The veteran population faces myriad health burdens, particularly regarding mental health. As veterans age, combined genetic, environmental, and biochemical factors with natural biological processes may increase their susceptibility to mental health disorders as well as neuropsychiatric and dementia-related disorders that present as persistent cognitive impairment. Multi-organizational, multidisciplinary research partnerships help explore relevant evidence-based methodologies and create a two-way continuum between basic science and clinical application to address veterans', often complex, health care needs. The Congressionally Directed Medical Research Programs (CDMRP), a global funding organization located within the U.S. Army Medical Research and Development Command (USAMRDC), fosters novel approaches to biomedical research in response to the expressed needs of stakeholders and, as directed by Congress, many CDMRP programs focus on topics that are relevant to the health care of veterans. The CDMRP's foundation as a research management organization includes a two-tier review process and fully integrates consumer advocates. The CDMRP complements the U.S. Department of Veterans Affairs (VA) research through collaborative partnerships and synergistic award mechanisms tailored to areas of greatest need. Continued partnerships between the VA and CDMRP can facilitate translation of basic research to clinical application and enhance health care in the veteran community. This perspective highlights the need for research to address mental health issues affecting the veteran community, describes how the CDMRP integrates veterans into its processes, and discusses how the CDMRP's processes and collaborations with the VA have the capacity to improve mental health care for veterans. Service members and veterans experience military-specific stressors that require focused research. Results from research conducted with the general population, therefore, may not translate to these subpopulations. Research and collaboration to address mental health conditions and to promote resilience among service members and veterans are priorities within the Department of Defense (DOD) and VA .The veteran population faces numerous and significant health burdens. Specifically, veterans experience traumatic brain injury (TBI) and mental health disorders at disproportionate rates compared to their non-veteran counterparts . In a laMulti-organizational, multidisciplinary research partnerships fostered by the CDMRP are well-positioned to address the many complexities with veteran healthcare. The purpose of this perspective is threefold: (1) to describe how key facets of the CDMRP's program cycle integrate veterans and veteran health care perspectives, (2) to discuss the importance of collaborative partnerships and synergy between the CDMRP and the VA when reviewing and conducting veteran-focused scientific research, and (3) to promote the bi-directional translation of basic science to clinical application to improve veteran mental health.The CDMRP is a directorate located within the USAMRDC that manages over 35 biomedical research programs, as directed by Congress see . The misThe CDMRP's research management model includes targeted funding opportunity announcements and active engagement with patients, including veterans, living with health conditions. Veterans weigh in on program policy, investment strategy, and research focus. This model enables a two-way continuum between basic science and clinical application and promotes promising approaches to advance research and enhance healthcare in the veteran community. Using complementary funding opportunity announcements and synergistic funding mechanisms that encourage collaboration, the CDMRP and the VA have the capacity to better harness the power of research and evidence and make sure it is translated into action.Each CDMRP-managed program has individually tailored goals and a distinct vision enabling funded research to meet the specialized needs of the research and patient communities. Several programs focus on mental health and other topics relevant to veteran health care, and opportunities for collaboration with the VA exist throughout the program cycle see .The first major milestone in the cycle is the Vision Setting meeting, during which the Programmatic Panel convenes to assess the research landscape and develop an investment strategy. Each Programmatic Panel is comprised of a multidisciplinary group of research scientists, clinicians, foundations, industry, other federal agencies [such as the VA and National Institutes of Health (NIH)], and consumer advocates. For example, the Alcohol and Substance Abuse Disorders Research Program (ASADRP) Programmatic Panel consists of members from the U.S. Army, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the Department of Veterans Affairs. Based on knowledge from their respective portfolios, the ASADRP Programmatic Panel recommended at a recent Vision Setting meeting an investment in multi-institutional research consortia involving teams of leading scientists and clinicians working together under one umbrella to identify pharmacotherapies that address alcohol and substance abuse disorders, with an emphasis on those related to TBI and PTSD in service members and veterans.After establishing the program vision and investment strategy, Program Announcements are developed to solicit research applications that will make a significant and non-incremental impact . CDMRP uA distinguishing CDMRP feature is the significant involvement from consumer advocates such as patients, survivors, family members, or caregivers impacted by the disease, condition, or injury throughout the program cycle. Applications are required to include an impact statement describing how the proposed research, if successful, will significantly advance the field and impact the patient advocate community . The potThe CDMRP model facilitates investment in high-impact and high-risk/high-gain studies that other agencies may not fund. Unlike other federally funded agencies that receive funding in the President's budget each fiscal year, the CDMRP develops an investment strategy based on additional, individually-directed Congressional appropriations each fiscal year. Due to the nature of funding, multi-year awards are fully allocated up front, ensuring research projects are not put at funding risk. This also allows programs to shift focus year-to-year based on innovative advances in the field without the need to fulfill out-year budgets of previously selected awards. Additionally, the CDMRP uses novel, focused award mechanisms, directed at each disease, condition, or injury specified in Congressional language. For example, the Idea Award was developed by the Breast Cancer Research Program to support research with little or no preliminary data. Supporting early concepts and ideas complemented other Federal funding programs that required preliminary data, supported the next logical step, and were not disease- nor condition-focused . This CDWhile industry, including pharmaceutical, biotechnology, and medical device firms, remains the largest funder of clinical trial research, the CDMRP's niche in this arena is the encouragement of preventive or therapeutic interventions that are in line with state of the art research and the priorities of the communities affected by the disease. For example, the ASADRP Pharmacotherapies for Alcohol and Substance Abuse (PASA) Consortium establishes pharmaceutical company partners who have compounds for ASUDs or PTSD available, but who need the complement of experts from the PASA to complete human studies to the U.S. Food and Drug Administration's (FDA) standards .While all programs managed or supported by the CDMRP are focused on solutions for service members and the American public, three programs are particularly relevant to veteran health—the Gulf War Illness Research Program (GWIRP), the Psychological Health and Traumatic Brain Injury Research Program (PHTBIRP), and the ASADRP. From 2018 to 2019, the GWIRP, PHTBIRP and the ASADRP yielded ~500 publications, 20 patents/patent applications, and 50 research products. Furthermore, in a 2018 internal review of 10% of CDMRP-managed clinical trials funded between fiscal year 2008 and fiscal year 2015, 74% of closed trials met the CDMRP-defined criteria for success. These outcomes, as well as the unique aspects of the review and management model described herein, illustrate how CDMRP is able to translate important research results into medical solutions for patient communities.The CDMRP has formed strong partnerships among the DOD, VA, and patient, scientific, and clinical communities to advance paradigm-shifting research and provide solutions that will lead to cures or improvements in care. CDMRP funding opportunities are open to VA researchers and clinicians as well as those from the military, academia, and the private sector. Inclusion of a military or VA investigator as an equal partner in the research is strongly encouraged in many CDMRP funding opportunities and the degree of this partnership is evaluated during the review process. Partnerships with the military and the VA are important to access relevant active duty and VA patient populations. In addition, the DOD and VA, with participation from the NIH, conduct a joint review and analysis of their portfolios annually.The collaboration between the GWIRP and the VA is an example of a funding partnership that makes the best possible use of available resources in support of high-quality, veteran-focused research. The GWIRP was established in 2006 when Conferees directed the Secretary of the Army to utilize authorized funding to undertake research on Gulf War Illness (GWI) and to coordinate with similar activities at the VA. GWI is characterized by multiple, diverse symptoms not explained by established medical diagnoses or standard laboratory tests. The GWIRP is the only CDMRP program completely dedicated to veteran health, and frequent communication and collaboration occur between the VA and GWIRP Program Managers (PMs). Specific examples of such collaborations include GWIRP PM participation on VA-convened working groups, VA funding of GWIRP spin-off proposals, sharing of funding data through electronic coordination, and a recent GWI State of the Science conference co-hosted by the VA Office of Research and Development and the GWIRP. In addition, the GWIRP awarded a Clinical Trials Consortium in fiscal year 2017 that includes two of the VA War Related Illness and Injury Study Centers as recruitment sites, further demonstrating collaborative and optimal use of resources.The CDMRP provides program and award management support for many other consortia that involve partnerships between the DOD, VA, and academia. These large awards bring together multidisciplinary, multi-organizational