Opioids comprise an important group of drugs used in cancer pain pharmacotherapy. In recent years, more and more studies have emerged indicating the potentially immunosuppressive effects of opioid analgesics and their serious consequences, including the risk of cancer progression. The identification of these risks has prompted a search for other effective, and most importantly, safer methods of perioperative analgesic management. Regional analgesia techniques, which allow for a significant reduction in opioid dosing and thus diminish the risk of immunosuppression associated with these drugs, seem to offer substantial hope in this respect. A number of studies available in the literature assess the effects of regional analgesia techniques on cancer progression; however, it is often difficult to interpret their results owing to several perioperative factors  which are also attributed immunosuppressive effects and tend to be implicated in increased risk of cancer progression. Further research is needed to verify the available data on both the potential adverse effects of opioids and the possible protective effects of regional analgesia techniques on cancer patients. Cancer pain poses a serious clinical and epidemiological problem. It may be the first symptom of the disease, occurs during its diagnosis and treatment, and accompanies patients at the advanced stages of the disease. It is estimated that, regardless of the stage, at least one-half of cancer patients experience pain, but their proportion is significantly higher as the disease progresses. The World Health Organisation (WHO) reports that over 5.5 million patients worldwide do not receive or receive inadequate treatment for cancer-related pain. The above data, due to the lack of worldwide registers, are based on epidemiological estimates . A meta-Apart from the unimaginable suffering and the humanitarian aspect of the problem, the consequences of insufficiently treated pain, both acute and chronic, can also be disastrous from a purely medical point of view. This is particularly important in cancer patients as more and more data indicate a correlation between severe pain and increased risk of cancer progression and a shorter time to the appearance of metastatic lesions . ResearcExperimental and clinical studies demonstrate the importance of effective pain management also in terms of cancer progression. Page et al. found a longer time interval to lung metastasis in a group of experimental animals  with effective analgesia  compared with a group of animals not subject to analgesic treatment . LillemoOpioids are being used by the anaesthesiologists not only to treat acute pain in the perioperative period but also to control chronic cancer pain. Studies conducted over the recent years have given results indicating the potentially immunosuppressive effects of opioids and their serious consequences, including the risk of cancer progression. This is a very important and complex problem both in perioperative period and in chronic pain treatment course. Morphine has immunosuppressant properties which can promote cancer, but on the other hand suppressing of pain alleviates the surgical stress and thus might be protective against tumour metastases.µ, mu), DOP , and KOP . Opioids can also affect other receptors, especially NOPs . In everyday practice, depending on the type of pain , the clinical condition of the patient, the coexisting diseases, and capacities of organs crucial for drug metabolism and excretion (liver and kidneys), different opioids are used, including morphine, oxycodone, hydromorphone, fentanyl, buprenorphine, tapentadol, methadone, tramadol, codeine; the last two are being classified as the so-called “weak” opioids.Pharmacotherapy constitutes the basic pain treatment method in cancer patients. For moderate to severe pain in cancer patients, the mainstay of the therapy is opioid analgesics . These drugs exert their clinical effects by influencing individual opioid receptors, which are currently classified into three groups: MOP  have been identified on the central and peripheral nervous system neurons. Moreover, based on the analysis of mRNA, receptor protein, or opioid binding capacity of cells or their opioid response, it has been confirmed that opioid receptors are also present on other cells, including cancer cells [Classically, three opioid receptor types , T cells, mast cells, macrophages and mediators, including cytokines (interleukins and chemokines). It turns out that acute and chronic administration of exogenous opioids affects both the cellular and humoral components of the immune response. Exogenous opioids affect several of the components of the immune system, including lymphocyte proliferation, their phagocytic activity, NK cell activity, cytokine expression, and antibody production . SeveralThe importance of central mechanisms is demonstrated by the fact that opioids that easily penetrate the blood-brain barrier have a stronger immunosuppressive effect compared with those that do not pass through it—the latter demonstrates this effect only after central administration . MoreoveThe peripheral mechanisms most likely involve the activation of MOP opioid receptors located on immunocompetent cells . Opioid A number of potential mechanisms of opioid-induced immunosuppression have been identified in experimental studies. It turns out that these drugs may reduce the number of macrophages available to fight infections  and weakA number of mechanisms via which opioids impair adaptive immunity have also been studied. It turns out that these drugs may impair the T-cell viability and their proliferative response , T-helpeAnother potential opioid-induced immunosuppression pathway is the hypothalamic-pituitary-adrenal (HPA) axis: the corticotrophin releasing hormone (CRH) stimulates the anterior part of the pituitary gland to produce adrenocorticotrophic hormone (ACTH), which, in turn, activates the adrenal cortex to produce glucocorticoids. The latter influences various components of the innate and adaptive immune system, suppresses cellular immunity, and contributes to the tolerance of various antigens by altering T- and B-cell function . The effα and β adrenergic receptors have been identified in experimental studies on lymphocytes and macrophages in rodents [Studies have shown that opioids also affect the sympathetic system and by activating it, may cause immunosuppression. It is manifested, among others, by depressed NK cell activity and suppressed peripheral blood lymphocyte proliferation . Felten  rodents .Not all opioid drugs share the same immune profile. Some opioids seem to have no effects on immune function, whereas others tend to be immunosuppressive. This is probably due to the combination of direct effects on immunocytes and indirect effects in vivo that involve centrally mediated mechanisms as well as the systemic production and release of immunomodulatory mediators. Studies suggest that morphine has the highest immunosuppressive potential, fentanyl ranks medium, while buprenorphine and tramadol show the lowest or no immunosuppressive effect . MorphinA list of opioids broken down by the degree of the immunosuppressive effect they induce is given in Several possible mechanisms which are jointly responsible for cancer progression in the perioperative period have been identified. Numerous studies have confirmed that surgical manipulation, tumour dissection, and resection cause cancer cells to migrate to the cardiovascular system and their subsequent spread throughout the body . AdditioThe findings also suggest that the choice of the surgical technique also appears to be important. Less invasive options, including laparoscopic ones, demonstrate a less intense immunosuppressive effect compared with laparotomy . Other fStress and pain, unfortunately often experienced by patients in the perioperative period, also constitute important factors. They lead to stress hormone bursts and impair cellular immunity, including NK cell activity , 44. Theµ) opioid receptors located on vascular endothelial cells, activate and promote angiogenesis and networking of new blood vessels, which play an important role in the transfer of cancer cells from the primary lesion site to the host cardiovascular system and further to the metastatic lesion sites. This mechanism involves, among other things, the vascular endothelial growth factor (VEGF) [µ) receptor, since the administration of methylnaltrexone, which is a peripheral antagonist of the MOP receptor, reduces angiogenesis. Moreover, methylnaltrexone administered in combination with bevacizumab, which is an anti-VEGF monoclonal antibody, shows synergy in the inhibition of VEGF-induced angiogenesis [Numerous studies suggest that opioids may promote cancer progression. The main mechanisms responsible for this adverse effect include the stimulation of angiogenesis and immunosuppression. Opioids, by activating MOP (r (VEGF) , 45. Stur (VEGF) . This meogenesis . Gupta eogenesis .Opioids may lead to progressive immunosuppression via many of the mechanisms described in the previous part of the article. Studies show that fentanyl, an opioid frequently used intraoperatively, blocks the cytotoxic effect of NK cells in the postoperative period, whereas sufentanyl and alfentanyl, apart from their effect on NK cells, further weaken mitogen-induced lymphocyte multiplication .  FigureThe increasing awareness of the immunosuppressive properties of opioids has prompted sustained efforts in search of other effective, but most importantly, safer methods of perioperative analgesic management. Regional analgesia techniques raise hopes in this respect. Their beneficial mechanism of action is complex: on the one hand, they provide effective analgesia, thus minimising the adverse effects of pain on the body of the operated patient and reducing the necessary doses of systemic analgesics (including opioids), which translates into improved safety of the therapy in terms of opioid-induced immunosuppression and potential risk of cancer progression. On the other hand, these techniques minimize the adverse effects of the surgical procedure itself by attenuating of the metabolic, neuroendocrine, and cytokine stress response to surgery and reducing the potential immunosuppressive and prognostic impact of stress and surgical trauma.A number of studies have assessed the impact of regional analgesia techniques on cancer progression. The interpretation of their findings is difficult, since the surgical injury itself, ineffective pain treatment, and perioperative stress all exhibit immunosuppressive effects and increase cancer progression risk. Moreover, most studies assess the impact of regional analgesia techniques on patients who have additionally received general anaesthesia for surgery, yet, as is well known, numerous anaesthetics administered either intravenously or inhalationally also produce immunosuppressive effects. However, it does not alter the fact that the appropriately chosen and performed regional anaesthesia techniques  very effectively relieve pain and effectively block the surgical trauma-induced neuroendocrine response of the body and thus better preserves the patient's immune status. In a study done by Koltun et al., it has been seen that patients receiving epidural anaesthesia during colectomy had lower plasma levels of epinephrine and cortisol, compared to patients receiving general anaesthesia, and also the NK cell activity was better preserved in patients receiving regional anaesthesia .β, and IL-1β) and on the reduction of the risk of cancer progression, including prolonged overall survival time in patients in whom these techniques were used, whereas other studies fail to confirm these results [Most of the studies in question assess the influence of central blocks  in prostate  and colo results , 55.The currently recommended optimal approach to pain management is the multimodal analgesia approach, which involves combining analgesics and anaesthetic techniques with different mechanisms of action in order to take advantage of their synergistic effects. One of the components of multimodal analgesia are regional anaesthesia techniques: continuous epidural anaesthesia, paraspinal blocks, plexus blocks, and interfascial blocks which are increasingly often used in everyday clinical practice, thanks to the recent developments in ultrasonography. In the event of contraindications to regional anaesthesia techniques, combination pharmacotherapy involving nonopioid drugs and coanalgesics is a recommended analgesic management method . Such an approach, thanks to the combination of drugs with different mechanisms of action, ensures satisfactory analgesia at lower opioid doses, which is an important aspect of safety of the latter group of drugs referred to a number of times in this paper. Experimental studies show that NSAIDs administered together with opioids reduce immunosuppression associated with the use of the latter . HoweverIt should also be emphasized that the development of effective therapeutic strategies requires a better understanding of cellular mechanisms underlying the pathogenesis of pain. Progress in pain research points to an important role of microglial cells in the development of pain. The inhibition of spinal microglia has been shown to attenuate postoperative pain as well as morphine-induced antinociceptive tolerance . TargetiInsufficiently treated pain and stress associated with cancer adversely affect the body's defence mechanisms, including cellular immunity, natural killer (NK) cell function, and humoral response. Experimental and clinical studies also show the importance of effective pain management for checking cancer progression. Apart from the basic humanitarian aspect, these data provide an argument for the need to effectively alleviate stress and suffering in cancer patients. The question of how to do it optimally and in the safest possible way is still relevant, given the substantial evidence concerning the potentially adverse opioid effects to have emerged in recent studies .It should be clearly emphasized that the findings of research on the latter issue are ambiguous and as such should be treated with great caution. They must not be interpreted as an argument against using opioids in pain management in cancer patients. Effective pain treatment, alleviation of suffering associated with cancer, and improvement in the quality of life should always be a priority, while the awareness of potential risks should prompt the use of regional analgesia techniques, using local analgesics and possibly coanalgesics. Where it is impossible, recommendations include combined systemic pharmacotherapy comprising nonopioid analgesics and coanalgesics, some of which (including lidocaine and NSAIDs) also exhibit proven oncologically beneficial effects. Such an approach contributes to the optimization of analgesic management, and thus to obtaining the best analgesic effects at lower opioid doses, which, in turn, reduces the frequency and intensity of adverse effects associated with their use. Further research is needed to verify the currently available data on both the potential adverse effects of opioids and the possible protective effects of regional analgesia techniques on cancer patients.


