Despite great advances in research and treatment, lung cancer is still one of the most leading causes of cancer-related deaths worldwide. Evidence is mounting that dynamic communication network in the tumor microenvironment (TME) play an integral role in tumor initiation and development. Cancer-associated fibroblasts (CAFs), which promote tumor growth and metastasis, are the most important stroma component in the tumor microenvironment. Consequently, in-depth identification of relevant molecular mechanisms and biomarkers related to CAFs will increase understanding of tumor development process, which is of great significance for precise treatment of lung cancer. With the development of sequencing technologies such as microarray and next-generation sequencing, lncRNAs without protein-coding ability have been found to act as communicators between tumor cells and CAFs. LncRNAs participate in the activation of normal fibroblasts (NFs) to CAFs. Moreover, activated CAFs can influence the gene expression and secretion characteristics of cells through lncRNAs, enhancing the malignant biological process in tumor cells. In addition, lncRNA-loaded exosomes are considered to be another important form of crosstalk between tumor cells and CAFs. In this review, we focus on the interaction between tumor cells and CAFs mediated by lncRNAs in the lung cancer microenvironment, and discuss the analysis of biological function and molecular mechanism. Furthermore, it contributes to paving a novel direction for the clinical treatment of lung cancer. According to global statistics, lung cancer probably accounts for one-fifth of all cancer deaths and is one of the most deadly malignancies . In receTumor cells do not exist independently, but are surrounded by tumor microenvironment rich in stromal components and vascular networks. Microenvironment-mediated tumor initiation, progression, metastasis, and even drug resistance are the result of continuous interactions between tumor cells and the surrounding stroma. Cancer-associated fibroblasts, a type of permanently activated fibroblasts, are the most prominent stromal components and have been proved to have profound effects on tumor regulation. CAFs are the most dominant cells that synthesize and reshape extracellular matrix (ECM) in the tumor microenvironment, which contribute to increasing the hardness of tumor tissue and thus increase the ability of local invasion and metastasis. Meanwhile, CAFs are also important sources of many growth factors, chemokines, cytokines, such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), interleukin-6 (IL-6) and stromal cell-derived factor-1 (SDF-1). CAFs play multiple carcinogenic roles by regulating these factors and participating in various signaling pathways. A better understanding of the contribution of CAFs to tumor progression will lead to promising therapeutic approach interventions for stroma.Ultimately, tumor is a genetic disease that alters the flow of information in cells to change cell homeostasis and promote its proliferation. The Cancer Genome Atlas (TCGA) and the Cancer LncRNA Census (CLC) have provided cancer researchers with useful datasets and annotated data that accelerate our understanding of molecular level of tumor, including the role of lncRNAs in tumor development . A growiTumor is a complex ecosystem, including not only tumor cells, but also many stromal components. The stroma is made up of many distinct cell types, including fibroblasts, adipocytes, myeloid-derived suppressor cells (MDSCs), macrophages, lymphocytes, smooth muscle, blood vessels, and extracellular matrix (ECM). Together, they compose the microenvironment in which the tumor is located, known as the tumor microenvironment (TME) . AlthougThere is growing evidence that CAFs are recognized as heterogeneous population of cells. This heterogeneity may be caused by different origins of CAFs . In-deptIn addition, other cell types in TME  may also participate in CAFs’ differentiation. In breast cancer, kidney cancer, lung cancer and liver cancer, epithelial cells and endothelial cells adjacent to the cancer cells can differentiate into CAFs through epithelial-mesenchymal transition (EMT) and endothelial-mesenchymal transition (EndMT) . AlthougDistant cells outside the TME can also be transformed into CAFs. When mesenchymal stem cells (MSCs) are recruited by colorectal carcinoma microenvrionment, CXCR4/TGF-β1 signaling signaling pathway in this environment can mediate MSCs differentiation into CAFs . Cancer Due to their heterogeneity, CAFs have been shown to promote lung cancer development through a variety of unique mechanisms. CAFs were first shown to promote tumor progression in a prostate cancer model . Navab eBased on the Encyclopedia of DNA Elements (ENCODE) project, 93% of the genome is transcribed into RNA, of which only 2% is translated to protein. Those RNAs that lack the ability of coding proteins are known as non-coding RNAs (ncRNAs). There are many types of non-coding RNAs, which can be divided by size into short non-coding RNAs with length less than 200 bp and long non-coding RNAs with more than 200 bp . Initialhttps://biorender.com).Multiple mechanisms have been involved in the lncRNA-mediated gene regulation in many diseases, including tumors. This is probably due to their interactions with DNA, RNA or protein at three levels of transcriptional regulation, post-transcriptional regulation and epigenetic regulation. Most studies have demonstrated that the ability of lncRNAs to interact with different biomolecules extensively is of great significance in tumor development, such as tumor proliferation, metabolism, differentiation, apoptosis, migration and drug resistance. A recent series of experimental evidence indicates that their roles in TME are being recognized . In addiNormal fibroblasts mainly transformed into CAFs through coordination of cytokines, growth factors, lncRNAs, etc. Epithelial cells, endothelial cells, adipocytes, pericytes and mesenchymal stem cells may also participate in the differentiation of CAFs through different mechanisms. CAFs interact with lncRNAs to maintain tumor proliferation, migration, immunosuppression and therapeutic resistance. LncRNA-loaded exosomes are also widely involved in crosstalk between tumor cells and CAFs.The crosstalk between tumor cells and the tumor microenvironment is deemed to be necessary for tumor progression . CAFs arin vivo  have stronger tumor-promoting ability in NSCLC . In addiin vivo .Perhaps the best-known function of CAFs is to promote tumor progression. Microarray gene expression analysis of CAF and NF cell lines showed that differentially expressed genes were mainly regulated by the TGF-β signaling pathway. CAFs can promote EMT and tumor cell metastasis in a variety of ways through TGF-β-dependent mechanisms . TGF-β1,In recent years, immunotherapy has become a hot topic in cancer treatment. Nevertheless, only a small percentage of cancer patients benefit from tumor immunotherapy, and a number of patients develop resistance to the therapy . There i+ T cell infiltration in the nude mouse tumor microenvironment of NSCLC cell lines by targeting TGF-β  into a tumor-supporting M2 phenotype. This leads to an increase in infiltrating macrophages in the microenvironment, which then progresses to an immunosuppressive phenotype . Teng etng TGF-β . The mecAccumulating studies have found that tumor drug resistance is not only related to tumor cells, but also closely related to TME. TME-mediated resistance can be induced by chemokine and cytokine secreted by tumor cells and stroma. In addition, it has been shown that CAFs affect the therapeutic resistance behavior of tumor cells through the release of exosomes containing lncRNA. CAFs can activate the β-catenin pathway by transferring exosome lncRNA H19, promoting chemotherapy resistance in colorectal cancer . ExosomeAs functional RNA molecules, lncRNAs and lncRNAs-enriched exosomes control crucial pathways in microenvironment and are expressed in specific ways at specific stages of progression. They have gradually become new biomarkers and therapeutic targets for cancer. We provide our perspective on the clinical use of lncRNAs as therapeutic targets or prognostic/predictive biomarkers, contributing to the development of precision therapy.Previous studies have found that abnormal expression of lncRNAs can regulate the interaction between tumor cells and stromal cells, which can be used to predict tumor behavior and patient prognosis. The ability to capture tumor interstitial correlation signals may be of great significance. The lipid bilayer of exosomes provides a protective membrane that encapsulates and protects biologically active molecules. Therefore, exosomes exist stably in various body fluids such as blood, saliva, bronchoalveolar lavage fluid, and sputum. Due to their small size, exosomes are easier to penetrate into a variety of body fluids, mediating signal and substance exchange between tumor cells and CAFs. Exosomes can be used as promising diagnostic and prognostic value due to these unique characteristics . PreciseThe roles of CAFs in cancer development makes them potential therapeutic targets. Nevertheless, due to the lack of specific CAFs markers, it is difficult to accurately target CAFs without damaging normal tissues. In addition, CAFs have both protumorigenic and antitumorigenic effects. Ongoing attempts to treat CAFs still face a number of challenges. A few of receptor antagonists targeting CAFs-derived paracrine factors are being developed to prevent tumor-stromal interactions. Siltuximab, as an anti-IL-6 monoclonal antibody, was found to have strong tumor suppressive effects in lung cancer xenograft models treated with CAFs .in vivo is one of the biggest problems encountered in drug development , short hairpin RNAs (shRNAs), short interfering RNAs (siRNAs), small molecule antagonists, and nucleic acid aptamers . The degelopment . The effelopment . As the elopment . It is celopment .Exosomes are effective carriers for communication of genetic material and other information between cells. Inhibiting the production and secretion of exosomes can be a potential therapeutic method. Several compounds have been identified as potential inhibitors of exosome production. The most common exosome inhibitor is a non-competitive inhibitor of membrane neutral sphingomyelinase (nSMase) inhibitor GW4869. According to the bilayer lipid structure of exosomes, exogenous SMase can induce exosomes formation. Accordingly, the use of GW4869 can inhibit lipid metabolism and reduce exosome production, thus interfering with tumor progression . Some stCancer-associated fibroblasts (CAFs) are key components in TME that support tumor growth, generate a physical barrier against drug and immune invasion, and help regulate malignant progression. Activation and function of CAFs are mainly controled by a large number of factors, among which lncRNAs act in indispensable roles. Through lncRNAs, CAFs regulate tumor cell proliferation, metabolism, immune escape and treatment resistance. Tumor cells and CAF-derived lncRNA-loaded exosomes are also extensively involved in this interaction. Therefore, it is widely accepted that therapies designed to block the interaction between tumor cells and CAFs can enhance the effectiveness of anti-cancer therapies. Although there are only a few reports of lncRNAs in CAFs. To sum up, the results provide new insights into the communication between tumor stroma and cancer cells, and demonstrate the therapeutic potential of targeting lncRNA mediated cross-talk between cancer and stromal cells in cancer therapy. At present, there are still many obstacles and challenges to carry out targeted work on CAFs. The design of novel therapies targeting the tumor stroma depends on a better understanding of TME’s interactions with cancer cells.