teams to tackle complex problems affecting service members and veterans such as PTSD, TBI, suicide, and ASUDs. An advantage of the consortium model is the ability to require collection of common data elements and aggregate data from numerous studies into a single data repository. The CDMRP strongly encourages the sharing of data and research resources generated from CDMRP-funded research, while protecting participant privacy, confidential and proprietary data, and intellectual property. The STRONG STAR Consortium to Alleviate PTSD (CAP), a jointly funded DOD-VA effort, and the Military Suicide Research Consortium (MSRC) are two CDMRP-managed consortia that house data which can be accessed by other researchers who are interested in conducting secondary analyses of de-identified data. Qualified investigators can access the STRONG STAR-CAPVA/DOD Clinical Practice Guideline for The Assessment and Management of Patients at Risk for Suicide, which directly impacts veteran mental health treatment  improved general self-reported health and physical functioning . The resWithin the PHTBIRP, research progress has been accelerated through studies seeking to translate existing interventions initially developed and evaluated with funding from the NIH, VA, or other agencies for military and veteran contexts. Examples include suicide, substance misuse, and sexual assault/harassment prevention interventions originally designed for use with college students and suicide treatment interventions designed for civilian medical settings adapted for use with military and veteran populations –15. TailThe ASADRP-funded PASA Consortium uses planning grants for clinical trials and full study research grants for pre-clinical trials. This is a novel risk mitigation strategy that allows them to leverage a relatively small appropriation to conduct complex/high risk research involving drug trials on human subjects. The purpose of a planning grant is to create a clinical development plan that includes study protocol development, regulatory pathway development, identification of study sites, pharmaceutical company support, determination of the need for additional studies by the FDA, and a study budget. Once this has been accomplished, the documents are submitted to the PASA and undergo a two-tier review before a funding recommendation is considered. Nine compounds are in pre-clinical trials for alcohol use disorder and PTSD while five other compounds are undergoing clinical review.These and other CDMRP funding opportunities demonstrate the value of leveraging and maximizing federal dollars to support veteran health. Such synergies can significantly accelerate progress, thus shrinking the pipeline for development of new therapeutics, new diagnostics, and changes in the standard of care.Multi-organizational, multidisciplinary research partnerships are needed to address the health burdens faced by veterans. Emerging results have the potential to be most impactful if they continue to feed into the two-way continuum between basic science and clinical application to inform patient care and future research priorities.The CDMRP management model has many integrated activities that rely on partnerships with the VA to ensure translation of basic research to clinical applications. Additionally, the CDMRP fully integrates consumer advocates, including veterans with significant health issues, in program policy, investment strategy, and research focus. Many CDMRP funding mechanisms promote the translation of science from discovery through different development stages, including the transition to clinical studies and product development. Collaborating with the VA early in the development of the program strategy and funding mechanism facilitates translation of innovative and impactful technologies funded by the VA and DOD. This creates new medical solutions for service members, veterans, and the American public. Emphasizing collaboration and stepwise translation may help funding agencies facilitate a seamless transition, capitalize on efficiencies, and reduce costs. Such efforts are integral to improving the mental health of the veteran population and advancing the field.https://cdmrp.army.mil.To learn more about the CDMRP and its programs or to receive funding opportunity notifications by e-mail, please visit ML and KL participated in conceptualization of the article, drafting, and final editing. RS and SD participated in drafting and reviewing the article. All authors approved the final version of the manuscript to be published and agreed to be accountable for all aspects of the work.The authors report no actual or potential conflicts of interest with regard to this article; however, the authors note that they are Department of Army employees affiliated with the CDMRP.


Polarization holography has the unique capacity to record and retrieve the amplitude, phase, and polarization of light simultaneously in a polarization-sensitive recording material and has attracted widespread attention. Polarization holography is a noteworthy technology with potential applications in the fields of high-capacity data storage, polarization-controlled optical elements, and other related fields. The choice of its high-performance materials is particularly important. To further develop polarization holography applications and improve the quality of the information recorded , a deeper understanding of such materials is needed. We present an overview of the polarization-sensitive materials, which introduced polarization holographic technology and the development of polarization holographic materials. The three main types of polarization holographic materials are described, including azopolymer materials, photopolymer material, and photorefractive polymer material. We examine the key contributions of each work and present many of the suggestions that have been made to improve the different polarization-sensitive photopolymer materials. Improvements in the capacity and reliability of data storage systems are urgently needed. One potential optical information storage technology uses a holographic approach in which recorded data are distributed throughout the volume of a thick medium with high density. Optical holographic recording technology can record information in a three-dimensional space versus traditional two-dimensional storage methods and offers a small volume, large capacity, and high density. In 1994, Heanue et al. first used holographic recording technology to realize the storage of digital images and compressed video data [In holographic data recording, the entire information contained in the light is stored at once as an optical interference pattern within a photosensitive optical material. Holographic storage technology usually uses the interference of light to record the interference fringes and uses the diffraction of light to reproduce the information of the recorded light. Holographic storage recording is achieved through the interference of two coherent laser beams irradiated at the same position in the photosensitive material. We describe a polarization holographic technology and reviewed three typical polarization-sensitive materials to more fully understand what is needed to optimize the performance for polarization holographic applications. More specifically, we describe the evolution of our understanding of what takes place inside these polarization materials and what happens during and after holographic recording. Finally, we propose a prospect for polarization-sensitive materials.The polarization properties of light and its anisotropy process in propagation increase as the degree of freedom, which can be controlled; this is called the polarization state. In 1965, Lohmann first proposed a method to record the polarization state of light with two orthogonal polarized beams . In 1968Since the concept of polarization holography was proposed, in 1974, Kakichashvili first gave a theoretical proof using the photoinduced anisotropy of polarization-sensitive materials for polarization holographic recording . This waIn the development of polarization holographic storage technology, the most vital thing is to find suitable polarization-sensitive materials. Polarization-sensitive materials include organic materials and inorganic materials. Inorganic materials, such as photorefractive crystals, have a high diffraction efficiency and a short response time. These materials have harsh production conditions and high costs, however, which limits their marketability. They are not suitable for permanent storage of information because they can be erased ,9. RecenAn excellent volume holographic recording material needs to have the following characteristics: (i) The material should have sufficient optical quality to ensure that the loss of the beam during reading and writing is extremely small, and the surface of the material should have optical flatness to avoid distortion during the imaging process. The scattering rate of the material is extremely low, and for holographic storage, it needs to have sufficient thickness to achieve a high storage density. (ii) The recording wavelength of the material should match the wavelength of the laser, and it should be sensitive to light waves in the wavelength range. (iii) The material should be processed without traditional holographic processing, such as heat treatment or solvent processing, to reduce costs. (iv) For long-term recording, the material must be nonvolatile, that is subsequent holographic recording and reading will not destroy the recorded hologram. (v) The material must be able to maintain long-term stability within a certain temperature and humidity range to achieve sufficient storage life. In this part, we will describe three typical polarization holographic materials, which are azopolymer materials, photopolymer materials, and photorefractive polymer materials, in detail.Azopolymers have good optical stability, good solubility, a low price, the ease of combination with polymers, high absorption strength, no fluorescence, and low phosphorescence loss. More importantly, their maximum absorption peak can be moved to the short-wave region (such as green and blue) through structural modification, which is expected to be a good polarization holographic recording material. The recording and retrieval capacity of polarization information in azopolymers is based on the birefringence induced by the preferential orientation of the chromophores in the material due to trans-cis-trans photoisomerization .Azo materials are a class of materials with a molecular structure of In 1972, Paik et al. discovered that when compounds containing azo-aromatic groups were irradiated with light of appropriate wavelengths, trans-cis and cis-trans isomerization occurred through photochemical processes . This diAccording to the study of photoanisotropy, research