Recent advances in cryo-electron microscopy (cryo-EM) have made it possible to solve structures of biological macromolecules at near atomic resolution. Development of more stable microscopes, improved direct electron detectors and faster software for image processing has enabled structural solution of not only large macromolecular  complexes but also small (~60 kDa) proteins. As a result of the widespread use of the technique, we have also witnessed new developments of techniques for cryo-EM grid preparation of membrane protein samples. This includes new types of solubilization strategies that better stabilize these protein complexes and the development of new grid supports with proven efficacy in reducing the motion of the molecules during electron beam exposure. Here, we discuss the practicalities and recent challenges of membrane protein sample preparation and vitrification, as well as grid support and foil treatment in the context of the structure determination of protein complexes by single particle cryo-EM. During the course of the past 10 years, spectacular advances have been made in the ability to solve macromolecular structures using cryo-EM, culminating in the 2017 Nobel Prize in Chemistry awarded to Jacques Dubochet, Joachim Frank and Richard Henderson for developing the technique and applying it to high-resolution structure determination of biomolecules in solution  genomes encode membrane proteins  . Under these conditions, ice crystals are unable to form, thus preserving the specimen integrity. Ideally, cryo-EM samples should be contained in a thin layer of vitreous ice, with a thickness as close as possible to the dimensions of the particles. This minimizes multiple scattering events and maximizes sample contrast in the microscope. In practice, approximately 3 μL of sample is deposited on the cryo-EM grid Figure  to promoIt is often the case that when applied to an EM grid Figure  the protOften, the protein concentration on the grid does not match the protein concentration in solution due to surface adhesion effects. Particle density can be higher than expected if they tend to absorb more to the surface, and lower if they are repelled from the surface or absorbed to the support structures. Taking into account that we need 5–10 times more sample concentration for cryo-EM than for NS-EM, a very helpful table that provides an estimation of the number of particles expected in the thin layer of vitreous ice on holey grids for a given concentration of sized macromolecular complexes can be found in the 2016 review by Vinothkumar and Henderson  orientation during cryo-EM grid preparation. In cases of dynamic complexes, glycerol gradient centrifugation coupled to chemical cross-linking  have also been considered and tested over the years for different reasons, but only a few of them have given good results and only in particular cases , the metal support shrinks more than the carbon foil causing the wrinkling of the latter (“cryo-crinkling”) and subsequent loss of tension  on top of the foil in order to provide an extra physical support for the particles to adsorb to. In practice, additional films may also help to overcome limitations such as low protein concentration, particle distribution in the grid holes, preferential orientation and air-water interface issues Figure . As showUnfortunately, amorphous carbon films contribute substantially to background signal, which is less of an issue when studying large protein complexes, but becomes significant for 150-kDa  complexes. In these cases, an alternative is to use a different type of film. Graphene (Pantelic et al., The practicalities, challenges and examples described above, along with numerous other studies, illustrate how intricate and difficult protein sample preparation can be. Determination of high-resolution structures by cryo-EM is a rapidly growing field, in particular with the recent developments in detection and recording, user-friendly microscopes and better preforming software. In this context, protein sample preparation still remains a trial and error process, where different approaches have to be explored in order to maximize the chances for success.The ultimate goal is to move from trial-and-error processes to more controlled and reproducible protein sample preparation protocols. Better grid supports will reduce specimen movement during data collection, diminish build-up of charge and help control the orientation and distribution of particles within the ice layer.We anticipate future advances such as the design and production of other automated vitrification devices based on different technologies, the development of rapid ice thickness screening protocols, the minimization of radiation-induced motion and charging, and the exploitation of more tunable interacting surfaces. Additionally, we will witness in the near future an increased investment in the development of new solubilization methods for membrane protein sample preparation, improved electron microscope detectors, recording hardware and data processing software. These new developments will allow us to reach the theoretical resolution limit of this powerful technique sooner than expected.GS wrote the manuscript and prepared the figures. TC edited the manuscript and figures, and supervised the work. Both authors approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


College students are increasingly reporting common mental health problems, such as depression and anxiety, and they frequently encounter barriers to seeking traditional mental health treatments. Digital mental health interventions, such as those delivered via the Web and apps, offer the potential to improve access to mental health treatment.This study aimed to review the literature on digital mental health interventions focused on depression, anxiety, and enhancement of psychological well-being among samples of college students to identify the effectiveness, usability, acceptability, uptake, and adoption of such programs.We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092800), and the search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) from the date of inception to April 2019. Data were synthesized using a systematic narrative synthesis framework, and formal quality assessments were conducted to address the risk of bias.A total of 89 studies met the inclusion criteria. The majority of interventions  were delivered via a website, and the most common intervention was internet-based cognitive behavioral therapy . Many programs  featured human support in the form of coaching. The majority of programs were either effective  or partially effective  in producing beneficial changes in the main psychological outcome variables. Approximately half of the studies  did not present any usability or acceptability outcomes, and few studies  examined a broad implementation of digital mental health interventions on college campuses. Quality assessments revealed a moderate-to-severe risk of bias in many of the studies.Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psychological well-being among college students, but more rigorous studies are needed to ascertain the effective elements of these interventions. Continued research on improving the user experience of, and thus user engagement with, these programs appears vital for the sustainable implementation of digital mental health interventions on college campuses. In the last decade, rising rates of college students experiencing symptoms of depression and anxiety have been observed -3. GlobaCampus counseling centers are well positioned to provide mental health care. However, many counseling centers across the country are underresourced, have difficulty reaching students in need, and operate at full capacity during much of the year .Digital mental health interventions, such as those delivered via mobile- and Web-based platforms, offer the possibility of treatment to college students with common mental health problems while circumventing many existing barriers to receiving traditional mental health services, including stigma and time -11.The evidence base for digital mental health interventions for general adult populations is vast -15, and However, there have been limitations of these past reviews, as they have focused exclusively on studies that were randomized controlled trials (RCTs). Although a focus on studies with RCT designs allows researchers to evaluate the efficacy and effectiveness of digital mental health interventions, the exclusion of papers reporting on other study designs presents a significant gap in our ability to assess the uptake and adoption of digital mental health interventions for university students . This is particularly important as the full public health potential of these types of interventions is tied not only to clinical efficacy but also to the successful implementation of these programs in real-world settings. Across the board, the implementation and integration of digital health tools into routine care settings has been a challenge. Many have called for testing digital health tools under more pragmatic conditions to maximize the transfer of knowledge from research trials to real-world implementation -21, and college students to refer to all students in postsecondary education, including medical students. All study designs were included, with the exception of technical validation papers reporting exclusively on the development of digital mental health interventions. Conference abstracts were also excluded.To be included in this