Optical fibers have been used to probe various tissue properties such as temperature, pH, absorption, and scattering. Combining different sensing and imaging modalities within a single fiber allows for increased sensitivity without compromising the compactness of an optical fiber probe. A double-clad fiber (DCF) can sustain concurrent propagation modes , making DCFs ideally suited for multimodal approaches. This study provides a technological review of how DCFs are used to combine multiple sensing functionalities and imaging modalities. Specifically, we discuss the working principles of DCF-based sensors and relevant instrumentation as well as fiber probe designs and functionalization schemes. Secondly, we review different applications using a DCF-based probe to perform multifunctional sensing and multimodal bioimaging. From their compact size and alignment robustness, fiber optics-based sensing systems have become a powerful asset for a wide range of minimally invasive medical procedures to access organs deep inside the body ,2. A novFiber optics-based biosensors monitor biological or chemical reactions by combining a biochemical receptor with a detector relying entirely on optical transduction mechanism . The recReviews have been performed around fiber optics-based biosensors and their applications ,7,8; howA DCF is characterized by a concentric structure comprising two distinct guiding regions: a core and an inner cladding, as shown in the inset of To couple each signal in and out of the fiber with minimal losses, double-clad fiber couplers (DCFCs) have been introduced ,14,15,16Sensors are used to measure or detect localized signals. The intrinsic proximity between the sensor and the probed sample generally requires optical fibers for signal transduction. For diffuse or contact measurement, the fiber tip can be used as-is. This is common in oncological applications where fiber tips are put in direct contact with suspicious sites ,20,21,22A compact focusing system can be achieved either by using a monolithic design or a free-space arrangement using micro-optics elements. The optical system may also include some scanning mechanisms. When motorized or automatic beam scanning across the sample is required, two approaches are possible: proximal or distal scanning schemes . ProximaFor in vivo or in situ measurements, an optical fiber probe needs to be packaged to preserve its integrity and biocompatibility. To reach organs through some inner lumen, such as the pulmonary system, the gastrointestinal tract, or arteries and veins, the probe may be inserted within a clear plastic tube . DependiTemperature, pH, displacement, distance, and pressure may be measured with a DCF-based probe.DCF-based temperature sensing has been achieved by using rare-earth upconversion  44]. Th. Th44]. DCF-based pH measurements have been realized by either injecting a pH-sensitive dye into some biological sample  or by atHowever, injecting a pH indicator into the human body may cause health issues and regulatory challenges. Recently, an alternative technique—attaching a pH sensor onto the fiber tip—has been proposed. pH sensing has not only been achieved at the tip of the solid fiber  but alsoCommercially available ratiometric pH indicators, such as seminaphthorhodafluor (SNARF) ,47 or 5,Fiber optic-based displacement and distance sensors can be achieved through different approaches such as fiber grating-based sensing, Fabry–Perot interferometers, intensity-based sensing , or low-coherence interferometers ,50. DCF-A simple dual-detection confocal displacement sensor can be achieved using a DCF in conjunction with a GRIN lens where the core and the inner cladding each acts as an independent detector . Since tA similar strategy can be employed to construct a simple pressure sensor using a reflective deformable diaphragm across a DCF in a sealed cavity . PressurThe use of a DCF allows the combination of different modalities through a single fiber. Typical implementations combine a structural imaging modality, such as optical coherence tomography (OCT) ,58, withCombined OCT and pH sensing can be attained using one single fiber: The OCT and fluorescence excitation light propagate through the core of DCF, and fluorescence emission is collected via the inner cladding of the DCF. It enables the co-localized and simultaneous acquisition of complementary information concerning structural changes and pH values in deep regions. In addition, the OCT function within such a biosensor allows for the visualization of the sample and precise placement of the biosensor. Due to the fact that the pH value within a biological sample can be highly heterogeneous , micromeIVF is a widely used alternative means of obtaining offspring for humans, livestock, and precious wildlife species . Capon eOCT has been used for the detection of cancer margins  and lympSimilar to fluorescence-based pH sensing, DCFs can also allow combined OCT and temperature sensing via a miniaturized single fiber-based device. By using the core of DCF to collect the OCT signal, such a device can utilize the OCT function of the device to guide the precise placement of the associated temperature sensor . This coDCF can be used to combine OCT imaging with fluorescence detection to probe specific molecular signatures of a sample. The DCF core is used for OCT while the inner cladding collects the fluorescence emission signal allowing an increased sensitivity. Either the core or the inner cladding can be used to deliver the fluorescence excitation light, although it was shown that a core delivery allows better fluorescence imaging resolutions . AdditioA host of multimodal approaches have been investigated in the field of cardiology for atherosclerosis plaques characterization, including combined OCT and fluorescence sensing . A propePulmonology can also benefit from a multimodal imaging approach using OCT to provide a structural contrast, while fluorescence sensing can probe the collagen and elastin fiber content of the tissue . Lung imAnother vast domain of study exploiting the combination of OCT and fluorescence-based molecular sensing through a DCF is oncology, where such a system is used to identify pre-cancerous and cancerous lesions in various organs. Early cancer detection in the rectum can be achieved through the architectural and vasculature network assessment using ICG, allowing the identification and differentiation of normal and abnormal colons exhibiting hyperplastic polyp, adenomatous polyp, and adenocarcinoma ,61. FiguMolecular contrast can also be achieved by using reflectance-based spectroscopic sensing techniques. Similarly to fluorescence imaging, a DCF allows for the inclusion of a second modality for increased signal collection. A combination of OCT with hyperspectral imaging (HSI) using a DCF and DCFC has been demonstrated . HSI allSingle fiber reflectrometry (SFR) spectroscopy, where a broadband signal is emitted and collected through a single fiber , is anotDCFs can likewise be exploited for multi-photon sensing such as multi-photon fluorescence and harmonic generation, where the single-mode core is used for the excitation and the cladding for collection. Since multi-photon generation processes benefit from intrinsic optical sectioning, the inner cladding for the emission collection does not affect the resolution . Multi-pIt is possible to use a multimodal approach to combine structural imaging with motion tracking. For example, El-Haddad et al.  demonstrPrevious sections relayed examples combining OCT, as a structural imaging modality propagating through the single-mode core, with a sensing modality. It is also possible to use the DCF’s inner cladding for intensity-based structural imaging, while the core can be used for interferometric distance sensing. Lemire-Renaud et al.  reportedIn the past 15 years, DCF sensors have multiplied at an accelerating pace. Researchers have leveraged the benefits of using DCF sensors to demonstrate multifunctional and multimodal systems combining various imaging and sensing modalities. Compared to its single-mode counterpart, a DCF sensor enables dual propagation mechanisms without sacrificing the compactness of the fiber optics probe, increased sensitivity for most applications, or multiscale capabilities. However, most studies, as reviewed in this paper, are conducted to demonstrate the feasibility of utilizing DCF sensors. We believe that there are still many technical advances and biomedical applications to be explored and realized. Herein, several potential future directions will be discussed in more detail.Emerging advanced manufacturing techniques, such as two-photon 3D photolithography, are likely to enable the physical fruition of novel DCF sensor designs to achieve unprecedented performances. For example, it has been proposed that a freeform micro lens-in-lens can be fabricated by two-photon 3D photolithography to allow an inner lens optimized for the core of the DCF and an outer lens optimized for the inner cladding of the DCF ,92. SuchIn addition, the combination of DCF and advanced sensing techniques, such as microfluidics and microneedles-based devices, shows great potential. There have been a few promising attempts to use DCF to enable high collection/excitation efficiency for micro-flow cytometer  and surfMost DCF sensors reviewed in Beyond what has been reviewed in In conclusion, DCF-based sensors have shown significant benefits for multifunctional sensing and multimodal bioimaging. As reviewed in this paper, this technology serves a wide variety of biomedical applications. As technology matures and additional tools are made available, it is expected that novel systems and applications will continue to emerge.