on polarization holographic recording of azopolymer materials has been continuously developed. In 1984, Todorov et al. proposed a new type of polarization-sensitive holographic recording material of polyvinyl alcohol polymer doped with azo-dye methyl-orange and proved that the material based on photoinduced anisotropy was an efficient material for polarization holographic recording, allowing for multiple erasure and repeated recording . The teaIn 1999, Birabassov et al. prepared a cellulose acetate film doped with azo dye Disperse Red 1 and used this material to provide a hologram with similar efficiency for the grating recorded with intensity and polarization modulation, storage, and reconstruction of the polarization state of elliptically polarized object light . In 2002Having a large refractive index modulation is important for polarization holographic recording of materials, and an elegant approach is to add photoreactive liquid crystals and azo-dyes as composites. Liquid crystals have demonstrated that they are sensitive to the polarization state of the recording waves. They can effectively enhance the diffraction efficiency under appropriate control of collective reorientation of the mesogenic terminal ends . In 2005ecording . Two ortecording . In 2012ecording . The polecording . This woTo enhance the photoinduced change in the refractive index, the fabrication of highly birefringent azo dye doped and azo liquid crystal control is a key process that can enhance the photoanisotropic of the material to improve the diffraction efficiency of polarization recording by the trans–cis isomerization and photo-orientation. Several approaches to obtain high-performance parameters of the Bragg holograms have been introduced . ResearcPhotopolymer materials have attracted increasing attention because of the advantages such as low cost, easy preparation, flexible composition selection, and designability. Compared with other organic materials, photopolymers are widely used as a holographic recording material suitable for one-time writing and permanent reading. These materials not only have a high refractive index modulation and diffraction efficiency, but also can improve performance through doping, which gives them great advantages in terms of holographic storage.A typical photopolymer system generally includes the photosensitizer, monomer, and initiator. The photosensitizer and initiator can form a photosensitive initiation system because both can promote the polymerization of monomers during the photopolymerization process . PhotoseOne type of polarization-sensitive holographic recording photopolymer material that has been studied extensively is polymethyl methacrylate organic polymer doped with phenanthrenequinone (PQ/PMMA). PQ/PMMA polymer was first proposed as a traditional holographic storage material and attracted attention. The main principle of recording holographic gratings is to use the polymerization reaction of the monomer and base material and the diffusion of the monomer material.The molecular structure of phenanthrenequinone has carbon-oxygen double bonds and carbon-carbon double bonds, which are highly conjugated two-dimensional planar structures. PQ molecules in different directions are randomly distributed in the material without illumination, and the material is isotropic, as presented in molecule ,37. ThisThe polarization holographic recording performance of PQ/PMMA materials can be evaluated by parameters such as diffraction efficiency and photoinduced birefringence. The maximum diffraction efficiency of the material is an important criterion for the potential of the material to become a polarization holographic storage material. Diffraction efficiency is the ratio of the diffracted luminous flux of the polarized holographic image to the luminous flux incident on the material and is defined as follows:Photoinduced birefringence is the macroscopic manifestation of the microscopic molecular anisotropy of the medium and is an important photophysical manifestation of anisotropic materials. It is mainly caused by the structural rearrangements of the photoproduct induced by the photochemical reaction of photopolarization-sensitive molecules . When thWhen material absorption is ignored, the photoinduced birefringence (given by :(2)Δn=n1In the early days, the research on the improvement of the holographic recording performance of photopolymer materials mainly focused on traditional holography. In 1969, Close et al. drew attention to photopolymers as holographic recording materials . The matMany groups are developing thicker photopolymers that inhibit volume shrinkage. After a long-term study by the Tomita research group in Japan, Naoaki et al. demonstrated a green permanent holographic storage with high diffraction efficiency and recording sensitivity in a methacrylate photopolymer film dispersed with titanium dioxide nanoparticles in 2002 . The difSince then, the research group has continued to work in related directions. In 2003, Tomita et al. proved a more than one-order-of-magnitude improvement of holographic recording sensitivities in the green channel by doping pyrromethene dye into silica nanoparticles dispersed in methacrylate photopolymer film . In 2005Phenanthraquinone-doped polymethyl methacrylate (PQ/PMMA) polymer materials have excellent properties. For example, the polymerization reaction of the monomer during the preparation process and the photochemical reaction during the exposure process can be separated, and thus, the shrinkage during the exposure process is negligible. The dual-polymer mode is adopted, and one of the polymers is employed to form the substrate of the material, which determines the thermal expansion coefficient and optical characteristics of the material. Another polymer is evenly distributed in the substrate and completes photopolymerization under light to modulate the refractive index. Therefore, some properties of the material are determined by just one of the polymers, which means that the specified parameters of the material can be adjusted without affecting the other properties. This increases the selection range of the material. These properties can be improved by doping other components and has received extensive attention especially in polarization holographic storage materials.In 2009, Trofimova et al. prepared the PQ/PMMA material and applied it to polarization holographic recording . Througheriments . The holIn the same year, C. Li et al. improved the photoinduced birefringence of the material by doping gold nanorods in PQ/PMMA and theoretically gave an explanation model of the working mechanism with gold nanorods . The difThe structure and concentration of photosensitive molecules also has a great influence on the properties of polarization sensitive materials. In view of the limitation of the PQ concentration in PQ/PMMA, in 2011, T. Fukuda et al. developed a new photoinitiator AK1with a photoinduced birefringence effect . The holIn 2017, Liu et al. used Irgacure 784 instead of PQ to investigate the holographic properties of Irgacure 784-doped polymethyl methacrylate photopolymer (Irgacure 784/PMMA) and compared it with PQ/PMMA . The matIn 2018, Fan et al. introduced benzyl methacrylate (BzMA) into PQ/PMMA photopolymers . Using B polymer . The difWork to improve PQ/PMMA photopolymer materials has continued in recent years. In addition to these methods of changing the photosensitizer composition and doping other components, some researchers have made progress by improving the preparation process of the materials to increase the concentration of PQ molecules . For pho3 and LiTaO3, the optical inhomogeneity of the crystal refractive index was observed and could be maintained for a long time without exposing the light [The photorefractive effect is a nonlinear optical phenomenon in which the variation of the refractive index of photoelectric materials is caused by the spatial distribution of light intensity under light irradiation. In 1966, Ashkin et al. found that when they focused the laser beam on LiNbOhe light . In 1968he light . At the During photorefraction, free carrier migration has three main mechanisms: diffusion, drift, and the photovoltaic effect . FerroelThe principle of photorefractive polymer materials is similar to that of inorganic crystals. Compared with inorganic crystals, photorefractive polymer materials have excellent nonlinear optical properties and electro-optical effects and are easy to prepare, which has attracted wide attention.In 1991, Ducharme et al. observed the photorefractive effect in amorphous electro-optical materials . The forAt present, there are few reports on the application of photorefractive polymer materials in polarization holographic recording, but researchers have conducted many theoretical and experimental studies on the polarization properties of photorefractive polymer materials and have obtained some performance.We report on the basic optical design of polarization holographic recording, as well as corresponding system demonstrations. Polarization holographic recording offers the best prospect for holographic data storage, including the fabrication of artificial anisotropic elements and polarization control. This includes the physical principles and high performance of polarization-sensitive media.We present an overview of reported work on the polarization-sensitive materials and discuss three types of typical polarization-sensitive material in detail. We examine the key contributions of each work, and many of these suggestions have improved the different polarization-sensitive materials discussed in this work. Clearly, many materials have provided promising polarization-sensitive capacities and are being developed for polarization holographic application. We emphasize photopolymers in this review, as they offer many advantages and are widely used as holographic data storage media. In particular, we discuss the polarization-sensitive mechanism of the PQ/PMMA material, which offers an in-depth understanding of comprehensive improvements in different photopolymers.Various approaches are summarized to improve performance in the field of polarization-sensitive holographic recording materials. Such improvements include (i) the introduction of the liquid crystal structure that betters the manipulated material polarization-sensitive properties; (ii) the introduction of nanoparticles that increase the absorption and promote effective photoconversion of photosensitive molecules; (iii) optimization of the photosensitizer composition structure and polymer composite substrate that improves the photoinduced birefringence of polarization-sensitive materials. The development of polarization holographic recording in optical holographic storage, optical element production, and other related fields needs continuous improvements.