review, studies had to (1) examine an intervention that aimed to improve psychological well-being, psychological distress, stress, depressive, and/or anxious symptoms; (2) deliver the intervention via a digital platform ; (3) include students enrolled in higher education institutions, such as 2-year community colleges, professional schools , 4-year colleges , and universities; (4) report outcomes related to psychological well-being, psychological distress, stress, depressive and anxious symptoms, and/or the use and reach of an intervention; and (5) be written in English. In this paper, we use the term JMIR Mental Health and Digital Health) are not indexed in the searched sources, an additional handsearch was conducted through these publications and through the reference lists of related systematic reviews. The searches were not limited based on publication date, language, document type, or study design. Throughout the study selection, the reference lists of included studies were further reviewed to identify relevant citations. The search strategy terms are presented in A comprehensive search strategy was developed using keywords and controlled vocabulary to describe university students, depression and anxiety, and digital mental health interventions. The search strategy was adapted to the electronic databases MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EBSCOhost), Web of Science (Thomson Reuters), and the Cochrane Library (Wiley). Each database was searched from the date of inception to April 18, 2019. As some relevant journals , presence of support, student population, setting, sample size, length of intervention, usability and acceptability outcomes, uptake and adoption outcomes, psychological outcomes, and type of analyses performed .This review examined the effectiveness, usability, acceptability, uptake, and adoption of digital mental health interventions for treating depression and anxiety and for enhancing psychological well-being among college students. The effectiveness outcomes included measures of depressive symptomatology  and quauptake and adoption were used in conjunction with one another [For the purpose of this review, the terms  another  and were another ). HoweveAs this review included both randomized trials and nonrandomized trials, the risk of bias was assessed using 2 separate tools: the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials  and the A systematic narrative framework was used to synthesize the data -40. OwinA total of 6428 article titles and abstracts were reviewed. Then, 187 full-text articles were reviewed for inclusion, with 89 studies included in the review for data extraction. See Of the 89 studies included in this review, 72 employed randomized study designs -112, wheWe examined if each study appeared to be designed specifically for students  or if college students appeared to be used as a convenience sample. As seen in The majority of these studies n=46 -127,131),131127,1A total of 71 studies utilized a Web-based technology -126,128),128126,1The majority of interventions studied offered some level of support or guidance to users—many of these interventions featured coaching from a human n=33 ,128,129),129128,1As seen in fully effective. To provide a conservative estimate, these studies were counted as partially effective.Of the 42 studies deemed effective in producing beneficial changes in the main psychological outcome variables, 36 of those studies utilized a control condition; although the quality of control conditions varied broadly and ranged from treatment as usual or waitlists to other digital programs or face-to-face treatment ,113,125.Approximately half of the studies included in this review n=45 -125,127),127125,1As seen in Uptake and Adoption column in not reported in this column. For studies that examined digital mental health interventions in standardized laboratory settings, we have listed N/A due to standardized within-lab use.The vast majority of studies did not specify the size of the pool of potential participants from which the study participants were drawn n=81 -127,129),129127,1Relatively few studies examined the implementation of a digital mental health intervention on a college campus and reported on the implementation outcomes ,93,98. AAs seen in As seen in Of the 16 nonrandomized studies screened for risk of bias, the majority of studies n=10 -125,128),128125,1This study aimed to synthesize the literature on the effectiveness, usability, acceptability, uptake, and adoption of digital mental health interventions for (1) treating depression and anxiety and (2) enhancing psychological well-being among college students. In doing so, the types of interventions that have been developed and tested were characterized. The vast majority of included studies reported that the digital mental health interventions of interest were either effective, or partially effective, in producing beneficial changes in the main psychological outcome variables. This is consistent with past meta-analyses on digital mental health programs for college students ,18 and iThe majority of programs were studied on university campuses and enrolled broad samples of undergraduate and graduate students. The focus on universities was not surprising, as many studies were conducted at the university with which the researchers were affiliated, likely because of a combination of ease and investment in one’s own community. Fewer studies took place within health professional  programs. It was notable that only 1 study comprised a community college sample, as it is widely recognized that community college students have higher rates of unmet mental health needs compared with students in traditional 4-year colleges and universities -138. FurCollege students are often used as a convenience sample for psychological research . TherefoSimilar to what has been observed in digital mental health intervention programs for general adult populations ,134, theAlthough user-centered design can produce programs that are more engaging and enjoyable for users, design principles alone are unlikely to produce interventions that are sustainably used on college campuses. The research-to-practice gap for digital mental health interventions is increasingly being recognized, and leaders in the field have proposed strategies to routinely incorporate implementation science methods into the study of digital mental health interventions ,149. TheThis study should be interpreted in light of its strengths and limitations. Consistent with best practices, the articles were reviewed by 2 independent reviewers and risk of bias was assessed. The moderate-to-severe risk of bias found in many of the included randomized and nonrandomized trials indicates that the results reported may be biased in favor of the digital mental health tools and should be evaluated in that context. Bias primarily emerged because the outcomes were self-reported in nature and the participants were aware of the intervention they received—2 issues that are exceedingly common in digital health research. Although the search strategy was developed with an experienced research librarian and an additional handsearch was used, it is possible that some relevant publications were missed in the search. Several reviewed studies used active controls or comparison interventions that produced similar effects to the intervention of interest, so we were unable to evaluate the effectiveness of intervention ingredients to inform what components  are relevant for achieving behavior change. Without the gold standard interventions in digital health for college students that could serve as comparisons with newly developed interventions, several studies that were reviewed used active controls or comparison interventions that produced similar effects to the intervention of interest. In addition, none of the included studies utilized noninferiority analyses. Therefore, the true efficacy of most of the interventions was unclear.Another strength is that we did not limit this review to RCTs of computer- and Web-based programs. As such, this study expands on past work by offering a much broader look at the types of digital mental health programs that have been available for students and a look at the uptake and adoption of such interventions. Uptake and adoption could not have been meaningfully examined if this review was limited to RCTs. However, the consequence of including multiple trial designs precluded us conducting a meta-analysis because of the heterogeneity of the data included.Digital mental health interventions for depression, anxiety, and the enhancement of psychological well-being have the potential to improve the mental health of college students around the world. The majority of interventions have focused on Web-based technologies, and there remains a need for further research on interventions delivered via mobile phones. To date, published studies on digital mental health programs have primarily been focused on establishing efficacy and/or effectiveness rather than on supporting program uptake and adoption across campus communities. For these programs to realize their potential, they need to be successfully and sustainably implemented on college campuses as part of the array of available mental health services. Further research on digital mental health interventions for college students should focus on designing and testing programs that are viewed as usable and acceptable to students and on methods of implementing such programs on college campuses.


