vitreous may depend on the synergistic action of multiple molecules, supporting the belief that inflammation and angiogenesis may be strictly correlated, with inflammation being a relevant factor in the formation of novel retinal blood vessels during PDR.The chick embryo CAM assay presents numerous advantages, such as its low cost, reproducibility and reliability, and simplicity in execution. Furthermore, in most countries the use of chick embryo until day 17 of development is not subjected to regulatory rules in order to obtain ethics committee approval for animal experimentation.in vitro experiments when the same samples were tested on cultured endothelial cells. These data indicate that such variability does not represent a drawback of the CAM assay but it rather reflects an individual heterogeneity among PDR patients, possibly related to differences in their medical case history and clinical features that result in a different angiogenic/inflammatory profile. Nevertheless, despite this heterogeneity, a significant direct correlation has been observed between the extent of neovascular and inflammatory responses elicited by PDR vitreous samples in the CAM assay, strengthening the concept that a tight correlation indeed exists between angiogenesis and inflammation in PDR. This concept is supported by the observations that different anti-inflammatory agents hamper the angiogenic activity exerted by PDR vitreous, as well as by recombinant growth factors/cytokines.As described in this review, recent experimental evidence has shown that the vitreous obtained from PDR patients elicits angiogenic and inflammatory responses when delivered on the top of the CAM. Notably, despite the fact the PDR vitreous samples are collected after pars plana vitrectomy at the end stage of the disease, when no other therapeutic innervations are available, individual samples are characterized by a highly variable biological effect when tested in the CAM assay. Such variability has been observed also in in vivo screening of novel drug candidates.The clinical observation that anti-VEGF therapies may show only a limited effect in PDR patients calls for new pharmacologic interventions. New insights into the impact of inflammation in the pathogenesis of PDR may allow the discovery of novel therapeutic targets. The association of anti-angiogenic and anti-inflammatory drugs may therefore be beneficial for treating PDR. In this frame, the CAM assay may represent a suitable platform for a rapid in vivo studies may be the lack of avian-specific reagents, as well as the presence of species-specific differences and the insufficient genomic information. However, the usage of retroviral, adenoviral, and lentiviral vectors has been applied to the infection of the CAM, making them express a long-lasting viral transgene. This technique has been employed for studying dominant-negative gene products, as well as for evaluating the effects of intracellular or membrane-bound proteins. In addition, the achievement of the chick embryo genome sequencing (A critical limitation in the use of the CAM for quencing  should sIn conclusion, the CAM assay may represent a cost-effective and rapid tool for the study of the relationship between neovascular and inflammatory responses elicited in PDR and for the screening of novel therapeutic agents .MP revised and redacted the final version. All authors contributed to the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Increasing evidence suggests a strong interplay between autophagy and genomic stability. Recently, several papers have demonstrated a molecular connection between the DNA Damage Response (DDR) and autophagy and have explored how this link influences cell fate and the choice between apoptosis and senescence in response to different stimuli. The aberrant deregulation of this interplay is linked to the development of pathologies, including cancer and neurodegeneration. Ataxia-telangiectasia mutated kinase (ATM) is the product of a gene that is lost in Ataxia-Telangiectasia (A-T), a rare genetic disorder characterized by ataxia and cerebellar neurodegeneration, defects in the immune response, higher incidence of lymphoma development, and premature aging. Importantly, ATM kinase plays a central role in the DDR, and it can finely tune the balance between senescence and apoptosis: activated ATM promotes autophagy and in particular sustains the lysosomal-mitochondrial axis, which in turn promotes senescence and inhibits apoptosis. Therefore, ATM is the key factor that enables cells to escape apoptosis by entering senescence through modulation of autophagy. Importantly, unlike apoptotic cells, senescent cells are viable and have the ability to secrete proinflammatory and mitogenic factors, thus influencing the cellular environment. In this review we aim to summarize recent advances in the understanding of molecular mechanisms linking DDR and autophagy to senescence, pointing out the role of ATM kinase in these cellular responses. The significance of this regulation in the pathogenesis of Ataxia-Telangiectasia will be discussed. Autophagy is a highly conserved catabolic pathway necessary for the maintenance of cellular homeostasis . PhysiolDNA damage response (DDR) is another essential pathway in the control of cellular homeostasis . In respAccumulating evidence has demonstrated a strong connection between autophagy and DDR in the maintenance of cellular homeostasis . AutophaAtaxia-telangiectasia mutated (ATM) protein, a 350 kDa evolutionarily conserved serine/threonine protein kinase, was first identified as a central player in the DDR pathway . Now it Here, we focus on the link between DDR and senescence, pointing out the role of ATM kinase in the modulation of autophagy as a bridging point between these cellular responses. The significance of the deregulation of this equilibrium in the pathogenesis of Ataxia Telangiectasia will also be discussed.As described above, it is well documented that autophagy is induced by DNA damage, and it is required for several functional outcomes of the DDR, such as DNA repair, senescence, and cytokine secretion . On the On the molecular level, it is well demonstrated that the DDR can trigger a rapid early induction of autophagy mediated by posttranslational modifications (PTMs), such as phosphorylation, ubiquitination, and acetylation . InteresAtg6/Beclin1 extends mouse survival and suppresses tumor development, only when p53 is functional  (OMIM:208900). As we discussed above, it is clear that ATM kinase, by regulating autophagy, plays a central role in the induction of senescence and the suppression of apoptosis, both upon DNA damage and oxidative stress. What is the role of these pathways and of senescence in the development of the A-T pathology?Ataxia-Telangiectasia (A-T) is an autosomal recessive disorder characterized by cancer susceptibility, radiation sensitivity, cerebellar degeneration, and telangiectasia . ImportaWhy do A-T cells show a senescent phenotype? The apparent paradox between the role of ATM in the promotion of senescence and the senescent phenotype of A-T cells may be explained by the central role of ATM in the maintenance of cellular homeostasis upon different stress induction, as previously outlined.The senescent phenotype could be explained in part by the fact that ATM-deficient tissues and cultured cells exhibit signs of chronic stress and low-level DDR that could contribute to SASP and senescence . In addiThe investigation of the molecular interconnection between ATM-autophagy and senescence will therefore support the comprehension of A-T pathogenesis and may also contribute to identify novel strategies to ameliorate patient’s management.VS and DB: conceptualization. VS: writing – original draft preparation. DB, VS, AF, and CC: writing – review and editing. DB and VS: supervision. DB: funding acquisition. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.