Cancer represents one of the conditions with the most causes of death worldwide. Common methods for its diagnosis are based on tissue biopsies—the extraction of tissue from the primary tumor, which is used for its histological analysis. However, this technique represents a risk for the patient, along with being expensive and time-consuming and so it cannot be frequently used to follow the progress of the disease. Liquid biopsy is a new cancer diagnostic alternative, which allows the analysis of the molecular information of the solid tumors via a body fluid draw. This fluid-based diagnostic method displays relevant advantages, including its minimal invasiveness, lower risk, use as often as required, it can be analyzed with the use of microfluidic-based platforms with low consumption of reagent, and it does not require specialized personnel and expensive equipment for the diagnosis. In recent years, the integration of sensors in microfluidics lab-on-a-chip devices was performed for liquid biopsies applications, granting significant advantages in the separation and detection of circulating tumor nucleic acids (ctNAs), circulating tumor cells (CTCs) and exosomes. The improvements in isolation and detection technologies offer increasingly sensitive and selective equipment’s, and the integration in microfluidic devices provides a better characterization and analysis of these biomarkers. These fully integrated systems will facilitate the generation of fully automatized platforms at low-cost for compact cancer diagnosis systems at an early stage and for the prediction and prognosis of cancer treatment through the biomarkers for personalized tumor analysis. Uncontrollable cell growth is produced due to the accumulation of genetic and epigenetic modifications that regulate the main tumor cell functions, such as proliferation, survival, development, propagation, and differentiation. This disorder, along with its respective alterations, gives rise to a series of heterogeneous diseases known as cancer. This condition is considered the second cause of death globally and according to the latest estimated cancer statistics available within the Global Cancer Observatory (GLOBOCAN) project, the number of cancer incidences has continued to increase drastically, reaching 18.1 million cases in 2018 and is estimated to be 29.5 million in 2040 . . 106]. TAnother exosome isolation and detection study was done by He et al. . They prAs mentioned before, blood is not the only body fluid in which this type of biomarker can be found. Liang et al.  developeNucleic acid (NA) biomarkers, such as cell-free DNA (cfDNA), circulating tumor DNA (ctDNA), messenger RNA (mRNA), and micro RNA (miRNA), can be biological properties exploited in diagnostic applications and for cancer monitoring. The quantification of ctDNA could be a powerful parameter for early detection, progression and prognosis of tumors .Cell-free DNA (cfDNA) is defined by Peters et al.  as the fMoreover, the common laboratory techniques for DNA purification and detection, as well as the different laboratory methods used, frequently display different results, which could augment the range of the standard deviation . The reaSome more sensitive techniques have been applied to detect exosomal DNA, including surface-enhanced Raman scattering (SERS) , electroCurrently, new technologies have been proposed for improving the sample treatment and DNA analysis at the nanoscale, in order to overcome the limitations of the previously described techniques. These technologies involved methods based on free-solution electrophoretic detection for increasing the variation in electrophoretic mobility of the target-probe, with drag-tags and single-stranded DNA binding protein , isotherZhang et al.  describeA highly sensitive, miRNA study, using an integrated Microfluidic Exponential Rolling Circle Amplification (MERCA) system, was reported by Cao et al., 2019  Figure B. As a pAnother integrated microfluidic technology was based on an ionic membrane modular biochip platform developed by Slouka et al., 2015  Figure C. With tAn innovative chemical-free exosome lysing system, coupled with membrane sensing, was integrated and presented by Ramshani et al. . The purLiquid biopsy has recently appeared as a novel technique for early diagnosis of cancer and is considered one of the most promising technologies for monitoring the evolution of the disease during treatment. However, the ability to detect, characterize and quantify ctDNA, exosomes and CTCs represents a remarkable challenge due to their very small concentration in blood. In the past years, the development of microfluidic systems for isolating and detecting body fluid cancer biomarkers has been improving by integrating sensing approaches in LOCs, which provide several advantages compared to the traditional methods like better efficiency, portability, time of analysis, automation and miniaturization, as well as lower consumption of reagents, time and cost effective and easier usage. This review shows the most relevant reported integrated methods for liquid biopsy separation and analysis. Some of the published works have presented high sensitivity that offers up to single-cell resolution, as well as the possibility to study the cell interaction, which is not possible with traditional microfluidic devices. The integration of electronic/electrochemical/optical sensors in microfluidic devices represents an excellent approach for identifying cancer liquid biomarkers avoiding additional labelling and external extra-steps. Moreover, these platforms have opened new avenues for quantifying CTCs through other biological features such as metabolic cell activity. Thus, the development of this kind of integrated platform provides new insights for more sensitive and effective liquid biopsy devices that allow for the consideration of other kinds of biological and physical cell properties.Nevertheless, most of the reported devices are in an early development stage and were not tested with a blood sample from a cancer patient. Exploiting the effectiveness of these systems in real patient samples could provide a clear landscape of the tumor heterogeneity, knowing better the aggressiveness and the overall molecular scenario, with more accuracy compared to traditional systems. In fact, the majority of CTC and exosomes separation based on immuno-separation just consider one type of antibody, the EpCAM. However, the tumors have a rich heterogenic mixture of different cells with distinct morphological and phenotypic profiles, which brings different gene expression, motility, proliferation, metabolism, and metastatic potential, and therefore, a different and individual treatment. The immuno-platforms based on positive capture of CTCs and exosomes need to be included in future multiparametric antibodies for considering the entrapment of the rest of the cells contained in the tumor. In contrast, the genomic analysis thought ctNA already considered a different type of gene expression, these platforms being closer to full incorporation as real liquid biopsy analysis tools in Hospitals.Exosome analysis, along with other tumor materials, such as CTCs and ctNA, are considered the foundation of emerging technologies for liquid biopsy applications, which are only beginning to be studied in order to be used for early diagnosis and personalized medicine. The development of these technologies allows low risk and low-cost testing of samples and plays a crucial role by offering an enormous opportunity for microfluidic-based solutions in routine early detection of cancer. It is interesting that several developments illustrated here have taken place over the past decade, suggesting that this area is still in its early stages. This compilation of literature provides a basis for potential advances by introducing new methods to collect, identify and analyze cancer-related biomarkers. These developments also provide guidance to further work needed to implement the vision of point-of-care applications based on these platforms.


Geminiviridae comprises more than 450 species divided in nine genera, based on genome organization, host range, and insect vector: Begomovirus, Mastrevirus, Curtovirus, Becurtovirus, Topocuvirus, Turncurtovirus, Capulavirus, Gablovirus, and Eragrovirus DNA genomes that cause devastating diseases in major crops worldwide. The family Apart from the obvious economic and practical interest propelling the study of geminiviruses, this virus family is an excellent model system to gain insight into plant processes. Geminiviruses replicate their DNA genomes in the nucleus by using the plant DNA replication machinery; the geminivirus genome forms minichromosomes that are subjected to epigenetic modifications; geminiviruses are both activators and suppressors of plant defense responses, and modulate plant developmental processes  of small, fast-evolving, multifunctional proteins, encoded by bidirectional and partially overlapping open reading frames (ORFs) . MonoparIn view of the fast pace of evolution of geminivirus genomes  and position in different geminivirus species are therefore referred to as positional homologs, have the same name, and the resulting proteins show sequence similarity at the amino acid level . Given tSome functions of positional homologs seem indeed to be conserved across geminivirus species and genera: this is the case of Rep, which facilitates replication of the viral genome in all known species by reprogramming the cell cycle and mediating initiation, elongation, and termination of viral DNA replication , and therefore the essential virulence functions provided by the proteins they encode must be fulfilled by other, non-homologous geminiviral proteins. Hence, caution must be taken when extrapolating functional information to positional homologs, and uncovering the roles of each geminivirus-encoded protein in individual species will in all cases require experimental assessment.AL and RL-D conceived the idea and prepared 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.


The surgical skill prediction models showed an accuracy of 83% with Objective Structured Assessment of Technical Skill (OSATS) and Global Evaluative Assessment of Robotic Surgery (GEARS). The proposed method was able to track instruments during robotic surgery, suggesting that the current method of surgical skill assessment by surgeons can be replaced by the proposed automatic and quantitative evaluation method.As the number of robotic surgery procedures has increased, so has the importance of evaluating surgical skills in these techniques. It is difficult, however, to automatically and quantitatively evaluate surgical skills during robotic surgery, as these skills are primarily associated with the movement of surgical instruments. This study proposes a deep learning-based surgical instrument tracking algorithm to evaluate surgeons’ skills in performing procedures by robotic surgery. This method overcame two main drawbacks: occlusion and maintenance of the identity of the surgical instruments. In addition, surgical skill prediction models were developed using motion metrics calculated from the motion of the instruments. The tracking method was applied to 54 video segments and evaluated by root mean squared error (RMSE), area under the curve (AUC), and Pearson correlation analysis. The RMSE was 3.52 mm, the AUC of 1 mm, 2 mm, and 5 mm were 0.7, 0.78, and 0.86, respectively, and Pearson’s correlation coefficients were 0.9 on the  Most types of robotic surgery require training, with a classic learning curve eventually resulting in consistent performance . It is iQualitative assessment methods such as OSATS and GEARS are subjective, being based on questionnaires ,5. In adCurrent methods of evaluating surgical skills during robotic surgery include the use of the da Vinci Skills Simulator (dVSS). The simulator presents various tasks to surgeons, such as ring and rail, in virtual robotic surgery environments and evaluates surgeons’ proficiencies based on its inbuilt evaluation criteria ,9. HowevSurgical skills have been determined by quantitatively measuring SI movements in actual surgical environments ,11. AlthImage-based methods can directly recognize the