Interstitial lung diseases (ILDs) include a large number of diseases and causes with variable outcomes often associated with progressive fibrosis. Although each of the individual fibrosing ILDs are rare, collectively, they affect a considerable number of patients, representing a significant burden of disease. Idiopathic pulmonary fibrosis (IPF) is the typical chronic fibrosing ILD associated with progressive decline in lung. Other fibrosing ILDs are often associated with connective tissues diseases, including rheumatoid arthritis-ILD (RA-ILD) and systemic sclerosis-associated ILD (SSc-ILD), or environmental/drug exposure. Given the vast number of progressive fibrosing ILDs and the disparities in clinical patterns and disease features, the course of these diseases is heterogeneous and cannot accurately be predicted for an individual patient. As a consequence, the discovery of novel biomarkers for these types of diseases is a major clinical challenge. Heat shock proteins (HSPs) are molecular chaperons that have been extensively described to be involved in fibrogenesis. Their extracellular forms (eHSPs) have been recently and successfully used as therapeutic targets or circulating biomarkers in cancer. The current review will describe the role of eHSPs in fibrosing ILDs, highlighting the importance of these particular stress proteins to develop new therapeutic strategies and discover potential biomarkers in these diseases. Interstitial lung diseases (ILDs) is a group of respiratory lung diseases affecting the lung interstitium which may lead to progressive lung fibrosis and ultimately, respiratory failure. Recent studies estimate that 13–40% of ILDs evolve to a fibrosing phenotype [ILDs are typically assigned to many disease categories for classification and management purposes, roughly on the basis of a known underlying disease , an inciting agent , or the absence of a known cause (idiopathic ILDs). Idiopathic ILDs include a large panel of diseases including idiopathic forms such as acute interstitial pneumonia (AIP), nonspecific interstitial pneumonia (NSIP) or idiopathic pulmonary fibrosis (IPF) , the mos223/225) in rat or mouse lungs leads to progressive and severe fibrosis [While fibrogenesis is different depending on the initiating insult and the affected organ, many of the major steps in its pathogenesis are similar . Epithelfibrosis . Moreovefibrosis . Furtherfibrosis . Heat shock proteins (HSPs) are upregulated in cells following various stresses ). They are classified in high molecular weight HSP  and the small HSP   Table 1Table 1. The intracellular role of HSPs in fibrogenesis has largely been investigated . HSP47 iAlthough HSPs were mainly studied for their intracellular cytoprotective and chaperon role, recent work highlighted a major role of secreted HSPs which interact with immune cells and act as immunomodulators . Furthermore, growing body of evidence has shown that extracellular HSP (eHSP) could be used as circulating biomarkers, mainly in cancer . ExtraceThe current review will describe the role of extracellular HSPs in several lung disorders involving ILDs and progressive lung fibrosis highlighting the importance of this particular stress proteins to develop new therapeutic strategies and discover potential biomarkers in fibrosing ILDs .Mycobacterium tuberculosis. In IPF and SSc-ILD, increased production of CCL18 by APC cells promotes collagen production by lung fibroblasts [Even if the origin of inflammation leading to fibrosis in ILDs depends on the pathogenesis of each diseases, similar sub-types of immune cells and cytokines/chemokines are involved in all cases. Briefly, it is clear that cells of both the innate and adaptive immune system such as macrophages, APC cells, CD4+ T-cells  are linked to the pathogenesis of fibrosing ILDs ,64 Figu. Oversimroblasts . Moreoveroblasts ,73. Immunomodulation by regulatory immune cells is crucial in dampening pathogenic immune responses and inhibiting the transition from inflammation to fibrosis. Therefore, many current treatments against fibrosis in all ILDs are based on immunoregulators such as glucorticoids and TNF inhibitors. It has been shown that extracellular or receptor-bound HSPs mediate immunological functions and immunomodulatory activity ,75. Thermycobacterium tuberculosis that participates to fibrosing SA, and environmental ILDs, are capable of eliciting important inflammatory immune response through TLR signaling to the extent that they have been labeled as “superantigens” [For instance, Hsp70, known to be involved in SSC-ILD, SA, RA, hypersensitivity pneumonitis or IPF promotes the production of anti-inflammatory cytokines and interacts with APC and macrophages by binding to their endocytic receptors resulting in the release of anti-inflammatory cytokine IL-10 that promotes fibrosis . Moreoventigens” . Their pThe complete mechanisms by which eHSPs modulate immunity and ILDs’ pathogenesis are yet to be understood. However, it is clear that they are a promising therapeutic target that can not only be used as a biomarker but also to modulate immune response in fibrosing ILDs .Idiopathic pulmonary fibrosis (IPF) is the most common and canonical chronic fibrosing ILD. It is a devastating disease with an unknown etiology and a median overall survival of approximately 5 years. This rare disease reaches a prevalence around 0.33 and 4.51 cases per 10,000 . This paHSPs and eHSPs were highlighted to take part in the pathogenesis of IPF and have been widely investigated . Dong etWallace et al. were the first to describe circulating autoreactive IgG against a 70–90 kDa alveolar epithelial cells’ antigen in IPF . RecentlRegarding HSP47, the collagen-specific HSP, the level of protein and autoantibodies in the sera were not significantly elevated in IPF patients compared with RA or mixed connective tissue disease (MCTD) patients . These rNonspecific interstitial pneumonia (NSIP) is often of unknown etiology but its development can also occur secondarily to a connective pathology or following toxin exposition . Still pSystemic sclerosis (SSc) is a rare chronic autoimmune disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs. Interstitial lung disease (ILD) affects approximately 30 to 50% of SSc patients and is in its progressive fibrosing form, the leading cause of death in SSc. SSc-ILD belongs to the connective tissue diseases (CTDs) and affects mostly young and middle-aged women ,95. ThisOther studies have shown that eHSP90 was associated with increased inflammatory activity, worse lung functions, and severe skin involvement in patients with SSc. In this study, baseline HSP90 level in plasma was predictive of the 12-month change in DLCO (diffusing capacity for carbon monoxide) in SSc-ILD patients . In addiRheumatoid arthritis (RA) is one of the main connective tissue diseases associated to ILD. Progressive lung fibrosis is a major complication of RA, which occurs in 30% of patients affected with this inflammatory joint pathology . RA-ILD Mycobacterium tuberculosis could be a promoting factor of SA-ILD [Mycobacterium tuberculosis (Mtb) HSP65, HSP70, and HSP16 were investigated in the context of SA. Mycobacteria antigens are recognized by the host immune system as PAMPs/DAMPs (pathogen-associated molecular patterns/damage-associated molecular patterns) and presented by antigen-presenting cells (APC). As a consequence, HSPMtb are expressed on the surface of APC to be presented to T-cells and may promote an autoimmune response involved in SA. Dubaniewicz et al. demonstrated that HSPMtb were present in lymph nodes from SA-ILD patients and participated at several stages of the disease’s development. HSP16Mtb was expressed at early stage whereas HSP70Mtb was expressed later and HSP65Mtb was continually expressed in capillary vessels in the lymph nodes [Mtb would be the main actor to initiate the autoimmune response in SA. Moreover, it appears that HSP16Mtb maintained M. tuberculosis in a genetic dormant stage in patients and is believed to further promote the development of SA [Mtb inhibited nitric oxide synthase’s expression, antimicrobial activity, and induced monocyte apoptosis resistance, a feature of sarcoidosis, suggesting that HSP16Mtb may have a prominent role in sarcoidosis pathogenesis. Treatment of peripheral blood mononuclear cells from SA patients with Mtb-HSPs induced a strong upregulation of pro-inflammatory cytokines suggesting that these antigens could elicit the host’s immune response [Lung are involved in 90 to 95% of cases of sarcoidosis, a pathology of unknown etiology, and patients present respiratory and systemic symptoms, including cough, chest pain, fatigue, musculoskeletal symptoms, fevers, and weight loss. Sarcoidosis-associated interstitial lung disease mortality is increasing over the years . Even thf SA-ILD . Some baph nodes . Highly nt of SA . Furtherresponse . Mtb-HSPresponse .In another study on patients diagnosed with sarcoidosis, it was shown that high levels of HSP65 and HSP70 were found in alveolar macrophages retrieved in BALF . Besides, it is worthwhile to note that several inflammatory bowel diseases, also associated with granuloma, generate pulmonary complications . For exaMycobacterium malmoense, a nontuberculous mycobacteria [Mycobacterium have been incriminated in ILD associated with sacroidosis, there is a potential interest, not yet investigated, to evaluate their expression and potential use as a biomarker in pneumoconiosis  exhibited increased basal level of HSP70 compared to control mice. However, a second stimulation with SR-antigen on these AMs, did not further enhance HSP70 levels in sensitized mice compared to control mice, which showed much higher HSP70 levels [Hypersensitivity pneumonitis is an immune-mediated inflammatory lung disease caused by the inhalation of a large variety of antigens from animals, bacteria, fungi, plants, metals, and chemicals found in the environment . These a0 levels . The abs0 levels . TherefoDrug-induced lung disease (DILD) is another set of ILD associated with an exposure. Kakugawa et al.  have evaThis review highlights the role of extracellular HSPs and their potential use as diagnostic and therapeutic tools in fibrosing interstitial lung disease . HSPs arMoreover, strategies in vivo to modulate eHSPs’ expression were somehow effective to prevent, limit or stop the progression of certain types of ILDs such as IPF. Finally, the current review highlights the lack of investigations on the role of extracellular vesicles and especially HSPs in EVs in the field of fibrosing lung diseases. Today, extracellular HSPs and, in particular, HSPs in exosomes are widely studied for their theranostic potential in cancer. It is important for the respiratory research and clinical field to take advantage of this knowledge about HSPs in exosomes that are the reflection of eHSPs from cells and try to discover new therapeutic targets and diagnostic strategies to overcome the burden of lung diseases that continues to increase over the years.