The complexity of the central nervous system (CNS), its limited self-repairing capacity and the ineffective delivery of most CNS drugs to the brain contribute to the irreversible and progressive nature of many neurological diseases and also the severity of the outcome. Therefore, neurological disorders belong to the group of pathologies with the greatest need of new technologies for diagnostics and therapeutics. In this scenario, nanotechnology has emerged with innovative and promising biomaterials and tools. This review focuses on ischemic stroke, being one of the major causes of death and serious long-term disabilities worldwide, and the recent advances in the study of liposomes and carbon nanomaterials for therapeutic and diagnostic purposes. Ischemic stroke occurs when blood flow to the brain is insufficient to meet metabolic demand, leading to a cascade of physiopathological events in the CNS including local blood brain barrier (BBB) disruption. However, to date, the only treatment approved by the FDA for this pathology is based on the potentially toxic tissue plasminogen activator. The techniques currently available for diagnosis of stroke also lack sensitivity. Liposomes and carbon nanomaterials were selected for comparison in this review, because of their very distinct characteristics and ranges of applications. Liposomes represent a biomimetic system, with composition, structural organization and properties very similar to biological membranes. On the other hand, carbon nanomaterials, which are not naturally encountered in the human body, exhibit new modes of interaction with biological molecules and systems, resulting in unique pharmacological properties. In the last years, several neuroprotective agents have been evaluated under the encapsulated form in liposomes, in experimental models of stroke. Effective drug delivery to the brain and neuroprotection were achieved using stealth liposomes bearing targeting ligands onto their surface for brain endothelial cells and ischemic tissues receptors. Carbon nanomaterials including nanotubes, fullerenes and graphene, started to be investigated and potential applications for therapy, biosensing and imaging have been identified based on their antioxidant action, their intrinsic photoluminescence, their ability to cross the BBB, transitorily decrease the BBB paracellular tightness, carry oligonucleotides and cells and induce cell differentiation. The potential future developments in the field are finally discussed. Stroke is one of the leading causes of death and disability worldwide. According to the most recent meetings of the American Heart Association the global prevalence of stroke was 42.4 million in 2015. Ischemic stroke was 24.9 million, and hemorrhagic stroke was 18.7 million in the entire world. Stroke incidence in the United States each year shows that approximately 610,000 people experience a first stroke attack and 185,000 are recurrent attacks . Direct and indirect costs with stroke accounted 40.1 billions of dollars between 2013 and 2014 .Stroke is defined by a sudden decrease of blood supply to the brain tissue. It can result in the manifestation of symptoms like numbness of face, arms and legs, confusion, aphasia, among others. Signs and symptoms will depend on the affected area and can have an outcome ranging from complete patient recovery to severe neurological deficits and death . It can In this review, we will focus on ischemic stroke and discuss the current diagnostic and therapeutic challenges. Despite the great incidence, the severity of the outcomes and the high economic costs of ischemic stroke, tissue plasminogen activator (t-PA) is the only treatment approved by the Food and Drug Administration (FDA). However, due to safety concerns such as the risk of cerebral hemorrhage after treatment with t-PA, the number of patients who can actually use this drug is very low . In addiIn this scenario, nanotechnology emerges with innovative tools for therapeutic, diagnostic and theranostic purposes. These tools include, for instance, imaging techniques, implants, sensors, biomarkers, drug development and carrier systems and biomaterials . RegardiAfter a brief description of the physiopathology and the current limitations of the diagnosis and therapy of ischemic stroke, this review highlights the recent progress achieved in the use of two important types of nanostructures: liposomes as first generation of drug nanocarriers, but still the most advanced and studied; carbon nanomaterials recently investigated as neuroprotective agents, membrane-permeable and permeabilizing agents, cell and drug-carrier systems and innovative biosensors for mechanistic evaluation in experimental models. These two types of nanostructures were selected for comparison in this review because of their very distinct characteristics and ranges of applications. Liposomes represent a biomimetic system, with composition, structural organization and properties very similar to biological membranes. On the other hand, carbon nanomaterials, which are not naturally encountered in the human body, exhibit new modes of interaction with biological molecules and systems, resulting in unique pharmacological properties.+ and Ca2+ entering the cell  and multimodal magnetic resonance imaging (MRI) .Although CT is widely available and less expensive, it is not sensitive for detecting ischemic stroke and distinguishing new events. Indeed, less than a third of patients with brain ischemia exhibits characteristics from CT findings within 3 h of symptoms onset . MoreoveConventional MRI is a vital and versatile imaging tool in clinical practice, offering advantages for the assessment of acute stroke, especially with diffusion-weighted imaging (DWI) . HoweverAlthough a more accurate diagnostic of ischemic stroke can still be achieved through the combined use of CT and MRI , there iRegarding therapeutic options for acute ischemic stroke, only two are available: thrombolysis and mechanical thrombectomy, both strategies focusing on reperfusion therapy. Thrombolysis is the leading treatment for acute stroke, performed by a pharmacological intervention using recombinant tissue plasminogen activator or t-PA, the only available treatment approved by the US FDA . HoweverMechanical thrombectomy utilizes a surgical process to mechanically restore the blood flow in large cerebral arteries promoting a more effective recanalization than thrombolysis . AlthougMoreover, even when recanalization is successful in installing reperfusion, there is still left sequels that can impair patients life quality, as reperfusion itself can induce ROS production and tissue damage . Aiming Several promising neuroprotective drug candidates have been identified in rodent models. However, most of the strategies established in animal models has failed in clinical trials . The pooMoreover, the complexity of the physiopathological events that take place during cerebral ischemia and the still limited knowledge about the molecular and cellular mechanisms involved and their spatial and temporal occurrence represent an obstacle to the identification of effective tissue biomarkers and the design of powerful nanotechnology-based strategies for diagnosis and therapy .In summary, the diagnosis and therapy of ischemic stroke need to be improved and, in that sense, a critical step seems to be the safe and effective delivery of substances to the ischemic region . In thisFigure 1 and discussed in details below, liposomes and carbon nanomaterials have been extensively studied as nanomaterials for application against ischemic stroke and several different strategies have emerged with promising results.As illustrated in Liposomes are the first generation of drug nanocarriers . They arLiposomes are classified according to their size and number of lamellae: small unilamellar vesicles (SUV) with a size up to 100 nm and one bilayer; large unilamellar vesicles (LUV) with a size of more than 100 nm and one bilayer; and multilamellar vesicles (MLV) that can reach several μm and are made of multiple concentric bilayers .Figure 2, liposomes are highly versatile, allowing accommodation of hydrophilic drugs in the aqueous space or hydrophobic drugs in the lipid bilayer and surface modifications to control their interaction with biological environments and fate  , transferrin or insulin receptors . This kiigure 1) . Followiigure 1) .in vivo metabolism of the peptide through proteolytic inactivation results in a short plasma half-life (less than 1 h) and biological actions, limiting its therapeutic potential. Furthermore, the high molecular weight and hydrophilic character of Ang-(1-7) prevent its absorption across biological barriers, such as BBB. Interestingly, it was shown that encapsulation of Ang-(1-7) into PEGylated liposomes prolonged the peptide biological action from 8 min to 5 days following microinjection into the rostral ventrolateral medulla (RVLM) of normotensive rats -Mas axis of the Renin Angiotensin System (RAS) are of special interest . The hepive rats . This daThe intranasal route has recently gained, attention once it is a region that has free access to the brain tissue by the olfactory and trigeminal nerve and it also constitutes a non-invasive alternative route . BesidesNanotheranostics is the field that combines at the same time nanoparticle-mediated therapy and the study of nanoparticles localization and fate usually through imaging . Agulla in vivo imaging for upregulated PirB region in a cerebral ischemic stroke model. These authors also used soluble PirB ectodomain, as a therapeutic reagent encapsulated in liposomes, showing a significant functional recovery in a model of ischemic stroke.After observing the increased expression of paired immunoglobulin-like receptor B (PirB) in the ischemic hemisphere of mice 24 h post-MCAO, Several concerns will need to be overcome before engineered liposomal nanocarriers can be incorporated into everyday clinical practice. The ideal nanoparticles for use as contrast agents must be detectable at reduced doses, should cross the BBB and target a time-accurate biomarker. It must also be non-toxic and preserve cellular functions. Hence, contrast agents associated to liposomes should be carefully chosen, or eventually optimized, so as to avoid adverse effects. For instance, a recent work emphasized the potential toxicities of QDs due to their specific metallic composition, the risk of release of toxic metal ions after prolonged exposure of biological systems and several undefined factors of nanoparticles themselves . Thus, min vivo release of the encapsulated drug from liposomes: (i) the spontaneous simple diffusion of the drug across the liposome bilayer; (ii) the endocytosis of liposomes by cells, their degradation by lysosomal phospholipases and the subsequent release of the drug in the cytosol or the extracellular medium after exocytosis; (iii) the induction of drug release from liposomes by specific stimuli, such as external magnetic field or focused ultra-sound, variations in temperature or pH, depending on the characteristics of liposomes : fullerenes , carbon nanotubes  and graphene , although structures such as carbon dots and nanodiamond have been reported  have been the subject of intense research during the last 30 years due to their unique properties related to the quantum confinement of the electrons movement at discrete energy levels in the nanometric structure. The most studied allotropes are the spreported . FullereCarbon nanotubes, tubular carbon structures with nanometric diameter, gained attention of the scientific community with the publication of in vivo applications, such as sensors, biomarkers, drug carrier for therapeutics . The purification of the CNMs is an earlier step that is crucial for elimination of residues or by-products, such as metal particles of catalysts used in the synthetic procedure amorphous carbons and other impurities that may exert toxicity.For biological applications, surface modifications  allow better dispersion of the nanomaterial in physiological medium and ensure biocompatibility. In a wider perspective, this approach can confer functional characteristics to the CNMs. The conjugation of the nanomaterials with different molecules, such as polymers, proteins, different DNA sequences or other specific compounds, can generate different functions for in vitro and in vivo , 3+, across the cell monolayer via energy-dependent transcytosis. In another study, f-MWCNTs were shown to enter into the brain via endothelium, following systemic injection in rodents, with accumulation not just in endothelium but also in brain parenchyma . Carbon nanotubes can be used either for their own action on the nervous tissue or their ability to carry other drugs (in vivo study has shown that hydrophobic carbon nanotubes (HPCNT) impregnated with subventricular zone neural progenitor cells (SVZ NPCs) could repair damaged neural tissue following stroke. HPCNT-SVZ NPCs transplanted rats exhibited improved behavior and reduced volume and area of infarct cyst, compared to experimental control. The majority of the transplanted HPCNT-SVZ NPCs collectively broadened around the ischemic injured region and the SVZ NPCs differentiated into mature neurons, attained the synapse morphology , and decreased microglial activation (CD11b/c [OX-42]). This study pioneered