SIs in robotic surgery views. Moreover, image-based methods have other advantages because they do not require external equipment and can therefore be applied to surgical robots made by other manufacturers and to laparoscopic surgery. Traditional image processing approaches, however, are limited in detecting SI tips in complex robotic surgery views ,16. A deThe present study proposes a system that quantitatively assesses the surgical skills of a surgeon during robotic surgery by visual tracking of SIs using a deep learning method. The algorithm consists of two frameworks: instance segmentation for occlusion and tracking for maintaining types of SIs. This method was able to stably track the tip positions of SIs in patients with thyroid cancer undergoing robotic thyroid surgery with a bilateral axillo-breast approach (BABA) and in a BABA training model ,32. The A deep learning-based tracking algorithm of multiple SIs was developed to assess surgical skills in robotic surgery. The SI tracking algorithm is a pipeline of deep learning-based algorithms involving an instance segmentation framework and a tracking framework, along with image processing methods to detect the tips of SIs and to recognize indicators a. The ouThroughout the process of SI tracking, surgical skills were evaluated based on the acquired trajectory. Motion metrics  are quanThe BABA to robotic thyroid surgery is a minimally invasive method used worldwide ,35,36. FSeveral types of daVinci surgical robots were used , along with four types of SIs: bipolar, forceps, harmonic, and cautery hook. The developed algorithm was applied to two types of surgical image. The first was a surgical image of a BABA training model developed for thyroid surgery training ,32; subjThese two surgical images were used as training and test datasets. Training datasets were used for two kinds of deep learning-based frameworks. The dataset used to train the instance segmentation framework consisted of 84 frames from the BABA training model, 454 frames from patients, and 1766 frames from an open database . The datTest datasets consisted of 14 videos from the BABA training model and 40 videos from patients. Test video lengths ranged from 1121 to 40,621 frames, with a 23 fps. A detailed description of the test datasets is given in The instance segmentation framework, Mask R-CNN , consistThe positions of the SIs determined by the instance segmentation framework, the bounding boxes, must be assigned to the next frame of the same SIs. The tracking framework was designed to associate the identification of an SI to the next identification of that SI and maintain these associations over frames. The framework consisted of a cascade structure, a tracker, and a re-identification method.The tracker used in this study was a deep simple online and realtime tracker (deep SORT) , which aRe-identification (ReID) was applied to the result of Deep SORT because the existing identity of an SI can change when an SI moves out of view or when SIs cross in close proximity. In addition, the maximum number of SIs that appear on the robot surgery view was set at three, thus limiting the number of SIs.In the proposed ReID method, offline and online learning algorithms were applied sequentially. ST-ReID  is an ofThe arm indicators that could have affected the trajectory consisted of instrument arm status and camera arm indicators. The instrument arm status indicator on both sides of the screen indicated the SI currently in use. Therefore, these indicators reflected the movement of two or fewer SIs actually being used rather than the movement of the SI that appeared in the robotic surgery view. Recognition of the camera arm indicator confirmed the movement of the laparoscope during the operation. The appearance of the camera arm indicator on the robotic surgery view indicated movement of the laparoscope; however, movement of the screen may have incorrectly indicated movement of the SI. Although varying according to the type of surgical robot, the positions of both indicators were fixed on the view and appeared when an event occurred. To recognize the arm-indicator, template matching  was applTwo surgeons reviewed recorded videos of surgeons being trained using the BABA training model and of surgeons performing thyroid surgery on patients with thyroid cancer ,49. PartBased on the acquired trajectories, motion metrics, mainly related movements of SIs, were used to develop a surgical skill prediction model. Seven metrics associated with motion were included ,33,51: tThe surgical skill prediction models were developed using these nine calculated motion metrics as well as ground truth from OSATS and GEARS scores. The total number of tested videos was 54, with these datasets divided into 40 training and 12 test sets. Surgical skill prediction models were developed using machine learning methods, a linear classifier, a support vector machine (SVM), and random forest, with the model predicting three groups consisting of novice, skilled, and expert surgeons.In the training process, five-fold cross validation was applied, and the class imbalance issue was solved by applying the synthetic minority over-sampling technique (SMOTE) . SVM useCumulative matching characteristics (CMC) , shown iThe unit of distance that each SI moved was converted from pixels to millimeters because the width and the height of each image were dependent on the type of da Vinci robot used. Thus, depending on the degree of magnification of the laparoscope, errors may have occurred when calculating the movement of the actual SIs. For unit conversion, the thickness of the surgical instrument was measured in advance (8 mm), and the thickness shown on the first screen was measured in pixels units. Therefore, through proportional relationships, the motion of each SI in pixels was converted to millimeters in all surgical images .This system also measured whether the end position of the SI predicted by the algorithm was within 1, 2, and 5 mm of the end position of the SI on the screen . True pox-axis) and 0.91 (y-axis) in the BABA training model and 0.89 (x-axis) and 0.86 (y-axis) in thyroid cancer patients  of 0.711 and 0.74, respectively. Each motion metric item was normalized to the operation time and then to the metric.The performances of a linear classifier, SVM, and random forest surgical skill prediction models were compared. The models were optimized by hyperparameter tuning, with the random forest showing the highest accuracy. The random forest model had the highest performance and accuracy of 83% with OSATS and 83% with GEARS. To the best of our knowledge, this is the first deep learning-based visual tracking algorithm developed for a quantitative surgical skill assessment system. Conventional methods of evaluating surgical skills such as OSATS  and GEARPreviously described SI tracking algorithms are limited by occlusion among different SIs and by multiple SIs being recognized as a single SI ,28. SI iThe SI tracking algorithm was developed based on robotic surgical environments. In this study, four types of SIs were used, but if only the shaft of the SI appeared on the surgical screen, it could not be discerned, thus we approached the binary classification problem that distinguishes the SI (foreground) from the background. In addition, SI may be difficult to discern when it is covered by tissues or when only a part is visible during surgery . TherefoOur findings also confirmed that the four most important metrics in OSATS and GEARS were the same: economy of motion, instruments out of view, average speed, and instrument switch. The video datasets used in this study were video segments from the beginning of surgery to the locating of the RLN during thyroid surgery. Therefore, the relative importance of the motion metrics may differ depending on surgical sites and tasks.This study had several limitations. First, the proposed system was applied to video sets of training model and patients with thyroid cancer who underwent BABA surgery. It is necessary to verify the effectiveness of the proposed system using various surgical methods and surgical areas.Second, we could not directly compare the performances of the kinematics and proposed image-based methods because access to the da Vinci Research Interface is limited, allowing most researchers only to obtain kinematic raw data . HoweverThe performance of the current method with the previous visual method could not be directly compared because no similar study detected and tracked the tip coordinates of the SIs. However, studies have used deep learning-based detection methods to determine the bounding boxes of the SIs and to display the trajectory of the center points of these boxes ,20. NeveThird, because SIs are detected on two-dimensional views, errors may occur due to the absence of depth information. Errors of magnification were therefore minimized by measuring the width of SIs on the view and converting pixels to millimeters. However, methods are needed to utilize three-dimensional information based on stereoscopic matching of left and right images during robotic surgery ,59.Fourth, because the proposed method is a combination of several algorithms, longer videos can result in the accumulation of additional errors, degrading the performance of the system. Thus, in particular, it is necessary to train additional negative examples with the instance segmentation framework, which is the beginning of the pipeline. For example, gauze or tubes on the robotic surgery view can be recognized as SIs .Finally, because errors from re-identification in the tracking framework could critically affect the ability to determine correct trajectories, accurate assessment of surgical skills requires manual correction of errors .The system proposed in this study can track surgical SIs automatically using deep learning-based visual tracking methods and enable the quantitative assessment of surgical skills. This proposed system may effectively educate students who require training in robotic surgery and will improve the surgical skills of surgeons accustomed to performing robotic surgery.


Overtraining syndrome (OTS), a common dysfunction among elite athletes, causes decreased performance and fatigue and has no standardized diagnostic criteria. The Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study identified more than 45 potential biomarkers of OTS. In the present study, we hypothesized that combinations of these biomarkers could be an accurate diagnostic tool for OTS.  We selected parameters with largest difference and fewest overlapping results compared to healthy athletes and highest feasibility and reproducibility. Among the multiple combinations attempted, we chose those that did not show overlapping results, according to the objective.  We included 11 clinical parameters, 4 basal hormones, and 5 hormonal responses in Insulin Tolerance Test (ITT). The three selected diagnostic tools were the (i) EROS-CLINICAL, with only clinical parameters, which was suitable as an initial assessment for athletes suspected of OTS; (ii) EROS-SIMPLIFIED, with clinical parameters and basal hormones, when the EROS-CLINICAL was inconclusive; and (iii) EROS-COMPLETE, with basal and hormonal responses to stimulation tests, which was valuable for population-based screening, research purposes, and unusual presentations of OTS.  