The importance of extracellular matrix (ECM) proteins in mediating bone fracture repair is evident, and fibronectin (FN) has emerged as a pivotal regulator of this process. FN is an evolutionarily conserved glycoprotein found in all tissues of the body, and functions in several stages of fracture healing. FN acts as a three-dimensional scaffold immediately following trauma, guiding the assembly of additional ECM components. Furthermore, FN regulates cellular behavior via integrin-binding and growth factor-binding domains, promoting downstream responses including cell recruitment, proliferation and differentiation. Due to its diverse functions, the development of FN-based strategies to promote fracture healing is under intense research. In this review, we discuss the recent advancements in utilizing FN-based biomaterials, showing promise in tissue engineering and regenerative medicine applications. The skeletal system is involved in many roles, including mechanical load bearing and movement, soft tissue protection, and as a supportive niche for hematopoietic cells . The perApproximately 5–10% of bone fractures result in delayed healing or non-union, which may require surgical intervention . The curThese concerns and limitations highlight the need for developing novel strategies aimed at promoting bone regeneration, which can be achieved by further elucidating the molecular mechanisms involved in fracture healing. Of particular interest is the role of extracellular matrix (ECM), which comprises approximately 90% of bone tissue in mass (v/v) . AdditioMany ECM molecules have been studied extensively throughout the years. This review seeks to integrate the findings related to one particular ECM protein, namely fibronectin (FN), which seems to be functionally relevant across several stages of fracture healing.Fracture healing is a tightly controlled process, which after the injury causing trauma can be divided into four main stages: (1) inflammation, (2) soft callus formation, (3) hard callus formation, and (4) bone remodeling. There seems to be temporal overlap between aforementioned stages of fracture healing , but makThe initial stage of inflammation arises from damage to soft tissue surrounding the fracture, which leads to bleeding that later develops into a hematoma. Inflammation itself is tightly regulated as the inflammatory cascade is essential to initiate fracture healing, but must be appropriately resolved at later stages  into the ECM, which are then mineralized to form hydroxyapatite crystals . RemodelFibronectin is an evolutionarily conserved glycoprotein, existing as a dimer composed of two nearly identical ∼250 kDa subunits . FN is aFibronectin protein can exist in 20 isoforms, arising from alternative splicing of a single pre-mRNA molecule . StructuFibronectin matrix structure is assembled into higher order fibrils of >10 nm in diameter and tens of micrometers in length . Three-din vivo  was shown to promote proliferation and differentiation of osteoblasts in vitro . Comparaneration . FN-mediin vitro .There is evidence that cFN is synthesized by inflammatory cells, neutrophils in particular, which infiltrate the fracture hematoma immediately within 48 h post-injury . It is hFibronectin has also been shown to bind a variety of GFs relevant to bone regeneration . A studyin vitro, which could promote osteogenesis via regulating the coupled process of angiogenesis  family, which have been shown to recruit, among others, MSCs, fibroblasts and chondro/osteoprogenitors . There iogenesis . pFN is ogenesis . Coupledogenesis .Due to its diverse properties in regulating both osteogenic and supporting cell types, along with orchestrating the assembly of various other ECM proteins and GFs, incorporating FN into regenerative medicine applications is under intensive research .in vitro. This approach could thus provide improved ex vivo expansion and differentiation of MSCs into desired cell type(s) for stem cell-based therapies. Another noteworthy finding demonstrated that the GF binding domain (FNIII 12–14) could also facilitate cell attachment and spreading to titanium surface when an RGD gain-of-function mutation was introduced within (d within .in vitro, and significantly promote fracture healing in vivo (in vitro (In addition to FN fragments which can be immobilized, the development of hydrogels also seems to be a promising avenue. Such hydrogels can potentially be administered surrounding the fracture site directly, which could alleviate the issue of difficult-to-access areas when using grafts.  in vivo . Another in vivo . The autin vitro .in vivo and in vitro (Despite the progress made, several biological questions remain unanswered. The negative relationship between aging and fracture healing has been well-described, and aberrations in FN functionality could mediate this reduced healing capacity. Interestingly, it has been shown that there is a significant effect of age on alternative splicing of FN both in vitro , but thein vitro , and levin vitro (Interestingly, relatively little is known about the role of FN during bone remodeling. There have been some demonstrations which suggest FN can upregulate osteoclast activity in vitro , but stuin vitro , it remaBone fractures will become increasingly common in the aging population, causing significant morbidity and financial burden. The involvement of ECM in fracture healing has been well-described along with its key molecular players, but recent evidence is further accumulating for the crucial role of FN. As it plays an important role in various stages of the healing cascade, studying FN functionality further, along with its incorporation into treatment strategies, could be of great utility.in vivo studies are warranted to evaluate their efficacy, perhaps investigating not just their effect on osteoprogenitors and MSCs, but to the highly relevant ECs and immune cell subsets as well. Several of the research lines summarized in this review have also highlighted the functional importance in utilizing recombinant FN fragments. Such recombinant fragments could pave the way for upscaling this approach, making it more feasible to translate into treatment strategies.Much attention has been devoted to developing FN-based biomaterials, and such three-dimensional scaffolds–especially those which can exert temporal control on GF availability–seem highly promising. Further JK performed the literature research, wrote the manuscript, and designed the figure. BE revised the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


These specialised lipids are important endogenous anti-oxidants with additional roles in regulating membrane fluidity and dynamics, intracellular signalling, immunomodulation and cholesterol metabolism. Lipidomic profiling of human population cohorts has identified new associations between reduced circulatory plasmalogen levels, an abundant and biologically active sub-class of ether lipids, with obesity and body-mass index. These findings align with the growing body of work exploring novel roles for ether lipids within adipose tissue. In this regard, ether lipids have now been linked to facilitating lipid droplet formation, regulating thermogenesis and mediating beiging of white adipose tissue in early life. This review will assess recent findings in both population studies and studies using cell and animal models to delineate the functional and protective roles of ether lipids in the setting of obesity. We will also discuss the therapeutic potential of ether lipid supplementation to attenuate diet-induced obesity.Ether lipids are a unique class of glycero- and glycerophospho-lipid that carry an ether or vinyl ether linked fatty alcohol at the  This is contrary to conventional glycerol-based lipids that have acyl chains attached by an ester linkage at the sn-1 position , such as linoleic acid (18:2), arachidonic acid  or docosahexaenoic acid  are typically at the sn-2 position , metabolic disease and some genetic disorders . This reAn early lipidomic study, analysing plasma samples from monozygotic twins discordant for obesity, demonstrated that obesity was associated with increased levels of lyso-phospholipid species, which possess some pro-inflammatory effects, and a concurrent decrease in ether lipids, independent of genetic factors . AnotherPeroxisomes are membrane bound organelles that perform multiple functions, including ether lipid synthesis, reactive oxygen species (ROS) metabolism, fatty acid oxidation and cholesterol transport . DeficieAdipose tissue plays a central role in regulating energy metabolism and homeostasis. There are three distinct types of adipose tissue; white (WAT), brown (BAT) and beige adipose tissue. WAT is comprised of uniocular lipid droplets and is involved in storing excess energy in the form of neutral lipids, such as triacylglycerols (TG), that can be remobilised in times of energy deficiency . Conversin vitro revealed contrary results  from lean and obese individuals offered greater insights into the composition of adipose tissue ether lipids in obese individuals . Specifiin vivo  genetic modulation of enzymes involved in the ether lipid metabolism and 2) supplementation with their metabolic precursors, such as alkylglycerols  .Gnpat knockout mouse model to induce plasmalogen deficiency, in vitro study has also shown that alkylglycerols are effective at reducing oxidative stress, a hallmark of obesity and subsequent metabolic diseases (Utilising a diseases . Culturediseases .Shark liver oil is a natural product rich in alkylglycerols. A recent preliminary clinical study assessed the ability of shark liver oil supplementation to modulate plasma and immune cell plasmalogen levels in overweight or obese men . The stuin vivo (A recent study examined the impact of supplementation of an alkylglycerol mix on the plasma and various tissues, including the liver, VAT and skeletal muscle of mice in vivo . After 1in vivo . As discin vivo  (Brites in vivo . Whilst in vivo . Furtherin vivo , 2020.in vivo. Combining these studies further suggests that the increased oxidative stress and inflammation associated with obesity promotes the dysregulation of ether lipids in adipose tissue. As lipid metabolism is highly complex, it remains unclear whether the reduced ether lipids drive obesity, or obesity drives the observed decrease in ether lipids. Importantly, this work highlights potential functional roles for ether lipids in the protection against diet-induced obesity. Thus, increasing plasmalogen levels may be beneficial in the attenuation of obesity and its complications via the promotion of thermogenesis, antioxidant effects and cellular signalling to reduce inflammation.In summary, ether lipids are important biological molecules with functional roles within adipose tissue. Numerous studies now demonstrate a clear relationship between circulating ether lipids and obesity, as reduced plasmalogen levels are apparent in obese individuals and facilitate diet-induced