the concept that CNTs can improve stem cell differentiation, leading to heal stroke damage . They exploited the intrinsic photoluminescence of single-walled carbon nanotubes (SWNT–IRDye800). This technique allows a fluorescence imaging to a depth of >2 mm, sub-10-μm resolution and imaging rate of ∼5.3 frames per second providing a non-invasive, real-time assessment of blood flow anomaly with high spatial and temporal resolution in a MCAO stroke model .Besides the development of new tools for the diagnosis of patients, another equally important approach is the use of biosensors to uncover the biochemical and pathophysiological mechanisms of stroke in animal and cells models. In this scenario, optical CNT-based biosensors show great promise, because of their unique fluorescence properties, allowing high spatio-temporal resolution at biologically relevant concentrations .2O2)  . These S2O2) , neurotr2O2) , 2017 an2O2) .in vitro, through direct interaction in cell culture. However, as demonstrated by in vivo. These authors used SWCNTs wrapped with DNA oligonucleotides functionalized with PEG (to enable systemic injections) as an in vivo nitric oxide sensor. They used a rodent model injected with RcsX tumor cells to cause liver inflammation and in situ generation of NO molecules in the liver. A strong fluorescence quenching effect in the presence of NO free radicals was detected (1 μM detection limit). The tissue autofluorescence and background signals were successfully removed from the characteristic NIR-II signals of the SWCNT reporters, based on their spectral differences. It is also noteworthy that SWCNT-fluorescence exhibits no blinking, no bleaching and a large Stokes shift  peptide hormone. Finally, the high complexity of liposome nanosystems and related stability and cost issues make necessary the development of specific nanoplatforms for industrial production. In that sense, the experience acquired in the development of existing pharmaceutical liposome-based product should be useful.in vitro and in vivo model, thus contributing to the development of more effective therapies for this pathology.We have shown here that carbon based nanomaterials, including nanotubes, fullerenes and graphene, display great versatility regarding size, morphology and surface physicochemical properties. CNTs started to be investigated for ischemic stroke and potential applications for therapy, biosensing and imaging have been identified based on their antioxidant action, their intrinsic photoluminescence, their ability to cross the BBB, transitorily decrease the BBB paracellular tightness, carry oligonucleotides and cells and induce cell differentiation. Therefore, their unique physicochemical properties and the improvement of functionalization methods, now offer a wide range of potential applications. However, considering that CNTs are not naturally encountered in the human body, an important step for clinical translation is the full evaluation of biodistribution and toxicological effects of these materials  after systemic administration. Thus, CNTs are at an early stage of development and much work is still needed to reach practical applications. It is felt that CNTs have their greatest potential as nanobiosensor for investigating the biochemical and pathophysiological mechanisms of stroke using FF and AM defined the outline of the manuscript. AM, GB, and LF wrote the first draft of the Section “Introduction.” AM and LF wrote the first draft of the Sections “Physiopathology of Ischemic Stroke” and “Current Limitations in the Diagnosis and Therapy of Ischemic Stroke.” LF and FF wrote the first draft of the Section “Liposomes as Drug Nanocarriers.” GB wrote the first draft of the Section “Carbon-Based Nanomaterials.” FF and AM fully revised the first draft of the manuscript. All the authors contributed to Abstract, Concluding remarks, and the final form of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Following a declaration by the World Health Organization that Liberia had successfully interrupted Ebola virus transmission on May 9th, 2015; the country entered a period of enhanced surveillance. The number of cases had significantly reduced prior to the declaration, leading to closure of eight out of eleven Ebola testing laboratories. Enhanced surveillance led to an abrupt increase in demand for laboratory services. We report interventions, achievements, lessons learned and recommendations drawn from enhancing laboratory capacity.Using archived data, we reported before and after interventions that aimed at increasing laboratory capacity. Laboratory capacity was defined by number of laboratories with Ebola Virus Disease (EVD) testing capacity, number of competent staff, number of specimens tested, specimen backlog, daily and surge testing capacity, and turnaround time. Using Stata 14 , medians and trends were reported for all continuous variables.Between May and December 2015, interventions including recruitment and training of eight staff, establishment of one EVD laboratory facility, implementation of ten Ebola GeneXpert diagnostic platforms, and establishment of working shifts yielded an 8-fold increase in number of specimens tested, a reduction in specimens backlog to zero, and restoration of turn-around time to 24 hours. This enabled a more efficient surveillance system that facilitated timely detection and containment of two EVD clusters observed thereafter.Effective enhancement of laboratory services during high demand periods requires a combination of context-specific interventions. Building and ensuring sustainability of local capacity is an integral part of effective surveillance and disease outbreak response efforts. BetweenCA, USA)  an RT-PCCA, USA) . DecreasCA, USA) . This ulCA, USA) , in whicCA, USA) . When prCA, USA) . This reWe analyzed laboratory and epidemiologic data generated daily between May and December, 2015. The Republic of Liberia is divided into five regions; North Eastern, North Central, South Central, South Eastern-A, South Eastern-B ; and conLaboratory capacity was defined with respect to daily and surge testing capacity, turnaround time, number of EVD suspected specimens tested, and specimen backlog as a measure of the difference between the number of specimen received and number of specimen tested by the laboratories. Daily testing capacity was defined as the number of EVD suspected specimens tested per day. Surge testing capacity was considered to be the maximum number of EVD suspected specimens that could be tested per day. Turnaround time was defined as the time taken by each laboratory to generate and disseminate test results to the Ministry of Health leadership, from the time a specimen was received. All the six laboratories that conducted EVD diagnosis, at some point, during the period of enhanced surveillance were included in the analysis. Other laboratories involved in clinical or public health diagnostics but not EVD diagnosis were not considered. Using archives from the epidemiologic surveillance database, we extracted data on number of specimens received, and number of specimens tested per laboratory per day. We also obtained the number of specimen that did not get tested the same day they were received in a given laboratory and defined this as specimen backlog. Non normally-distributed continuous variables were summarized by median and interquartile range while categorical data were summarized as proportions. We reported the trend of number specimen tested and specimen backlog per month. Stata 14  was used for all analyses. This was a retrospective analysis of data as part of documentation of best practices, and did not necessitate ethical approval; however, the use of data, analysis and report were approved by Ministry of Health, Liberia, and the WHO Liberia Country Office.Country laboratory coverage: at the start of enhanced surveillance in May 2015, Liberia had a total of four EVD testing laboratories , ELWA III laboratory, in Montserrado County and opened on 28th September, 2015 , WHO, academic consortium combating Ebola in Liberia (ACCEL) and United States Centers for Disease Control and Prevention (CDC), in Liberia. Four machines were installed at ELWA III laboratory in September 2015, one was installed at Redemption hospital laboratory in August 2015, two were installed at Phebe Hospital EVD laboratory in November 2015 and three was installed at Jackson F. Doe (JFD) Hospital EVD Laboratory in November 2015. The National Reference Laboratory (LIBR-NRL) partly used two GeneXpert machines that belonged to the National Institute of Health (NIH) research laboratory located at the Liberia Institute of Biomedical Research (LIBR) premises. Plans to establish a new EVD testing site, to use GeneXpert, in Maryland County, South Eastern-B region, were pending implementation by the time of this report. Implementation of the OraQuick® Ebola Rapid Antigen Test  was in the process of being rolled-out at the time of enhanced surveillance and is therefore not discussed further.Recruiting and training of personnel: between May and July 2015, there were 10 Liberian laboratory technicians competent in EVD diagnosis. Starting in August 2015, 16 technicians were recruited and trained in EVD molecular diagnostics. By October, 15 of them were competent in EVD diagnostic techniques. An additional 4 personnel were trained specifically on use of Xpert Ebola technology for Ebola diagnosis. By mid-October, there were up to 29 laboratory technicians proficient in EVD diagnosis  to availing the results to the data manager. The staff assignment to a particular step or steps was based on their level of proficiency and comfort in carrying out the task in a timely manner and with accuracy regardless of the number of specimens. Bong EVD lab and NRl/LIBR established and published the cut-off time for sample reception and same day testing. The JFD EVD lab in Tappita normally received specimens towards the end of the official working hours so the laboratory maintained long opening hours. The Xpert Ebola Assay was introduced in these two laboratories when real-time EVD surveillance had been regained, that is to say, after all backlogged specimens had been tested and results disseminated). In addition, in July 2015, the JFD EVD laboratory began conducting semen testing for EVD, two days per week, in support of the National Men’s Health Screening Program thus requiring further adjustment in the working schedule.Overall impact: the median daily and surge testing capacity averagely increased from 35 and 102 to 77 and 134 specimens, respectively, excluding Redemption hospital EVD testing laboratory . LIBR-NRL and Phebe Hospital EVD laboratories had longer turn-around-time  because This is a documentation of best practices and not a research study, therefore, data used was obtained retrospectively. As a result, some data presented are estimates from a range recorded in the data sources. We have, however, included these ranges in the results to ensure accuracy of the data presented.A combination of opportunity and supporting measures was adjusted to be responsive to the prevailing circumstances in Liberia with the aim of enhancing and maintaining of laboratory capacity for timely EVD diagnosis. These included leveraging available resources; maximizing the testing capacity at each laboratory using existing and new diagnostic platforms and supplies; emergency procurement of supplies and reagents to meet the demand; effective coordination and monitoring of testing at each laboratory; better forecasting and re-budgeting to stabilize the demand-testing equilibrium; and deploying additional staff. Enhancing and retaining local capacity and competencies to respond to any disease outbreak cannot be underscored. Given the possibility of reemergence of disease clusters or future outbreaks; a well-trained, competent and motivated workforce will enable continuity of laboratory services for disease surveillance, routine patient services and sustained vigilance for emerging and re-emerging disease threats. Data-driven decision trees should be used by all stakeholders to inform suspension or scaling down of essential laboratory services during a disease outbreak. This strategy is necessary to ensure that such services can be easily reinstated or re-scaled upwards during or after future disease outbreaks. Establishing key services during any given disease outbreak or crisis by governments, partners and other stakeholders should preferably be done by incorporating these services into already existing structures and involving local staff to enable sustainability and longevity. A robust supply chain and inventory system as well as budgeting and forecasting mechanisms by responsible parties to prevent shortage of essential reagents and other consumables are central to providing consistent and reliable diagnostic services.There is limited laboratory capacity especially in developing countries affecting timely diagnosis and therefore response to epidemic-prone diseases;Development of laboratory capacity in such settings usually takes a lot of time and requires a lot of resources.This paper demonstrates how a combination of context specific interventions can rapidly enhance laboratory capacity in a cost-effective manner, especially during times of abrupt high demand.The authors declare no competing interest.