We identified innovative tools with 100% accuracy for the diagnosis of OTS, without the need to exclude confounding disorders. A persistent imbalance between training and recovery among athletes, which may lead to decreased performance and fatigue, has been termed overtraining syndrome (OTS). Chronic insufficient energy availability and the depletion of repair mechanisms lead to multiple dysfunctional adaptations in hormonal, immune, inflammatory, and metabolic pathways and ultimately to the clinical manifestations of OTS –5. IndeeOTS substates include functional overreaching (FOR), when performance decreases for a few days, with further improvement after recovery ; nonfunc21. Therefore, the diagnostic assessment of OTS remains disputable, based on a flowchart with clinical and biochemical exclusion criteria  and muscle mass [%]), comprising nine clinical parameters. Also included were four basal hormones  and five hormonal responses to an insulin tolerance test (ITT) , comprising nine biochemical parameters. The ITT is the gold standard for evaluating the responsiveness of three hypothalamic–pituitary axes  and is independent of physical performance, which eliminates underperformance bias found in OTS-affected athletes when compared to healthy athletes. For the EROS-RISK score, we also included self-reports of sleep quality , the total POMS score, and the POMS depression and confusion subscales.Using the 18 selected parameters, we tested 262,125 combinations to diagnose OTS, including 120 combinations with only clinical parameters (expect body composition), 2,036 with clinical and basal biochemical parameters (without stimulated hormones and body composition), and 259,969 with clinical, biochemical, and at least one stimulated hormone and/or body composition parameter. Of the 262,125 combinations, 13,648 distinguished all OTS-affected athletes from healthy athletes, including eight clinical-only parameters, 1,024 combined clinical and basal biochemical parameters, and 12,616 combined clinical, basal biochemical, and stimulated hormone parameters, which showed that OTS can be diagnosed using different combinations of biomarkers of OTS. The number of attempted combinations of parameters and the selection process for each score are detailed in We proposed three different diagnostic tools, one from each cluster of combinations. Drawing from combinations with only clinical parameters (the EROS-CLINICAL combinations), we selected the combination with all nine clinical parameters for the present study because it detected the largest difference  between the scores of the OTS-affected athletes and healthy athletes. Furthermore, these markers were simple to test and did not require the use of any device or technology. The proposed diagnostic tool is presented in Among the combinations that included the clinical and basal biochemical parameters, the one we selected as the EROS-SIMPLIFIED diagnostic tool included all nine clinical parameters and four basal biochemical parameters, for a total of 13 parameters, which yielded a 6-point (out of 13 points) difference between the scores of the OTS-affected and healthy athletes (with one outlier). The parameters included in this combination were also simple to test, as no bioelectrical impedance device or any other device was needed. The set of parameters for the EROS-SIMPLIFIED, a diagnostic tool, are shown in The EROS-COMPLETE set of parameters that combined clinical, basal, and stimulated hormones included 11 clinical parameters, of which nine were clinical parameters of the EROS-CLINICAL tool, plus two body-composition parameters and nine biochemical parameters, including four basal and five hormonal responses to an ITT, for a total of 20 parameters, as presented in The EROS-RISK, a diagnostic instrument, which is intended to address the prevention of OTS in high-risk athletes, included four of the five major risk factors of OTS, which were identified in the EROS study: carbohydrate, protein, and caloric intake—each one independent of the other, and inadequate sleep quality, and total and subscales of the POMS questionnaire, since the active self-perception of feelings and fatigue are underestimated by many athletes, as they tend to avoid perceptions of potential barriers to their trainings –14. AlthIn contrast to the current shortage of diagnostic tools for OTS, different diagnostic tools were proposed in the present study, using combinations of highly accurate clinical and/or biochemical parameters. Some of the selected combinations of biomarkers identified for OTS and all three proposed diagnostic tools were found to be effective for diagnosing OTS with 100% accuracy in this sample of athletes. The diagnosis of OTS using these tools did not require the exclusion of confounding conditions [Although single markers were unable to distinguish OTS-affected athletes from healthy athletes, because of the high heterogeneity of OTS among the individual athletes, the relatively large number of true and naturally occurring OTS-affected athletes (the largest number among the studies on OTS –4) and tsine-quo-non criteria of OTS, they might appear only in the more severe stages of OTS, and progress unnoticed without proactive surveillance of athletes. At this stage, recovery is challenging and not always complete. Therefore, the identification of OTS at earlier stages is highly desirable, as recovery should be easier, faster, and less likely to compromise a training program. At this point, the presentation of OTS may be considered “unusual” because of the absence of a prolonged decline in performance, which is more likely to be underreported at this stage.With respect to the two additional criteria included in all the proposed tools, although decreased performance and sense of increased effort to achieve the same level of training were the initial hallmarks and The diagnostic tools proposed in the present study made the possibility of diagnosing OTS feasible, as the presence of an unexplained decline in performance and increased sense of effort were optional and would strengthen the diagnosis of OTS but were not required. However, some authors would consider the existence of OTS impossible without a decline in performance because fatigue and underperformance would be likely to appear in milder forms of OTS, including functional and nonfunctional overreaching, while a complete recovery would avoid the development of OTS. However, the false perception of full recovery from these earlier stages, which is common because of the high motivation to return to the training sessions, could hide an underlying process that could ultimately lead to OTS. In addition, the belief that overreaching happens in the very early stage of OTS might not be true, as minor symptoms in the early stage are usually ignored by athletes. Finally, although many authors consider overreaching and overtraining as different stages of the same process, others claim that the underlying mechanisms between these states differ, as OTS tends to result from a more chronic, deeper, and central process, while overreaching tends to be characterized as an acute physical process. Therefore, our proposed diagnostic tools could be helpful to identify athletes prior to clinical signs of OTS with true underperformance, regardless of previous episodes of overreaching.The EROS-CLINICAL is a diagnostic tool based on a combination of nine clinical parameters to yield a clinical score for athletes suspected of OTS, without the need to conduct biochemical tests. Our choice to exclude body fat and muscle mass as clinical parameters did not lead to any loss of information or reduction in the quality of the diagnostic assessment because not all facilities have available devices to analyze body composition, thereby precluding its clinical application, which is contrary to the main purpose of this diagnostic tool.When the EROS-CLINICAL was inconclusive, the EROS-SIMPLIFIED with its combination of four additional basal hormones was successful in identifying most of the affected athletes not identified by the EROS-CLINICAL. Moreover, although the EROS-SIMPLIFIED tool includes biochemical parameters, it is simple to use, as functional tests are unnecessary.The EROS-COMPLETE is a more comprehensive diagnostic tool encompassing the combination of all 18 selected parameters plus two inclusion criteria for OTS. It is valuable for (1) population-based screenings, irrespective of the presence of risks or suspected features of OTS, as OTS presentations are highly diverse; (2) research purposes, as it includes current biomarkers of OTS and can be used for comparisons with potential markers or assessment methods to identify new tools or improve our understanding of OTS; (3) unusual presentations of OTS that might remain undiagnosed if the guidelines with the diagnostic flowchart are used, as it provides a broad variety of markers, covering the full spectrum of OTS presentations; (4) exceptions, for an individual-based diagnostic approach, when the EROS-CLINICAL and EROS-SIMPLIFIED fail to diagnose OTS; and (5) understanding the unique underlying pathophysiology of each OTS-affected athlete.In the EROS study, triggers of OTS other than excessive training were identified –8. ThereUnfortunately, no single risk factor was able to identify all athletes at high risk. However, a combination of some modifiable risk factors invariably led to OTS when analyzed collectively. Given the lack of other tools to detect athletes at high risk for OTS, the EROS-RISK can be a helpful tool to identify these athletes and prevent the occurrence of OTS. At the prevention level, OTS can be addressed more effectively than it can at the treatment level. The POMS subscales may predict future occurrences of OTS, and for this reason, all of the POMS subscales are present in the EROS-RISK tool.Despite their 100% accuracy for the diagnosis of OTS, further tests of the proposed tools with larger populations are needed. The results of other studies may be inconclusive, as clinical presentations of OTS vary widely and the markers identified in our sample of athletes might not always be present. However, when the diagnosis of OTS is inconclusive using the EROS-CLINICAL, two additional diagnostic tools (the EROS-SIMPLIFIED and EROS-COMPLETE) can offer answers.Despite the potential use of the diagnostic assessments recommended in the present study, they should be reproduced by further studies to strengthen and amend them as needed. They should not be considered as the gold standard of diagnostic tools for OTS at present, but rather, as an additional instrument.Only male athletes that practiced both endurance and strength sports were evaluated. Therefore, whether these markers are present in other populations is unknown and should be addressed in future studies.To the best of our knowledge, these are the first diagnostic tools for OTS to achieve 100% accuracy in distinguishing OTS-affected athletes from healthy athletes without the need to exclude confounding disorders, or the need to include the presence of decreased performance. Furthermore, the tools are easy to use and are not time-consuming. The diagnostic tools proposed in the present study were made possible through the selection of parameters after more than 260,000 combination attempts. This is also the first study to suggest a preventive approach to OTS through an active search of forthcoming OTS in athletes at high risk, which has not been addressed by the current guidelines for OTS [Although the proposed tools should not be the initial assessment for larger populations of athletes suspected of having OTS until they are reproduced and validated by further studies, they can be used in exceptional situations when the guidelines' flowchart is inconclusive or misleading.The most important message of the present study is that while single markers did not diagnose OTS, combinations of OTS markers were found to be a feasible way to diagnose OTS accurately, in contrast to previous diagnostic tools. Further studies are needed to validate our findings and improve the tools' scoring systems by testing combinations of markers. This diagnostic approach corresponds to the major feature of OTS: its unique combination of alterations in each affected athlete.In the present study, innovative tools were proposed for the diagnosis and prevention of OTS that yielded 100% accuracy in distinguishing overtraining syndrome from healthy states. This was done without the need to include the presence of decreased performance or exclude confounding disorders in this sample of athletes. These diagnostic approaches should be reproduced and validated as optional assessment tools for the diagnosis of OTS. Although OTS is highly heterogeneous, a combination of markers rather than a single marker appears to be more appropriate for the diagnosis of OTS, regardless of the proposed method.All the research, including the participants enrolled and collection of the data, was conducted in Brasilia, Brazil, while the analysis of the results and development of the present manuscript were performed in São Paulo, Brazil.