obesity YLS: writing—original draft preparation. YLS, SP, ACC, and PJM: writing—manuscript revision. SP, ACC, and PJM: supervision. All authors have read and agreed to the published version of the manuscript.PJM is inventor on a patent; WO 2021/007623 A1; Title: Compositions for maintaining or modulating mixtures of ether lipid molecules in a tissue of a human subject. The remaining authors declare that the review was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Covid-19 pandemic has exposed critical inequities in global healthcare supply chains and the need for these systems to be analyzed and reoriented with an equity lens. Implementation research methodology can guide the use of evidence-based interventions to re-orient health supply chains towards equity and optimize health outcomes. Using this approach, private and public sector entities can adapt their strategies to focus not just on efficiency and cost savings but ensuring that vulnerable populations have access to essential medications, vaccines, and supplies. Findings can inform regulations that address supply chain inequities at the global level, strengthen existing systems to fill structural gaps at the national level, and address contextual challenges at the subnational level. This methodology can help account for historical practices from prior health initiatives, identify contemporary barriers and facilitators for positive change, and have applicability to the Covid-19 pandemic and ongoing vaccine distribution efforts. An implementation research approach is critical in equipping health supply chains with a path for more resilient and equitable distribution of necessary supplies, vaccines, and delivery of care. The Covid-19 pandemic has illuminated deep fault lines and inequities in healthcare systems, including chronic weaknesses in health supply chains, that must be addressed [Lower- and middle-income countries (LMICs) have historically lacked the resources and influence that higher-income countries (HICs) have had over global supply chains with the Covid-19 pandemic only exacerbating this power imbalance . HICs ha12Unfortunately, lessons of supply chain failures or gaps due to power disparities found in prior pandemics (including the Ebola epidemic in West Africa) have not translated into stable fixes . Many ofIn addition to analyzing the gaps, both public and private sector health supply chains need to orient toward an equity-focused agenda to mitigate the long-term disparities evidenced by the Covid-19 pandemic. Strengths and weaknesses within these systems should be identified, leveraged, and addressed to restructure these systems with a focus on health outcomes. Private and public sector manufacturers and distributors of essential goods have historically focused on improving efficiency to maximize profit and cost savings . Yet, thImplementation research can guide the use of evidence-based interventions to re-orient health supply chains towards an equity focus even amidst an ongoing pandemic straining our global health system. Implementation research has been defined as “the scientific study of the use of strategies to adopt and integrate evidence-based health interventions into clinical and community settings to improve individual outcomes and benefit population health” . This meWithin healthcare, evidence-based interventions can include health activities such as community nutrition education sessions, prenatal check-ups, or facility-based deliveries of babies . Within 9Contextual factors are defined as “the set of circumstances or unique factors that surround a particular implementation event” [n event” . In impln event” . ContextImplementation strategies are understood as the approaches used for successful and sustained application of interventions [ventions . These sventions . For exaImplementation outcomes are understood as the larger scale results of implementation of evidence-based interventions [ventions . Key outventions . Supply However, there are limitations to applying this implementation research approach framework to a supply-chain context. This paper highlighted only a few of many research frameworks that could be applied to this context. Further adapting equity-oriented frameworks to analyze supply chain evidence-based interventions would require that both private and public sector stakeholders have some understanding of contextual factors, strategies, and outcomes. This analysis will require interdisciplinary collaboration, including stakeholder engagement from implementation science experts, health-sector leaders, and supply chain experts from private sector manufacturers to local transporters. During a dynamic pandemic that is already overstretching current capacity in LMICs, facilitating this analysis among key stakeholders and applying it to the Covid-19 pandemic may be challenging. Nonetheless, this approach is crucial in identifying lessons learned and addressing structural challenges within the field.By using an implementation research approach, supply chain evidence-based interventions can be better designed and implemented to link manufacturing of essential materials in factories worldwide to individuals receiving care and protection, especially within LMICs. Here, we provide an example of how implementation research methods have been applied to international supply chain challenges in access to antiretrovirals (ARVs) at all levels of implementation, from the global to subnational levels.In the mid 2000s, there was a major global effort to achieve universal access to HIV treatment. However, there were distinct barriers for LMICs to meet this objective given the difficulty for them to procure ARVs . At the national level, countries faced challenges with forecasting demand and weaknesses in their national logistics systems affecting their ability to distribute ARVs. In Rwanda, the government addressed these barriers by leveraging funding for HIV programs to strengthen national logistics systems, train healthcare workers in supply chain management and develop electronic inventory management systems in partnership with the USAID Global Health Supply Chain Program [At the  Program . These s Program 14. Other Program .subnational level, barriers were identified in the last mile of ARV delivery and storage. In Ghana, Kenya and South Africa, large regional warehouses were built for storage of ARVs and essential materials to reduce local stockouts and facilitate faster transport to areas with high demand [At the h demand . In recoh demand 16.In turn, this approach can be applied at all levels when preparing for and implementing Covid-19 vaccine delivery. For example at the global level, pooled procurement efforts such as with the African Union or COVAX can take into account lessons learned using similar methods used by the Global Fund and CHAI 18. At thFor the foreseeable future, the continued spread of Covid-19 and inequities in vaccination supply highlight the importance of conducting supply-chain analyses with an equity lens. An implementation research approach can identify creative solutions that can potentially overcome these barriers, not only for the sake of Covid-19 vaccine distribution, but also to address future health threats. This analysis can lead to adaptation of global regulations, policies and context-specific strategies that optimize equity in healthcare delivery.In the long term, promoting equitable supply chains through implementation research will help facilitate many countries efforts towards Universal Health Coverage . This co


Late-onset disease (LOD) refers to invasive GBS infections between 7 and 89 days of life. LOD transmission routes are incompletely understood, but may include breast milk, household contacts, nosocomial, or community sources. Invasive GBS infections and particularly meningitis may result in significant neurodevelopmental injury and long-term disability that persists into childhood and adulthood. Globally, EOD and LOD occur in more than 300,000 neonates and infants annually, resulting in 90,000 infant deaths and leaving more than 10,000 infants with a lifelong disability. In this review, we discuss the clinical impact of invasive GBS neonatal infections and then summarize virulence and host factors that allow the bacteria to exploit the developing neonatal immune system and target organs. Specifically, we consider the mechanisms known to enable GBS invasion into the neonatal lung, blood vessels and brain. Understanding mechanisms of GBS invasion and pathogenesis relevant to infections in the neonate and infant may inform the development of therapeutics to prevent or mitigate injury, as well as improve risk stratification.Group B streptococci (GBS) are Gram-positive β-hemolytic bacteria that can cause serious and life-threatening infections in neonates manifesting as sepsis, pneumonia, meningitis, osteomyelitis, and/or septic arthritis. Invasive GBS infections in neonates in the first week of life are referred to as early-onset disease (EOD) and thought to be acquired by the fetus through exposure to GBS  Streptococcus agalactiae) are Gram-positive, β-hemolytic bacteria, which represent an important cause of neonatal and infant morbidity and mortality. GBS are typically commensal organisms and colonize the gastrointestinal (GI) and female lower reproductive tracts in approximately 20–25% of women  or reduce LOD case rates has led to exploration of other clinical practices to prevent invasive GBS infections. Further, there is a strong push to develop novel therapeutic and prophylactic strategies that might more effectively target the wide range of GBS-associated outcomes.Clinical practices markedly alter the outcome of invasive GBS disease in neonates. In the 1970s, GBS infections appeared as the leading cause of neonatal mortality and morbidity, igniting the need for potential therapeutics. During this time, EOD incidence was strikingly higher than LOD at 2–3 cases per 1,000 births and 0.2 cases per 1,000 birth, respectively . The useScreening and IAP policies vary by country and have fluctuating effectiveness depending on the regional prevalence of GBS maternal colonization and distribution of serotypes. While universal screening programs test all pregnant women and treat all women who are rectovaginally colonized with GBS, a risk-based IAP policy only administers IAP if women are at higher risk for invasive disease  or if they have experienced adverse outcomes due to GBS in a previous pregnancy . UniversGBS encodes a plethora of virulence factors that impact its ability to transition from asymptomatic colonizer to successful invasive pathogen. One major factor is the GBS sialylated capsular polysaccharide (CPS), which aids in evasion of host immunity . There aGBS strains are categorized by CPS serotype but may also be sub-grouped into sequence types or clonal complexes  by multi-locus sequence typing . Four maHowever, antibiotic resistance is not restricted to ST-17 or other emerging hypervirulent complexes. Reduced