The brain/body relationship and interdependence has been one of the most prevalent questions toward understanding psychobiological mechanisms underlying human behavior Gover, . Currentmanipulation of abstract symbols and representations. However, the mainstream epistemological stance in Psychological and Cognitive Sciences still pursues the anthropogenic representational and computational capacities of the mind , have co-evolved with the mammalian immune system. Hence, there is a good reason to believe that the increment of chronic inflammatory disorders and others such as Alzheimer in industrialized countries might relate to reduced or increased exposure to certain microbial communities (Raison et al., Considering the ecological niche of the organism presents a major challenge for microbiota research . Given timposed to planet Earth from the cosmos (Parada and Rossi, imposed onto the body through the development of a symbiotic relationship unfolding throughout ontogeny and phylogeny. Therefore, adequate scientific study of human behavior will include as many levels as possible: socio-cultural, psychological, microbiological, etc. (Parada and Rossi, Cognitive process and associated states such as well-being are embodied, in a process of phylogenetic and ontogenic interdependencies, encompassing an organism's both internal and external environments. Diurnal mammals' physiology has been enslaved by the day/night cycle, IP-G and FP conceptualized the present work and wrote the current version for publication.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 skin forms the barrier to the environment. Maintenance of this barrier during aging requires orchestrated responses to variable types of stress, the continuous renewal of the epithelial compartment, and the homeostasis of long-lived cell types. Recent experimental evidence suggests that autophagy is critically involved in skin homeostasis and skin aging is associated with and partially caused by defects of autophagy. In the outer skin epithelium, autophagy is constitutively active during cornification of keratinocytes and increases the resistance to environmental stress. Experimental suppression of autophagy in the absence of stress is tolerated by the rapidly renewing epidermal epithelium, whereas long-lived skin cells such as melanocytes, Merkel cells and secretory cells of sweat glands depend on autophagy for cellular homeostasis and normal execution of their functions during aging. Yet other important roles of autophagy have been identified in the dermis where senescence of mesenchymal cells and alterations of the extracellular matrix (ECM) are hallmarks of aging. Here, we review the evidence for cell type-specific roles of autophagy in the skin and their differential contributions to aging. Changes of the skin belong to the most recognizable signs of aging. Accordingly, skin aging is a major area of interest for cosmetic and skin care industries. From the medical viewpoint, aging of the skin is associated with health problems including increased skin fragility, delayed wound healing and the increased occurrence of skin cancers, the most abundant types of malignancies in humans. The prevention and management of skin aging depends on a thorough understanding of the aging process in general, which can be defined as the time-dependent decline in tissue and organismal functions , and on Autophagy is a process of cellular self-digestion by delivering cytoplasmic material to the lysosome for breakdown. Three pathways of autophagy can be distinguished mechanistically, i.e., macroautophagy, microautophagy, and chaperone-mediated autophagy. Macroautophagy is controlled by autophagy-related proteins (ATGs) and depends on the sequestration of material within double-membraned vesicles (autophagosomes) in the cytoplasm. These vesicles fuse with lysosomes to form autophagolysosomes in which the cargo is degraded by lysosomal enzymes. Breakdown products are released from lysosomes and subsequently are utilized for catabolic processes or energy production. Microautophagy is characterized by the invagination of the lysosomal membrane in yeast, whereas in mammals it involves the invagination of the late endosomal membrane to trap cytoplasmic material which is then degraded either in late endosomes or in lysosomes after endosomal-lysosomal fusion . ChaperoHere, we review the features of skin aging at the levels of the tissue and the cells and then describe the contributions of autophagy to the control of skin aging. We propose a concept in which aging is driven by changes in three categories of cells with different dependencies on autophagy.The skin is a composite organ consisting of a layer of subcutaneous fat tissue, the mesenchymal dermis and the outermost epithelial layer, the epidermis . In addiThe subcutaneous fat tissue functions both as insulation against temperature fluctuations and as energy storage, and is composed mostly of lobules of adipocytes which are surrounded by a lattice of collagen septae and blood vessels. It provides the link of the skin with the underlying muscles and fasciae. The dermis consists mostly of extracellular matrix (ECM) with collagen, elastin, and glycosaminoglycans as the principal components, all of which are produced by fibroblasts, the most abundant cell type within the dermis. The dermal ECM provides the skin with both strong mechanical resistance and elasticity . EmbeddeAttached to the dermis by specialized proteins of the basement membrane, the epidermis forms the outermost skin layer. It is a stratified epithelium consisting mainly  of keratinocytes, which undergo terminal differentiation and form the stratum corneum, which serves as the ultimate barrier against the environment . BesidesIn contrast to internal organs, the signs of skin aging are immediately recognizable also to non-medically trained observers. Most obvious are the occurrence of facial wrinkles which are either the consequence of repeated activity of the underlying muscles during facial expression, or tissue slackening as a consequence of loss of elastin and collagen fibers. Tissue slackening manifests with a loss of the facial oval and sagging of the upper eyelids. In addition, pigment irregularities of sun-exposed skin are a hallmark of aging skin .When analyzing skin aging, one has to take into account that apart from intrinsic aging which proceeds in all organs and is genetically determined, skin aging is also strongly modified by extrinsic factors such as chronic sun exposure and life style habits in particular cigarette smoking . IntrinsIn contrast to intrinsic or chronological aging, photoaging concerns only body regions which are chronically exposed to sunlight or to artificial sources of ultraviolet (UV) radiation . The difAging is a complex phenomenon which includes many effects at the systemic level but also critical changes at the level of isolated system components such as DNA, cells, and tissues. Here, we put forward the hypothesis that drivers of aging mediate their effects differentially on the various types of cells in the skin and perhaps also in other tissues. We propose to distinguish three categories of cells that change during aging in different ways .First, stem cells have a long lifetime and relatively low metabolic activity. Within the epidermis the stem cells themselves do not directly contribute to the epidermal barrier, but they give rise to differentiating daughter cells that achieve this function. A decline in the number and activity of stem cells is both driver and marker of skin aging. Of note, epithelial structures with a high cell turnover, such as epidermal keratinocytes strongly depend on stem cells during homeostasis whereas other skin compartments require stem cells predominantly or only during wound repair.Second, there are cell types that differentiate and undergo fast turnover when they fulfill their function. The metabolic activity of these cells is very high. Examples for this category are epithelial cells of the interfollicular epidermis, sebaceous glands, hair follicles, and the duct of the sweat gland. The maintenance of function of these differentiating cells requires their continuous derivation from stem cells.Third, differentiated skin cells of diverse developmental histories fulfill specific functions over prolonged periods of time or even during the entire life of an organism. Typically, these cells have significant metabolic activity over long times. Examples of this cell category are neurons, melanocytes, Merkel cells, secretory cells of sweat glands, and fibroblasts.The skin provides several examples to illustrate the two main interactions between autophagy and aging: (1) Autophagy decreases the rate of aging and (2) the activity of autophagy declines during aging. Autophagy suppresses aging in a cell-autonomous manner by maintaining intracellular homeostasis and in a non-autonomous manner by contributing to various cell features that protect other cells. For instance, autophagy supports the differentiation of epithelial cells which allows them to protect other cells against external noxae . Since aAutophagy was reported to play various roles in the homeostasis and stress response of skin cells that were reviewed previously . Most re(1)Long-lived and mostly quiescent stem cells require autophagy for intracellular homeostasis and for continuous ability to supply functional progeny cells . Inheren(2)In short-lived differentiating cells, autophagy also contributes to intracellular homeostasis, however, autophagic activity needs to be maintained only over a short time for these cells to be functional. External and internal factors have little time to impair autophagy during differentiation and consequently an aging-associated decline of autophagy is less likely to occur in these cells. Nevertheless, autophagy defects can be inherited from the long-lived precursor cells (stem cells) and potentially compromise processes such as the defense against microbes, the release of cytokines, and most importantly, the protection against stress factors from the environment .(3)In long-lived differentiated cells, autophagy contributes to the maintenance of cell survival and function. A decrease of autophagy leads to the accumulation of damaged or even toxic components and/or energy crisis. These disturbances of intracellular homeostasis impair the processes essential for cell functions and eventually lead to a loss of these cells .Importantly, the process of aging is not fully understood at present and several new concepts of aging drivers have not yet been investigated for their potential interaction with autophagy. For instance, stem cell competition for adherence to the basement membrane depending on proteolytic decrease of COL17A  has emerThe literature on roles of autophagy in the skin is largely organized into reports that focus on cell types of specific developmental origins. Here, we review these reports in separate sections, divided in epithelial and non-epithelial cell types. Non-epithelial skin cells are largely long-lived and differentiated, i.e., category 3 cells as defined in the previous sections of this article, with regard to autophagy and skin aging. Among the non-epithelial skin cells, there are also stem cells (category 1), but the changes in long-lived differentiated cells are considered the main contributors to aging. Epithelial cells of the skin include only a quantitatively minor portion of long-lived differentiated cells (category 3), such as Merkel cells and secretory cells of the sweat glands, whereas the main portion of epithelial cells are short-lived, differentiating cells (category 2), such as keratinocytes of the interfollicular epidermis, hair follicle keratinocytes, sebocytes, and sweat duct cells. The replenishment of the differentiating epithelial cells strongly depends on epithelial stem cells (category 1) . The conKeratinocytes are the main cell type of the epidermis where they represent more than 95% of the total cell population and autonomously establish a stratified epithelium. Keratinocyte stem cells reside in the basal layer of the epidermis and in special locations of epidermal appendages, such as the bulge of hair follicles and the duct of sweat glands . ProlifeAP1S3, leading to accumulation of p62/sequestosome-1 (Sqstm1) and inflammation  to anagen (the phase of active hair growth) in mice . SimilarAtg7 or Atg5 leads to premature breakdown of the nucleus in differentiating sebocytes , indicating that the function of melanocytes changes with age . The mosThe incidence of melanocyte-derived cancers is generally correlated with increasing age, however, malignant melanoma is also relatively frequent in young adults. Nevus cell nevi, commonly known as moles, show age-related variations in shape and appearance . Non-proEPG5 cause a recessive neurodevelopmental multisystem disorder, Vici syndrome, which is associated with hypopigmentation  protein display impaired autophagy due to interaction of CSB with HDAC6 and cytoskeletal components. Importantly, the restoration of autophagic function could revert the premature aging and photosensitivity phenotype in a CSB mouse model . The movLoss of homeostasis in protein quality control – termed proteostasis – and thereby the accumulation of oxidized proteins is observed in the chronologic and photo-aging processes of the skin . ProteosFibroblast autophagy is required for clearance of lipofuscin, an accumulation of misfolded and modified proteins and lipids . ImpairmIn vitro, activation of autophagy by rapamycin prevented UVB induced senescence by limiting ROS production  and damaging effects from the environment (extrinsic drivers of aging) compromise the machinery of autophagy, leading to a self-accelerating decline in cellular waste disposal and recycling in long-lived skin cells and decreasing protective functions of skin epithelia. Together, autophagy-dependent and independent processes lead to tissues changes that manifest in skin aging. Further characterization of autophagy in distinct skin cells may help to identify new approaches for maintaining the normal function of the skin in aged individuals.LE, ET, and FG wrote 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.