Diabetic retinopathy (DR) is a common complication of diabetes mellitus that disrupts the retinal microvasculature and is a leading cause of vision loss globally. Recently, optical coherence tomography angiography (OCTA) has been developed to image the retinal microvasculature, by generating 3-dimensional images based on the motion contrast of circulating blood cells. OCTA offers numerous benefits over traditional fluorescein angiography in visualizing the retinal vasculature in that it is non-invasive and safer; while its depth-resolved ability makes it possible to visualize the finer capillaries of the retinal capillary plexuses and choriocapillaris. High-quality OCTA images have also enabled the visualization of features associated with DR, including microaneurysms and neovascularization and the quantification of alterations in retinal capillary and choriocapillaris, thereby suggesting a promising role for OCTA as an objective technology for accurate DR classification. Of interest is the potential of OCTA to examine the effect of DR on individual retinal layers, and to detect DR even before it is clinically detectable on fundus examination. We will focus the review on the clinical applicability of OCTA derived quantitative metrics that appear to be clinically relevant to the diagnosis, classification, and management of patients with diabetes or DR. Future studies with longitudinal design of multiethnic multicenter populations, as well as the inclusion of pertinent systemic information that may affect vascular changes, will improve our understanding on the benefit of OCTA biomarkers in the detection and progression of DR. Diabetic retinopathy (DR) is an important rising cause of blindness globally . The iniDiabetes mellitus, more simply referred to as diabetes, is a group of chronic, progressive diseases characterized by high levels of blood glucose. Around the world, an estimated 463 million adults  are living with diabetes in 2019, compared to 151 million in 2000 [When diabetes is poorly controlled, it can damage the vasculature, often separated into either damage to the large blood vessels of the body , or small vascular damage , which are the major causes of morbidity and mortality in diabetes .Diabetic retinopathy is recognized as an important cause of blindness , that plApproximately a third of the diabetes population has some clinically visible DR, while a further one-third of those will develop the vision-threatening state of the disease, characterized by proliferative DR or diabetic macular edema . HoweverThe pathophysiology of DR is complex and multifactorial ,10. ChroFrom a clinical perspective, DR can be broadly classified into two stages: non-proliferative and proliferative. In the early non-proliferative stage, the loss of pericytes and endothelial dysfunction results in the weakening in the wall of retinal capillaries, which are seen as microaneurysms and develop into exudative changes (leakage of lipoproteins (hard exudates) and blood (blot hemorrhages)) from the damaged vasculature ,12. LocaThe key to reduce diabetes-related blindness is early detection, considering the availability of numerous treatment options, i.e., laser, anti-VEGF agents, and steroids . The diaRetinal vascular changes are well-documented in diabetes and DR. Damage to the blood-retinal barrier breakdown represents the first consequence of DR ,19,20. AThe breakdown of the blood retinal barrier is associated with vascular basement membrane thickening due to enhanced production of vascular basement-membrane components . This leWhile the initial triggers are directly a result of the metabolic dysregulation inherent to hyperglycemia, the subsequent progression of DR is related to the neuronal exposure to toxins crossing the damaged blood-retinal barrier and ischemic damage as a result of impaired blood supply due to the vascular occlusion . RetinalGiven that pericytes and endothelial cells are key players in regulating vascular tone, it does not come as a surprise that diabetes and DR are associated with vascular dysregulation that has been confirmed in a wide variety of clinical and experimental studies. Neurovascular coupling or functional hyperemia, which describes the adaptation of local perfusion to local changes in neuronal activity ,27,28 isWhile the signs of DR are often documented as vascular changes, studies have also shown early neural damage in diabetes . Some inImaging modalities, such as fluorescein angiography, B-scan ultrasonography, and OCT, can be incorporated with exam techniques, depending on the manifestation of DR . FluoresOCT is akin to performing an optical biopsy of the retina, where different layers of the retina can be visualized . OCT worOCT can provide high-resolution, 3-dimensional topographic maps of the retina non-invasively. Given its excellent reproducibility, OCT measurements of retinal thickness are used to quantitatively and qualitatively monitor macular edema to guide the therapeutic intervention of DR . FurtherSignificant improvements in the sensitivity and speed of the OCT imaging platform have led to the development of OCTA, which is capable of providing depth-resolved images of the microvasculature in the retina and choroid at a depth and clarity, coming close to that of histology . OCTA caOCTA also uses the method of low coherence interferometry, as seen in OCT to gain depth information . The ideFluorescein angiography requires intravenous dye injection, which can lead to adverse reactions . The risFluorescein angiography is not able to provide images of the distinct layers of blood vessels, because it is limited to two dimensions and does not provide depth resolution. In contrast, OCTA has the capability of visualizing the distinct retinal vascular layers with high axial resolution . HoweverPubMed literature search was utilized as a source of literature between 1 January 2014 and 31 March 2020. English language articles were retrieved using the keyword search terms, such as optical coherence tomography angiography, diabetes, diabetic retinopathy and diabetic macular edema. The following types of studies were included in the review: cohort, case-control, cross-sectional or intervention trials. We excluded case reports, retrospective, review articles and animal studies. The electronic search yielded a total of 326 citations. After screening, 196 relevant articles were studied, and key findings were extracted.Many of the common vascular features of DR, as seen on fluorescein angiography, including microaneurysms, neovascularization, and retinal nonperfusion regions, have been comprehensively studied and described using OCTA  Figure .Microaneurysms, which are the first clinically detectable sign of DR, are seen as homogeneous hyperfluorescent punctate spots in fluorescein angiography . In OCTAOn fluorescein angiography, retinal neovascularization is detected on identifying characteristic vessels with excessive leakage in the later phase. However, excessive dye leakage can obscure the vascular details of these abnormal vessels. In OCTA, the contrast depends on erythrocyte movement and the images are acquired over a short time, hence, dye leakages have no impact on the quality of images. As such, the vascular characteristic of neovascularization is displayed with greater clarity in OCTA compared to fluorescein angiography.Since OCTA can provide information on the various retinal layers, it can help to distinguish between retinal neovascularization, which develops anterior to the retinal vessels and above the inner limiting membrane, and intraretinal microvascular abnormalities, which occur in the same plane as the retinal blood vessels ,82. De CWhile OCTA is unable to provide information on vascular leakage, morphologic evaluation of neovascularization using OCTA may be able to estimate the activity status of the neovascularization. Ishibazawa and co-workers reported that exuberant vascular proliferation (irregular proliferation of fine new vessels) in OCTA should be considered as a sign of active neovascularization . Hence, With fluorescein angiography, nonperfusion regions are seen as dark areas, with loss of capillaries surrounded by larger retinal vessels. OCTA can visualize these corresponding areas of nonperfusion within the superficial vascular plexus and the deep vascular plexus ,81,85. PWidefield fluorescein angiography revealed that peripheral retinal nonperfusion is a common finding in eyes with DR . These pIn the retina, the center of the macula is generally capillary-free; this region is named as the foveal avascular zone (FAZ) and is encircled by a foveal capillaries ring. Alterations to the perfusion of the foveal capillaries greatly affect the patient’s vision . With flThe shape and size of FAZ are found to be comparable between OCTA and fluorescein angiography . FAZ met2Several methods to quantify OCTA vascular density outcomes have included perfusion density  or nonflow area , have agreed closely with the grading of DR based on clinical features and worsening of visual acuity ,109,110.Of note, vessel density at the deep capillary plexus showed the strongest correlation with DR severity ,118 and Researchers have drawn mixed conclusions in diabetic eyes without retinopathy when using the OCTA-derived measurements. When using FAZ metrics, some reported a small but significant enlargement of the FAZ in diabetic eyes without retinopathy compared to healthy eyes ,123,124.Other OCTA metrics, such as areas of retinal nonperfusion, drew conflicting results as well. Nesper et al. found larger areas of retinal nonperfusion in eyes of patients with diabetes without DR than in healthy eyes . These rEven though DR is generally considered to be a disease of the retinal vasculature, histopathological and dye-based angiographic studies have shown choroidal changes to be associated with diabetes ,140,141.Although the concept of diabetic choroidopathy is well-established, the role of the choriocapillaris in DR remains poorly understood . This maStudies have reported vascular abnormalities in the choriocapillaris in diabetic eyes compared to healthy eyes ,146. RegOnly a few studies have used OCTA to investigate the blood flow of the optic nerve head in diabetics ,152,153.In studying the vascular changes of DR with OCTA, it is essential to consider the effects of confounding factors. OCTA metrics can be confounded by the effects of axial length and individuals’ systemic vascular risks. Axial length can affect the lateral magnification of OCTA images and consequently can affect the accuracy of quantitative OCTA metrics ,157. ThiThe quantification of OCTA metrics can also be confounded by interindividual variation, age and systemic vascular risks. For example, OCTA metrics such as retinal capillary density, choriocapillaris flow impairment, FAZ dimensions are known to vary even in normal persons ,163,164.Furthermore, patients’ systemic disease status and medication use may cause a decrease in blood flow and alter the entire OCTA image. Some early studies have reported that systemic blood pressure levels ,169, andThe clinical applicability of OCTA is limited by several factors. Since OCTA is based on motion detection, it is particularly sensitive to the patient’s eye movement . The neeThe limited field of view with current OCTA results is another limitation of OCTA in the detection of peripheral vascular changes, such as peripheral retinal nonperfusion and neovascularization. Current OCTA can image areas of 12×12 and 15×9, however these remain far from comparable to ultra-widefield angiography. To increase the field of view of OCTA, one can montage multiple images together . In addiAnother limitation of OCTA is in its inability to quantify blood flow. Current OCTA has a sensitivity threshold and therefore it will detect flow only above a minimum threshold, otherwise known as the slowest detectable flow . MoreoveArtefacts can affect the accurate quantification of vascular changes. As seen from The accuracy of segmentation algorithms in the identification of retinal layers, especially in eyes with pathological abnormalities, imposes the limitation in OCTA data interpretation. The occurrence of segmentation error was 11% in the non-proliferative DR category and increased to 50% in the proliferative DR category . FurtherAnother limitation of existing OCTA devices is the derivation of measures related to the deep capillary plexus. Studies have suggested that impairment in the deep capillary plexus may play a critical role in vision loss in DR ,118,119.Different quantitative OCTA metrics have been introduced, such as vessel density, area of nonperfusion and choriocapillaris flow voids. However, wide discordance exists in the way these OCTA indices are calculated. A detailed overview of how different quantitative measures are derived from OCTA is beyond the scope of this review, but the reader is referred to a recent review article . BrieflyThe majority of the studies mentioned here are cross-sectional in nature, except for one study, where Sun et al. demonstrated the predictive value of OCTA measures for progression of DR . MoreoveThe future of OCTA technology for the imaging of DR looks promising. The qualitative visualization of vascular changes in varying stages of DR has improved our understanding of the pathophysiology of DR. Quantitative OCTA measurements can objectively grade progressive vascular changes at the retinal, choroidal and optic nerve, highlighting its potential to be used as an objective tool for monitoring of DR progression. Of interest is the capability of OCTA to detect DR even before it is clinically detectable, highlighting its possible use as an early screening tool for DR. Novel widefield OCTA technology can provide a wider view of the peripheral retina and can improve the detection of peripheral retinal nonperfusion and neovascularization.