sensitivity to many antibiotics, including penicillin G, ampicillin, clindamycin, and vancomycin has been detected in GBS-colonized pregnant women in Kenya, China, Ethiopia, South Korea, Brazil, Poland, and the United States . ErythroAs expected, drug resistance has also been noted among numerous neonatal populations . The druFurther, rates of resistance are highly variable between studies and thus it is difficult to determine GBS susceptibility profiles on a global scale. Although most GBS isolates, particularly those in neonates, remain sensitive to first-line beta-lactam antibiotics used for IAP, the detection of strains that are resistant to these and other drugs raise concerns regarding the long-term efficacy of IAP against invasive GBS in neonates. These data also emphasize a need for more consistent surveillance of antibiotic resistance for GBS isolates and for novel therapeutic strategies that can be used safely to prevent neonatal disease.N = 1,206) in Australia revealed that children with invasive GBS infections had three times the adjusted odds ratio (aOR) for death compared to all live births   . GBS dis2.1–4.3) .Invasive GBS infections in the neonate and infant are also associated with long-term sequelae related to brain injury. Meningitis is a major risk factor for neurodevelopmental impairment (NDI) with 1 in 5 survivors of infant GBS disease developing moderate to severe NDI over 18-months . In Denmin utero, male offspring had elevated IL-1β levels in the blood compared to females   and is athesized  evidencethesized . Furtherthesized . Maternathesized . Thus, cIn immunocompetent mothers, the placental transfer of GBS-specific antibodies is an important modulator of neonatal susceptibility. Maternal IgG transfer is most abundant during the third trimester; the last 4 weeks of pregnancy is the window during which most antibodies are transferred . High neAdditionally, neonatal susceptibility to GBS disease can also be attributed to their propensity for immunosuppressive responses to bacterial infection. For instance, neonatal mice rapidly produce high levels of IL-10 in response to GBS, which in turn suppresses neutrophil trafficking to infected tissues and thus prevents bacterial clearance. When IL-10 production is blocked, neonates exhibited increased neutrophil recruitment and reduced bacterial burden, showing that these neonates were resistant to GBS sepsis . In anotNeonates also have intrinsic immune deficiencies that prevent clearance of GBS and contribute to severe disease. Compared to adults, neonates have defective T helper 1 (Th1) responses to GBS. In adults, splenocytes produce type 1 pro-inflammatory cytokines  in response to GBS infection and recruit T cells through the early release of chemokines, such as CXCL9, CXCL10, and CCL3. In turn, CD4+ T cells activate and differentiate into Th1 cells, which produce robust level of IFN-γ and facilitate bacterial clearance . NeonateAlthough neonates have several neonatal immune perturbations that predispose to an invasive GBS infection, they can paradoxically also exhibit exaggerated inflammatory responses that promote disease. At a high bacterial burden, preterm infants had elevated IL-6 levels compared to adults, which is consistent with the inflammatory nature of neonatal GBS sepsis . AdditioThe neonatal lung is a highly susceptible organ to GBS invasive disease. GBS can enter the fetal or neonatal lung with aspiration of GBS-infected amniotic fluid or vaginal fluids during delivery . This prTo invade the neonatal lung, GBS must first evade host immune defenses. A major GBS factor enabling immune evasion is CPS . GBS canIn neonates, however, the immune system fails to efficiently clear GBS. A study of the cellular and molecular mechanisms underlying neonatal susceptibility to GBS-associated lung injury used a mouse model and focused on an analysis of Siglec receptor and Sn expression alveolar macrophages . Lung-reAfter evading the first line of pulmonary immune defense, GBS must adhere to the pulmonary epithelium to successfully invade the lung. GBS employs a multitude of surface-associated adhesins to interact with the lung epithelium, including Spb1 (pili), BibA, and fibrinogen binding protein (FbsB) . In addicylE, which encodes the β-hemolytic pigment. The GBS hemolysin is a key virulence factor enabling invasion of the neonatal blood vessels and dissemination.Once GBS has established a niche in the lung mucosa, it can penetrate lung endothelial barriers to gain access to the bloodstream. The loss of endothelial barrier integrity appears to be largely mediated through the actions of the GBS pore-forming toxin, hemolysin  . PreviouGBS hyperhemolytic membrane vesicles (MVs) have also been shown to exacerbate pulmonary and systemic GBS infection in neonatal mice. In a systemic challenge model, co-infection of neonatal mice with hemolytic MVs and nonhemolytic GBS resulted in reduced survival compared to infections with nonhemolytic GBS and/or nonhemolytic MVs alone . Co-infein utero. Nonhuman primate (NHP) models have advanced the understanding of in utero infections that lead to GBS invasion and fetal lung injury, which can manifest as EOD. In a pigtail macaque (Macaca nemestrina) model, GBS is inoculated into the choriodecidual space between the uterine muscle and the placental chorioamniotic membranes  compared to postnatal day 5 (P5); taxonomic analysis of the intestinal microbiome at these timepoints observed an underdeveloped phenotype at P1 compared to P5. Reconstitution of P1 pups with P5 microbiota rescued this phenotype, suggesting that susceptibility to GBS intestinal colonization is microbiome-dependent . HoweverHuman clinical studies also indicate that intestinal GBS may promote the development of meningitis. A longitudinal study tracking microbial colonization of the gut observed that, prior to LOD-associated sepsis, GBS clones found in the blood of septic preterm infants was genetically identical to GBS clones previously isolated from the infant’s stool . To coloAnother ST-17 surface protein, Srr2, is also implicated in binding to the intestinal wall. Srr2 interacts with intestinal M cells to enhance GBS transcytosis across the intestinal epithelium, permitting subsequent access to the bloodstream . GBS train vitro adhesion of GBS to brain endothelial cells through the cytoskeletal protein vimentin; mice infected with BspC-deficient GBS exhibit a lower bacterial burden in the brain, inflammation, and mortality (Many virulence factors that are critical for colonization and invasion of the neonatal intestine also facilitate BBB traversal. For example, HvgA facilitates adhesion and crossing of the choroid plexus and microvascular endothelial cells that constitute the BBB. Oral challenge of neonatal mice with HvgA-expressing GBS leads to bacterial invasion of the brain and meningitis . Howeverortality . Some GBThe BBB is a tightly controlled interface that separates the microvasculature from the parenchymal tissue of the brain. This protects the central nervous system from circulating pathogens that may be contained in the blood. This essential barrier is made up of interlinked layers of perivascular pericytes and astrocytes that sit atop a basal membrane made of the extracellular matrix, and each component is involved in regulating BBB integrity . Unique via epithelial-mesenchymal transition (Multidimensional quantitative proteomics of infected whole brains revealed that GBS infection altered proteomic signatures corresponding to upregulated interferon signaling and leukocyte recruitment. In the brain microvasculature, proteins involved in barrier function, such as maintaining integrity of the BBB after brain hemorrhage, were downregulated . This loansition .The immature intestinal epithelial barrier provides another example of how GBS exploits host signaling cascades to facilitate dissemination to the brain. Neonatal mice infected with GBS displayed dysregulation of the epithelial junction proteins E-cadherin, occludin, and claudin-3 . WhereasDrosophila infection model, GBS Blr, a lipoprotein on the bacterial surface, interacts with host LpR2 to translocate into the brain through endocytosis. GBS engagement of LpR2 through Blr is required for GBS infiltration of the brain as corroborated in a mouse model of infection (GBS can also exploit other host pathways to facilitate infection of the brain. In a novel nfection . Additionfection . AltogetEarly-onset disease and LOD are invasive GBS infections of the neonate and infant that contribute to neonatal mortality and long-term disability. In this review, we considered how GBS exploits vulnerabilities in immune defenses to initiate and propagate infection within the neonatal lung, intestine and brain. The pathogenesis of GBS invasive disease is reliant on the organism’s ability to overcome host barriers. The use of animal models that closely mirror GBS maternal-infant transmission and pathogen acquisition by the infant has been pivotal in identifying how these bacteria exploit the underdeveloped neonatal immune system for dissemination and pathogenesis. GBS expresses a variety of virulence factors including CPS, hemolytic pigment, adhesins and extracellular enzymes that can act in concert to subvert, counteract, or promote immune responses conducive to GBS dissemination in the neonate. Many of these virulence factors are critical for colonization and/or invasion of GBS at various host niches leading to neonatal disease. While GBS screening coupled with IAP has been successful in reducing invasive disease, the emergence of antibiotic resistant GBS strains raises concerns about the long-term efficacy of this approach. Unravelling the mechanisms of GBS colonization, invasion and pathogenesis leading to EOD or LOD is key to discovering novel antimicrobial targets that will allow for the development of new therapeutics and prophylaxis strategies to better control and prevent invasive GBS disease in the neonate. Fully elucidating the molecular basis of interactions between GBS and the neonate will be essential to accomplish this endeavor.All authors listed have made a substantial, direct, and intellectual contribution to the work, wrote the manuscript, and approved it 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Vaccines are an essential component of pandemic preparedness but can be limited due to challenges in production and logistical implementation. While vaccine candidates were rapidly developed against severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), immunization campaigns remain an obstacle to achieving herd immunity. Dissolvable microneedle patches are advantageous for many possible reasons: improved immunogenicity; dose-sparing effects; expected low manufacturing cost; elimination of sharps; reduction of vaccine wastage; no need for reconstitution; simplified supply chain, with reduction of cold chain supply through increased thermostability; ease of use, reducing the need for healthcare