Infection prevention and control (IPC) in health care facilities is essential to protecting patients, visitors, and health care personnel from the spread of infectious diseases, including Ebola virus disease (Ebola). Patients with suspected Ebola are typically referred to specialized Ebola treatment units (ETUs), which have strict isolation and IPC protocols, for testing and treatment  of which were reported from North Kivu (Nord-Kivu) and Ituri provinces, in the northeastern part of the country, bordering Uganda , and U.S. CDC. Upon arrival at the facility, assessment teams first met with the medical director to explain the assessment. Interviews, using a semistructured questionnaire,Within the screening domain, the assessment focused on determining the location of the screening station, assessing availability of screening supplies, reviewing social distancing practices and use of a standardized case definition, and assessing the capacity of screening staff members. The assessment of isolation focused on ascertaining the availability of IPC consumables and other supplies, reviewing the suitability of the isolation area layout and the designated PPE donning and doffing areas, assessing whether the chlorine dilution process was performed properly, reviewing appropriate waste disposal, and assessing the level of training of health care personnel caring for isolated patients. Within the notification domain, the assessment focused on whether staff members were aware of the proper public health authority to contact when a suspected case was identified, whether a posted list of contact numbers for the district health office was available, and whether a functional mobile phone with adequate phone credit had been provided to staff members.The assessments were conducted at facilities in Bundibugyo, Kabarole, and Kasese districts, in western Uganda . AssessmA summary of the baseline IPC assessment findings was presented during the Ebola National Task Force meeting held on August 22, 2018, to Uganda Ministry of Health (MOH) staff members and other stakeholders present at the meeting. Based on the findings, the National Task Force identified additional funds to purchase needed IPC supplies. Furthermore, the Uganda MOH, CDC, and Makerere University’s IDI developed a training curriculum targeting the identified IPC weaknesses and a strategy to provide IPC mentorship to priority health care facilities within high-risk districts. An initial training of 23 national and district mentors was conducted on September 12, 2018, focused on screening, isolation, and notification of patients with suspected Ebola and other IPC topics. The national mentors who attended the training included representatives from the Uganda MOH, staff members from IDI, and clinicians from other district hospitals who had received previous IPC training. District health officers from a subset of high-risk districts also participated in the training. Mentorship teams that included one national mentor and one district mentor were created. Mentors have begun performing on-site mentorship at priority facilities to set up screening and isolation areas and to ensure that facilities are conducting appropriate screening, isolation, and notification. Training materials and curricula have been shared with partners in Rwanda and South Sudan to strengthen Ebola IPC preparedness in other countries neighboring DRC. In addition, this preparedness work is consistent with the capabilities that Uganda has been building under the Global Health Security Agenda and the International Health Regulations framework.The southward spread of confirmed Ebola cases in late 2018 to the Butembo and Katwa health zones of DRC identified additional high-risk districts in Uganda; trainings of mentors and health care personnel have now been conducted in Kanungu and Kisoro districts. On June 11, 2019 the Uganda MOH confirmed the initial cluster of three Ebola cases in Kasese district  outbreak demonstrated the importance of strengthening infection prevention and control (IPC) capacity at frontline health care facilities to prevent health care–associated transmission.IPC assessments were performed in four frontline health care facilities in Uganda shortly after an Ebola outbreak in neighboring Democratic Republic of the Congo was recognized. Recommendations were made to address identified gaps in screening, isolation, and notification practices.Ebola preparedness should include a focus on ensuring that general health care facilities have the capacity to rapidly identify suspected Ebola cases and refer patients for treatment to protect patients, staff members, and visitors.


Inflammation is an adaptive response triggered by noxious stimuli and conditions such as infection and tissue injury ,2. It haWhilst it is crucial to identify, in a selected plant, the PhC responsible for the pharmacological effects, it is also important to analyse whether different PhC, within a plant extract, synergistically cooperate to exert the specific health benefit. Along these lines, this Special Issue has been devoted to collecting original research papers and reviews on the effects and mechanisms through which plants extracts exert anti-oxidative and anti-inflammatory effects. New information has been added in this field by means of 15 articles, with 14 original papers and one review.Fraxinus angustifolia Vahl, the so-called manna, and its reductive and antioxidant capacity in water, as well as in the lipid phase. Authors found that the extract was effective in scavenging several reactive radicals, including those derived from heme-proteins, showed the lipoperoxyl radical-scavenging capacity in solution, and, more importantly, provided antioxidant protection in a complex environment, such as human red blood cells. Interestingly enough, the extract also showed anti-inflammatory effects in an in vitro model of intestinal bowel disease [In the first paper, Attanzio et al. report for the first time the polyphenol composition of a hydro-alcoholic extract of the sap from  disease .In line with the current growing interest in cosmeceuticals, the work of Zovko Koncic et al. has optimized the extraction methods of phenolic compounds from licorice root using glycerol, a non-toxic and eco-friendly solvent. The prepared extracts displayed relevant and interesting radical-scavenging, antioxidant, and anti-inflammatory effects. These activities, together with the tyrosinase and elastase inhibitory activities, may suggest that these extracts are highly-active components for cosmeceuticals products with anti-aging properties .Laserpitium species, the work of Szewczyk et al. has undertaken the qualitative and quantitative analysis of phenolic acids and flavonoids in the etheric and methanolic extracts of the fruits of Laserpitium kraffii Crantz and evaluated their antioxidative and cytotoxic effects. The study led to the identification of 12 phenolic acids and nine flavonoids and showed that both extracts have high cytotoxic and antioxidant potential [In light of the negligible current knowledge about the chemical constituents and biological activity in the otential . Nigella sativa oil obtained from a cultivar produced in the region Marche is of particular interest. The authors demonstrated that its thymoquinone content is higher than that from other cultivars in the Mediterranean area, Asia, and Indonesia. More interestingly, they showed how storage may affect thymoquinone content as well as the anti-inflammatory and antioxidant effects of the oil. Finally, they also demonstrated that both the antioxidant and anti-inflammatory effects of the oil does not simply rely on thymoquinone content, but also on other oil components that may exert synergistic effects [It is well known how the composition of a plant extract can vary considerably according to several factors, including the conservation procedure. In this regard, it appears that the work by Gabbianelli et al. on  effects .Crataegus almaatensis leaves. The authors found that the three main flavonoids  optimized their isolation technique and evaluated extracts for their vascular, anti-nociceptive, and anti-inflammatory effects, in vitro and in vivo [A novel chemical investigation came from the work of Kukula-Koch et al. on the flavonoid constituents of  in vivo . In light of the current interest on the alternative use of vegetal wastes, the study from Catoi et al. investigated 10 tomato varieties in terms of carotenoids content, phenolic composition, and their related antioxidant and antimicrobial activities. Taking into account the results obtained, the authors concluded that tomato industrial by-products may represent a source of natural bioactive molecules with applicability in the nutraceuticals and food industries . Notwithstanding its nutritional role and properties, meat has been recently linked to an increased incidence of non-communicable diseases, such as colorectal cancer. In the study from Nieto et al., authors aimed to evaluate the inflammatory role of processed meat and develop a functional meat product enriched in natural extracts with antioxidant and anti-inflammatory properties. The authors found that cooked ham that is low in fat and salt had antioxidant and anti-inflammatory properties related to the inhibition of substances involved in gut inflammation, such as reactive oxygen species, nitric oxide, and cytokines produced by macrophages. These health-promoting inhibitory properties were significantly increased when the cooked ham was enriched with bioactive phytochemicals. Therefore, the authors proposed that incorporating botanical extracts rich in phenolic compounds  in cooked ham is a good strategy to produce a healthy functional meat product .Studies on the health-promoting effects of green tea have typically focused on catechins. Unlike catechins, green tea flavonols have received little attention with respect to their usage and functionality. In their paper, Kim