The increased recognition of the high prevalence and important burden of cancer pain and the documentation of a large proportion of patients receiving inadequate analgesic treatment should have reinforced the need for evidence-based recommendations. The World health Organization (WHO) guidelines on cancer pain management—or palliative care—are traditionally based on a sequential, three-step, analgesic ladder according to pain intensity: nonopioids  to mild pain in step I; weak opioids  to mild-moderate pain in step II; and strong opioids to moderate-severe pain in step. III. Despite the widespread use of this ladder, unrelieved pain continues to be a substantial concern in one third of patients with either solid or hematologic malignancies. The sequential WHO analgesic ladder, and in particular, the usefulness of step II opioids have been questioned but there are no universally used guidelines for the treatment of pain in patients with advanced cancer and not all guideline recommendations are evidence-based. The American Society of Clinical Oncology and the European Society of Medical Oncology have recommended the implementation of early palliative care (EPC), which is a novel model of care, consisting of delivering dedicated palliative service concurrent with active treatment as early as possible in the cancer disease trajectory. Improvement in cancer pain management is one of the several important positive effects following EPC interventions. Independent well-designed research studies on pharmacological interventions on cancer pain, especially in the EPC setting are warranted and may contribute to spur research initiatives to investigate the poorly addressed issues of pain management in non cancer patients. The percentage of responder patients was higher in the low-dose morphine group, as early as at 1 week, and clinically meaningful (≥30%) and highly meaningful (≥50%) pain reduction from baseline was significantly higher in the low-dose morphine group (p < 0.001). A change in the assigned treatment occurred more frequently in the weak-opioid group, because of inadequate analgesia. Also, the general condition of patients, based on the Edmonton Symptom Assessment System overall symptom score, was better in the morphine group and adverse effects were similar in both groups [Approximately one third of cancer patients still do not receive pain medication proportional to their pain intensity . A recenh groups . Our stuh groups . Unfortuh groups . Despiteh groups . Consisth groups , which hh groups  indirecth groups , with a h groups . Similarh groups .In conclusion, based on a revision of several guidelines, and especially the most recent ESMO, NCCN, and WHO guidelines ,17,18, sOne of the possible reasons for the successful completion of our RCT study, in due time , may resWe think that the implementation and dissemination of evidence-based knowledge on the use of drugs in cancer pain management, especially in the favorable and clinically relevant context of EPC interventions, may be a pragmatic and effective way to counteract the opioid misuse and abuse, in the oncology and hematology wards and among patients and their caregivers. The further dissemination of scientific results, leading to a robust knowledge on cancer pain management, may, in turn, spur a broad scientific interest and multiple novel research initiatives and well-designed studies on the management of pain in non-cancer patients and contribute to generate new insights on such themes either in the scientific community or in the clinical care wards or in the general population.


Plant natural products are important secondary metabolites with several special properties and pharmacological activities, which are widely used in pharmaceutical, food, perfume, cosmetic, and other fields. However, the production of these compounds mainly relies on phytoextraction from natural plants. Because of the low contents in plants, phytoextraction has disadvantages of low production efficiency and severe environmental and ecological problems, restricting its wide applications. Therefore, microbial cell factory, especially yeast cell factory, has become an alternative technology platform for heterologous synthesis of plant natural products. Many approaches and strategies have been developed to construct and engineer the yeast cells for efficient production of plant natural products. Meanwhile, metabolic mass transfer has been proven an important factor to improve the heterologous production. Mass transfer across plasma membrane (trans-plasma membrane mass transfer) and mass transfer within the cell (intracellular mass transfer) are two major forms of metabolic mass transfer in yeast, which can be modified and optimized to improve the production efficiency, reduce the consumption of intermediate, and eliminate the feedback inhibition. This review summarized different strategies of refining metabolic mass transfer process to enhance the production efficiency of yeast cell factory , providi Plant natural products are secondary metabolites with complex molecular structures and inherent bioactivities , includiSaccharomyces cerevisiae, is one of the most favorite hosts for its inherent characteristics such as abundant precursors and complete endomembrane system , stilbene synthase (STS), and tyrosine ammonia lyase (TAL) were necessary enzymes in the polyketide resveratrol biosynthetic pathway in yeast. When the 4CL and STS were expressed in a fusion protein, the yield of resveratrol was increased by 15-fold . The titrevisiae . By fusirevisiae . To imprrevisiae . Moreoverevisiae . The fusS. cerevisiae, and the yield of resveratrol was increased by five times  transporter of maltose can enhance the trans-plasma membrane of glucose and maltose. When it was expressed in engineered yeast, the production of ivermectin was improved by obtaining more precursors . Transpoed yeast . In addied yeast . HoweverEscherichia coli–S. cerevisiae coculture system. The precursors can be synthesized in E. coli and secreted to the medium efficiently. Meanwhile, the secreted precursors are ingested by S. cerevisiae, which can provide membrane system and suitable environment for expressing cytochrome P450s  to produce the oxygenated taxane (Because of the lack of studies on transporters of plant natural products, some non-specific transport methods have been proposed, including the usage of vesicular, endocytosis, and exocytosis. Vesicle could be used to store tetraterpenes and involves their trans-plasma membrane transport in prokaryote. Regarding the biosynthesis of plant natural products in yeast, vesicle has been proven to be useful as a functional compartment and storage pool. For example, to identify the functional enzyme and improve the titer of tropane alkaloids, more than 20 proteins were integrated into yeast. Among them, the acyltransferase was located to the vacuole to improve the production of products in yeast . These rme P450s . For exad taxane . The opid taxane . Compared taxane . BasicalOver the past 20 years, the rapid development of synthetic biology and system biology has provided a versatile technical platform for heterologous synthesis of plant natural products. Yeast is turned out to be an attractive host strain. Although various feasible metabolic engineering tools and useful strategies have been developed in yeast to improve the production of plant natural products, there are still many obstacles in the large-scale production. One notable obstacle is the unbalance of metabolic mass transfer process. In this regard, the regulation of metabolic mass transfer has attracted many interests in metabolic engineering applications. For example, regulation and optimization of intracellular and trans-plasma membrane mass transfer can enhance the transfer efficiency, eliminate the feedback inhibition, and reduce the cytotoxicity of products. However, most studies on the optimization of mass transfer process were under specific conditions and lacked of systematization and universality. More importantly, there are seldom successful studies on the mining of direct transporters for plant natural products, which is the main bottleneck for the export of plant natural products in yeast. Thanks to the repaid progress in synthetic biotechnology and sequencing technology, the candidate transporters of plant natural products can be mined by the omics data, bioinformatics analysis and machine learning. Another limitation in the exploring of mass transfer strategies is the lack of high-throughput screening method. As a result, the mining of transporter as well as the integrated platform for high-throughput screening would be future research directions.In summary, the study of mass transfer has achieved initial success. With the comprehensive progress of the metabolic engineering as well as the genome editing method, the challenges in this field for the synthesis of plant natural products will be solved in the near future. Meanwhile, the mechanisms of metabolic mass transfer process will be revealed and may have a far-reaching significance for constructing a comprehensive and efficient yeast cell factory.All authors contributed to the conception and design of the study. HX and WS participated in searching and analyzing literature for this review and wrote the manuscript. YW and CL edited and corrected the manuscript. All authors 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.