providers; and greater acceptability compared to traditional hypodermic injections. When applied to coronavirus disease 2019 (COVID-19) and future pandemic outbreaks, microneedle patches have great potential to improve vaccination globally and save many lives. Many of the great pandemics in the 20th and 21st centuries have been caused either by an influenza or coronavirus. Many experts have warned that repeated pandemics are inevitable and likely imminent [The COVID-19 pandemic has overwhelmed both health and economic systems. While vaccine candidates were rapidly developed against SARS-COV-2, immunization campaigns remain an obstacle to achieving herd immunity. In previous pandemics, some countries have had trouble accessing vaccines and other essential health products . OverwheGiven these challenges, in addition to regional protectionism, the implementation of vaccination programs could be jeopardized. The founding of the COVID-19 Vaccines Global Access (COVAX) Facility by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO) is an attempt to garner resources and unite higher- and lower-income countries for a coordinated, rapid, transparent, and equitable access to COVID-19 vaccines worldwide.The WHO identified vaccine hesitancy as one of the top ten global health threats in 2019 . VaccineAs a possible solution for pandemic countermeasures, dissolvable microneedle patches should be considered as a vaccine delivery method . The patThis paper examines the potential ways that microneedle patches may overcome limitations in traditional vaccination campaigns by hypodermic injection and review their applications to the current COVID-19 pandemic and beyond.There are several barriers for effective vaccination campaigns in all resource settings, including the need to increase vaccine immune response, simplify the supply chain, eliminate biohazardous waste, improve cost-effectiveness, and reduce reliance on trained healthcare providers .Microneedle patches have been studied for their potential application against many pathogens, including other respiratory viruses see . For seaA large healthcare workforce is required to have mass vaccination campaigns, which can be limited in developing countries and could cause crowding in the pandemic era. Most vaccines that are administered by hypodermic needle and syringe injection require a trained healthcare provider to administer the vaccine. Microneedle patch vaccination allows for administration by minimally trained personnel, including self-administration, which could dramatically hasten roll-out and dissemination as well as reduce the burden on the healthcare system. Acceptability studies using pressure sensitive microneedle patches with an auditory force feedback indicator found that participants reported little to no pain with self-administration and overwhelmingly preferred microneedle patches over intramuscular injections .Microneedle patches reduce the risk of sharps and sharps waste because the microneedles disappear after dissolving in the skin. The risks with sharps include unintentional re-use, needlestick injuries, and cross contamination. Up to 3.62 per 100,000 vaccinations result in needle-stick injury. The spread of bloodborne pathogens is a major concern, with an estimated 1.3 million deaths resulting from needle re-use according to WHO estimates, especially in developing countries ,78. FurtStandard hypodermic needle vaccination may be wasteful via multi-dose vials and the need for reconstitution. In general, vaccine wastage rates increase as the number of vaccine doses per vial increases. Estimates suggest wastage rates for 10-dose vials may be as high as 25% for liquid vaccines and 40% for lyophilized vaccines ,82. SingMicroneedle patches have improved stability and can often be stored at ambient temperature, eliminating the cold chain, and allowing for easier stockpile and storage ,82. FurtThe cost of vaccination is the cost of vaccine plus the logistical costs associated with making the vaccine available for use. Healthcare providers, waste disposal, vaccine storage, transportation, cold chain, and vaccine wastage all contribute to the cost of vaccination. While vaccine manufacturers often sell vaccines at significantly reduced cost for use in developing countries, the logistical costs to vaccinate can remain a significant barrier. Analyses suggest that the use of self-administered microneedle patches could not only improve vaccination coverage but would also be cost-effective ,84. The Limitations of dissolving microneedle patch delivery systems for vaccines exist, including theoretical issues with dosage accuracy; inability to deliver large doses of medications (which could be an issue if using certain adjuvants require milligram doses); possibility of skin irritation and external environment affecting delivery, such as hydration of the skin or excessive sweating; and uncertainty about cost and capability of large-scale manufacturing . These lThe science of microneedle patches is robust, as shown by the many different licensed and experimental vaccines delivered see . Four weRecently, the US government through the Biomedical Advanced Research and Development Authority (BARDA) funded a total of $1.9 million to three groups developing microneedle skin patches . The patIn response to the COVID-19 outbreak, there was an unprecedented effort to develop new vaccines with remarkable speed. The current bottleneck, however, is the rapid distribution and administration of the vaccines to achieve herd immunity in the global population. This depends not only on manufacturing sufficient vaccine supply, but also on the logistical and fiscal challenges of global distribution, sometimes complex cold chain requirements, and the need for skilled human capital.Microneedle patch vaccination can ease these limitations of traditional vaccination methods, especially in resource-limited settings, although the slow pace of vaccination even in advanced economies points to the need for simplified vaccination mechanisms worldwide. However, microneedle patches for SARS-CoV-2 vaccination are currently not available due in large part to a lack of existing manufacturing and regulatory infrastructure needed for rapid development. Continued and expanded investment in innovative vaccine delivery platforms such as microneedle patches is needed to ensure the technology and infrastructure are in place for the pandemic needs of the future.Microneedle patch immunization has the potential to overcome many factors affecting the uptake and distribution of traditional hypodermic intramuscular injection campaigns. Dissolvable microneedle patches are advantageous for many possible reasons: improved immunogenicity; dose-sparing effects; expected low manufacturing cost; elimination of sharps; reduction of vaccine wastage; no need for reconstitution; simplified supply chain, with reduction of cold chain supply through increased thermostability; ease of use, reducing the need for healthcare providers; and greater acceptability compared to traditional hypodermic injections. When applied to COVID-19, microneedle patches have great potential to improve vaccination globally and save many lives. While the timeline for COVID-19 microneedle patch vaccine deployment may be a missed opportunity for the current pandemic, there is a need for investment today to be better prepared for tomorrow’s pandemic needs.


Tumor cells communicate with the stromal cells within the tumor microenvironment (TME) to create a conducive environment for tumor growth. One major avenue for mediating crosstalk between various cell types in the TME involves exchanges of molecular payloads in the form of extracellular vesicles/exosomes. Autophagy is a fundamental mechanism to maintain intracellular homeostasis but recent reports suggest that secretory autophagy plays an important role in promoting secretion of exosomes that are packaged with non-coding RNAs (ncRNAs) and other biomolecules from the donor cell. Uptake of exosomal autophagy-modulating ncRNAs by recipient cells may further perpetuate tumor progression.Autophagy is a fundamental cellular homeostasis mechanism known to play multifaceted roles in the natural history of cancers over time. It has recently been shown that autophagy also mediates the crosstalk between the tumor and its microenvironment by promoting the export of molecular payloads such as non-coding RNA (ncRNAs) via LC3-dependent Extracellular Vesicle loading and secretion (LDELS). In turn, the dynamic exchange of exosomal ncRNAs regulate autophagic responses in the recipient cells within the tumor microenvironment (TME), for both tumor and stromal cells. Autophagy-dependent phenotypic changes in the recipient cells further enhance tumor growth and metastasis, through diverse biological processes, including nutrient supplementation, immune evasion, angiogenesis, and therapeutic resistance. In this review, we discuss how the feedforward autophagy-ncRNA axis orchestrates vital communications between various cell types within the TME ecosystem to promote cancer progression. Cancer is one of the leading causes of death worldwide, with almost 10 million cancer deaths reported in 2020 [The TME is made up of a variety of cell types, including tumor cells, cancer stem cells, fibroblasts, immune cells, endothelial cells, and adipocytes . It is wTumor cells are the main residents of the TME. They were once normal cells but accumulated malignant genomic alterations over time to acquire the various hallmarks of cancer: hyperproliferation, decreased growth repression and cell death, replicative immortality, increased angiogenesis, enhanced invasion and metastasis, genome instability and mutation, tumor-promoting inflammation, reprogrammed energy metabolism, and escape of immune destruction . In receCancer-associated fibroblasts (CAFs) represent the predominant non-hematopoietic stromal cell type in the TME . AlthougMSCs are multipotent stromal cells that have been shown to be recruited to tumors, where they serve as a source of fibroblasts and pericytes . They arDuring immune surveillance, host immune cells infiltrate tumors in an attempt to halt tumor progression. Depending on the tumor type, inflammatory cells recruited to the TME vary in composition, and may include both the adaptive and innate immune cells, such as dendritic cells (DC), T-lymphocytes, B cells, macrophages, and polynuclear leukocytes . Tumor-dEndothelial cells (ECs) play a key role in carcinogenesis. As the tumor mass grows, the hypoxic center requires increased vasculature to aid in the delivery of nutrients and oxygen. Angiogenesis also promotes metastasis, as decreased endothelial cell–cell junctions and increased attachment of tumor cells to the ECs aids the invasion of tumor cells into the circulation. Furthermore, neovascularization renders a tumor inaccessible to chemotherapeutics ,16.Adipocytes have long been hypothesized to promote tumorigenesis. Given that obesity is a risk factor