et al. investigated the antioxidative, anti-inflammatory, and antiproliferative effects of flavonol glycoside (FLG)- and flavonol aglycone (FLA)-enriched fractions isolated from green tea extract. These fractions contained 16 and 13 derivatives, respectively, including apigenin, kaempferol, myricetin, and quercetin. FLA exhibited higher radical-scavenging activity than that of FLG. Interestingly, both attenuated intracellular oxidative stress in neuron-like PC-12 cells significantly reduced inflammatory genes in murine macrophages and inhibited proliferation of both the colon adenoma cell line DLD-1 and the breast cancer cell line E0771. Moreover, treatment with FLG or FLA combined with paclitaxel had synergistic anticancer effects on the DLD-1 cell line. The authors concluded that flavonols from green tea may exert beneficial health effects that may be superior to those of flavan-3-ols .Salvia apiana and Salvia farinacea, particular interest comes from the work by Cardoso et al., which demonstrates significant antioxidative and anti-inflammatory effects of these two Salvia extracts, which also exert cytotoxic and antimicrobial effects. In light of the, so far, underexplored properties of Salvia apiana, to its richness in rosmanol, hydroxycarnosic acid, and a derivative of sageone [In this regard, the authors suggest that the bioactive properties of the two extracts are associated with their phenolic components and, in the particular case of  sageone .Rumex crispus and Rumex obtusifolius , collected at both the flowering and fruiting stages. The maximum number of phytochemicals was found in the reproductive organs, both in the flowering and fruiting period. On the contrary, stems showed a minimum content of active compounds [The accumulation and concentration of phytochemicals in different parts and organs of plants can considerably vary with regard to the function of these compounds in a plant’s lifecycle and growth phase. The work of Maslennikov et al. has investigated the accumulation of phenolic compounds and the antioxidant activity of extracts from different parts of ompounds . Glycyrrhiza glabra leaf extracts, as well as the anti-oxidative and anti-inflammatory profile of their three main components, i.e., pinocembrin, glabranin, and licoflavanone. Interestingly, the authors demonstrated a modulation of NF-κB/MAPK pathways by licoflavanone, highlighting the potential of this natural compound as a new scaffold in anti-inflammatory drug research [The valorisation of agrochemical wastes has been widely recognized as a crucial way to reduce the health spending and improve the accessibility of bioactive natural compounds. In line with this, Aiello et al. have investigated the chemical composition of three research .Carpinus turczaninowii extract has been demonstrated to attenuate high glucose-induced inflammation and arterial damage. Relevantly, authors provided mechanistic insights of the protective effects observed, as well as the identification of 15 types of phenolic compounds present in the extract  that exhibit antioxidant and anti-inflammatory properties [Hyperglycemia-induced oxidative stress fosters severe vascular damage and induces an inflammatory state strictly implicated in the etiopathogenesis of atherosclerosis. In the work by Kim et al., operties .Anji white tea is a unique variety of green tea rich in polyphenols. In the work by Zhao et al., the effect of Anji white tea polyphenols on the prevention of carbon tetrachloride-induced liver injury was investigated. Interestingly, the extract effectively counteracted liver injury through a redox-, anti-inflammatory-, NF-κB-dependent mechanism with an efficacy comparable to that of silymarin .Nigella sativa produced in the Marche region, this second work from Gabbianelli et al. has evaluated its analgesic and anti-inflammatory potential in a rat, adjuvant-induced arthritis model. Interestingly, at the same time, the authors evaluated its safety profile in vivo. Results showed that the extract was effective in the control of acute phase inflammation and prevented the development of rheumatoid arthritis (RA). On the other hand, it was not able to ameliorate the severity of arthritis in the chronic phase. Interestingly, despite the positive effects on the clinical signs of RA, the extract did not reduce plasma IL-6 levels, whereas it decreased plasma total cholesterol levels, strongly suggesting a potential control of cholesterol metabolism [In light of the previously reported data on the antioxidant and anti-inflammatory properties of a crude oil extracted from the seeds of tabolism .Pistacia lentiscus. A total of 19 studies were analyzed showing how, from preclinical evidence, the antioxidant potential of Mastiha may be correlated to the inhibition of protein kinase C, while its anti-inflammatory capacity is correlated to the inhibition of NF-κB activation [Finally, in their work, Kaliora and Papada reviewed the current knowledge on Mastiha, a natural product of the Mediterranean area found as a dried resinous exudate from the stems and branches of the tree, tivation .


Malvaceae plant Corchorus olitorius as a reducing and stabilizing agent. The size and shape of the obtained nanoparticles were modulated by varying the amounts of the metal salt and the broth extract in the reaction medium. Only one hour was required for the complete conversion to Au NPs, suggesting that the reaction rate was higher or comparable to those of nanoparticles synthesized by chemical methods. The obtained nanoparticles were characterized by UV–visible spectroscopy, transmission electron microscopy (TEM), X-ray diffraction (XRD), Fourier-transform infrared (FTIR) spectroscopy, and thermal gravimetric analysis (TGA). While infrared spectroscopy was employed to characterize the various functional groups in the organic layer that stabilized the particles, TEM images were used to optimize the conditions for NPs growth. A low concentration of the C. olitorius extract yielded mixed triangular and hexagonal shapes; in contrast, quasi-spherical shapes of Au NPs with an average size of 37–50 nm were obtained at a higher extract broth concentration. The Au NPs displayed Surface Plasmon Resonance (SPR) bands at 535 nm. An in vitro cytotoxic assay of the biocompatible Au NPs revealed a strong cytotoxic activity in three human cancer cell lines, namely, colon carcinoma HCT-116, hepatocellular carcinoma HepG-2, and breast adenocarcinoma MCF-7. In-silico bioactivity, drug-likeness, and ADMET  predictions were conducted in order to examine the pharmacokinetic behavior of the compounds present in the C. olitorius extract.A facile bottom-up “green” synthetic route of gold nanoparticles (Au NPs) is described, using a leaf extract of the  Over the past few decades, the possibility of developing new materials for biomedical applications has gradually increased because of the abundant advances made in the field of cancer diagnosis and therapy using nanoparticles (NPs). Nobel metal nanoparticles, such as gold (Au), platinum (Pt), and silver (Ag), are deemed as valuable precursors for the creation of innovative nanodevices and nanosystems that are constructed on the basis of a rational design with the precise integration of the tailored functional properties of NPs.The unique Surface Plasmon Resonance (SPR) in gold nanoparticles triggers their photostability and extremely efficient absorptivity of light ,2,3,4, tThe green synthesis of nanoparticles has attracted many researchers because of the high demand to produce clean, nontoxic chemicals, environmentally benign solvents, and renewable materials. Moreover, this methodology improves the biocompatibility of the obtained NPs ,10,11. FNeem leaves  × 100%, where ODt is the mean optical density of the wells treated with the tested compound, and ODc is the mean optical density of the untreated cells. The relation between surviving cells and drug concentration was plotted to obtain the survival curves of each tumor cell line treated with the NPs. The 50% inhibitory concentration (IC50), i.e., the concentration required to cause toxic effects in 50% of intact cells, was estimated from the dose response curves for each concentration, using the Graph pad Prism software  [The tumor cell lines were suspended in medium at a concentration of 5 × 10CA, USA) . VinblasC. olitorius leaves, without any special reducing or capping agents. Upon the addition of the gold solution to the plant extract, the color changed from colorless to red, with the SPR band at 535 nm, signifying the formation of Au NPs. The size and shapes of the obtained nanoparticles were manipulated by varying the ratio of the broth extract and the metal solution and were visualized using TEM. X-ray diffraction was used to confirm the crystalline nature of the nanoparticles. The obtained biosynthesized nanoparticles exhibited stability up to two weeks. The predictive analyses revealsedthat the main constituents of this plant extract have moderate to good bioactivity and drug-likeness scores. The ADMET studies were also undertaken to predict the pharmacokinetic behavior of these main components, thus supporting a future drug development program for drugs with increased effectiveness and decreased toxicity. Moreover, these synthesized particles displayed strong to moderate cytotoxic activities against three cancer cell lines . It is important to note that, in spite of other reports, this methodology shows the successful isolation of nanoparticles at ambient temperature, which allowed us to utilize the richness of the plant extract without any degradation of its components. In addition, it enhanced the cytotoxicity of the obtained nanoparticles in the tested cancer cell lines, as a result of the combination of the nanoparticles with the plant extract.In conclusion, we have presented a one-step green synthesis of gold nanostructures using naturally occurring biodegradable plant-based surfactants from