for cancer, and that adipocyte mass and tissue phenotype is altered in obesity, it is highly plausible that the adipocyte–tumor cells crosstalk enhances tumor progression. Cancer-associated adipocytes (CAAs) are adipocytes activated by tumor cells to secrete proinflammatory factors known as adipokines to promote tumor growth .Extracellular vesicles are small, membrane-encapsulated vehicles that contain biological payloads actively secreted from cells. They are primarily categorized into two groups—exosomes and microvesicles. Exosomes are typically 30–150 nm extracellular vesicles that are secreted during the fusion of multivesicular endosomes with the cell surface . MicroveExosomes have long been implicated in the communication between cancer cells and other cell types in the TME. Studies have shown that cancer or stromal cells release exosomes in order to transport lipids, proteins, and nucleic acids, including various non-coding RNAs (ncRNAs), to reprogram the recipient cells, thereby building a conducive microenvironment for cancer progression . The traAutophagy is a fundamental cellular homeostasis mechanism that governs a wide variety of stress adaptation responses, including turnover of protein aggregates and organelles for nutrient recycling . AutophaIn mammalian cells, autophagy is canonically viewed as a lysosomal digestion process wherein specific cytoplasmic contents are delivered to lysosomes for destruction as a means of recycling biosynthetic building blocks for the maintenance of cell homeostasis ,26,27. ICentral to the classical digestive autophagy and non-canonical secretory autophagy pathways is LC3. In classical digestive autophagy, LC3 identifies and transports proteins to the autophagosome for subsequent digestion in the lysosome . In secrThis was a very recent seminal discovery by the Debnath laboratory, because only the ESCRT-dependent pathway was previously known to drive exosomal secretion ,40. AlthncRNAs were first detected in exosomes and have been postulated to serve as second messengers to mediate cell-to-cell communication . ncRNAs The packaging of ncRNAs into exosomes is largely dependent on their protein binding partners  and theimiRNAs are small ncRNAs that are 19–25 nucleotides long. They have been largely shown to downregulate gene expression via the RNA-induced silencing complex (RISC). Notably, recent studies demonstrated that gene expression could also be upregulated by miRNAs in specific contexts, such as assembling the ribosomal complex at 5′ UTR of messenger RNA (mRNA) transcripts to promote protein translation . Given tkB signaling and downstream autophagy. Consequently, these epithelial cells exhibit increased proliferation and migration [To date, miRNAs are the most extensively studied group of exosomal ncRNAs and their roles in cancer were comprehensively reviewed by Sun and coworkers . Exosomaigration . Conversigration . In addiigration .In addition to augmenting tumor growth, exosomal miRNAs also play important but under-appreciated roles in inducing therapy resistance and side effects. The transfer of exosomal miR-425-3p from cisplatin-treated non-small cell lung cancer (NSCLC) cells to their cisplatin-naïve counterparts decreased the sensitivity of the recipient cells to subsequent cisplatin treatment. This is, in part, attributed to the activation of autophagy in the recipient cells by miR-425-3p-dependent targeting of AKT1 . SimilarLong non-coding RNAs (lncRNAs) represent another group of RNA species that are commonly found in exosomes. They have sequence lengths that range from 200 bp to 10 kb and are functionally diverse. lncRNAs can be categorized based on (1) how they are synthesized (whether they are transcribed from intergenic or intronic sites of the genome in sense or anti-sense direction), and (2) their functions (cis-acting lncRNA functions at sites where they are transcribed or trans-acting lncRNAs function at sites different from where they are transcribed). In general, IncRNAs regulate gene expression by direct interaction with gene regulatory elements or recruitment of regulatory protein effectors to the site of action .The opposing roles of lncRNAs in various forms of cancers have been well documented. A growing number of studies have demonstrated that lncRNAs drive chemoresistance, metastasis, and proliferation of cancer cells, possibly via exerting their effects on the different stages of autophagy  ,74. NotaExosomes from CD90+ liver cancer cells have been shown to be enriched in lncRNA H19, and uptake by human microvascular vein endothelial cells (HUVECs) leads to increased angiogenesis . lncRNA Exosomal lncRNAs have also been reported to suppress autophagic functions in recipient cells. For instance, FJ22447 , which was isolated from OSCC exosomes, has been shown to prevent autophagy-dependent degradation of Interleukin-33 (IL-33), leading to a cancer-associated fibroblast phenotype that enhanced tumor growth and proliferation . SNHG9 eThe influence of exosomal circular RNAs (circRNAs) on autophagy and the consequent effects on cancer pathogenesis have been described but not as extensively as those of exosomal miRNAs and lncRNAs ,53,78. cSmall nucleolar RNAs (snoRNAs) are a class of ncRNAs primarily located in the nucleolus. They play essential roles as guide RNAs in post-transcriptional modification of target RNAs, but numerous reports have revealed alternative roles for snoRNAs . snoRNAsncRNAs such as piRNA ,88 and tThe roles of autophagy in tumor cells in helping to create a permissive pro-growth TME have been discussed in other reviews ,92,93,94Autophagy in CAFs promotes tumor growth by supplying paracrine-produced nutrients to the cancer cells . MultiplIn addition, several studies suggest that cellular senescence and autophagy may participate in the same metabolic pathway, known as the autophagy-senescence transition ,106,107.Like CAFs, autophagy modulation in mesenchymal stem cells (MSCs) is also associated with tumorigenesis. In vitro studies have demonstrated that serum deprivation led to an increase in autophagy in MSCs, promoting survival and supporting adjacent tumor cell growth by secreting paracrine factors . MSCs weAutophagy in MSCs also influences the composition and function of other stromal cells in the TME. Activation of autophagy by NOTCH inhibition in human bone marrow-derived MSCs (BM-MSCs) led to adipogenic differentiation , which mThe role of autophagy in the immune response is well documented ,124. AutSeveral studies have shown that autophagy impairs antigen presentation, thereby affecting the anti-tumor immune response. In pancreatic ductal adenocarcinoma, MHC-1 molecules are selectively targeted for lysosomal degradation via an autophagy-dependent mechanism involving autophagy cargo receptor NBR1. Inhibition of autophagy conversely led to an enhanced anti-tumor response, as the presence of more surface MHC-1 molecules improved antigen presentation and enhanced anti-tumor T cell responses . ProductIn mice, EC-specific ATG5 knockdown led to an increased number of immature blood vessels with abnormal EC lining . Beclin1Although these reports appear to be contradictory, the discrepancy in observations may be partially due to differences in the models used (in vivo vs. in vitro). It is noteworthy that ATG5 and Beclin1 are known to participate in alternative cellular pathways independent of autophagy, which may potentially convolute our assessment of the real effect of autophagy on ECs in the TME. Hence, additional studies are warranted to determine the exact role(s) of autophagy in ECs in tumor angiogenesis and other pro-tumor effects.Autophagy is known to regulate lipid metabolism in adipocytes by a process known as lipophagy, in which the autophagy machinery breaks down lipid droplets into free fatty acids (FFAs) . FFAs arAutophagy plays a vital role in the crosstalk between various cell types of the tumor, stroma, and immune system within the TME. We summarized the multifaceted roles of autophagy in mediating exchanges of exosomal ncRNA effectors across different cell types. The autophagy-dependent LDEL secretory pathway loads ncRNAs into exosomes for export into the extracellular space to mediate cell-to-cell communications. Exosomal ncRNAs are secreted from the various cell types in the TME and are taken up by recipient cells to regulate cellular processes (including autophagy) in a highly specific but elusive manner to promote or suppress cancer growth. Hence, it will be critical to delineate the composition of exosomes and their biological payloads (including ncRNAs) from each of these cell types in the TME to fully understand the complexity of these cellular conversations. We also described how the stromal cells respond to the changes in autophagic flux and contribute to further disease progression.In conclusion, we envisage that ongoing efforts to specifically target second messengers in exosomes or selective delivery of autophagy inhibitors or autophagy-modulatory ncRNAs to specific cell types in the TME will contribute to our armamentarium against cancer. Most RNA-based therapeutics in clinical trials target mRNAs. Although an increasing number of ncRNA therapeutics are being evaluated in clinical trials , none ofHowever, we suggest that therapeutic resistance in cancer is fundamentally inevitable. Even if we do eventually find effective agents that target the autophagy-ncRNA axis, the presence of intra-tumoral heterogeneity means that there may be cancer cells that are innately resistant to these ncRNA-targeting therapies. The presence of inter-tumoral heterogeneity also means that therapies that work in one patient may not necessarily work in another. Cancer is an incredibly complex disease, and we still have much to learn about it.Nevertheless, by harnessing our knowledge of exosomal ncRNAs that mediate the conversation between the tumor and its microenvironment, we can seize the opportunity to selectively target important pro-tumorigenic signals to control tumor growth more effectively.


Despite high levels of racial disparities in health and well-being among older adults, curricula addressing how aging services systems contribute to or work to ameliorate these disparities are scarce. This paper introduces a module on inequalities and anti-racism in aging developed for an online course on aging services within a Master of Social Work program. First, materials that help students identify and understand racial inequalities in aging and in the programs that serve older adults are presented. Next, students are introduced to the applied context of how COVID-19 has exacerbated these inequalities. Finally, students critically engage in reflections and assessments of the available resources within aging services and advocacy organizations, providing recommendations for how these systems may better incorporate anti-racist practices. Challenges and opportunities will be discussed, including piloting this module in a virtual, asynchronous environment.