The association between obesity, cancer and cardiovascular disease (CVD) has been demonstrated in animal and epidemiological studies. However, the specific role of visceral obesity on cancer and CVD remains unclear. Visceral adipose tissue (VAT) is a complex and metabolically active tissue, that can produce different adipokines and hormones, responsible for endocrine-metabolic comorbidities. This review explores the potential mechanisms related to VAT that may also be involved in cancer and CVD. In addition, we discuss the shared pharmacological treatments which may reduce the risk of both diseases. This review highlights that chronic inflammation, molecular aspects, metabolic syndrome, secretion of hormones and adiponectin associated to VAT may have synergistic effects and should be further studied in relation to cancer and CVD. Reductions in abdominal and visceral adiposity improve insulin sensitivity, lipid profile and cytokines, which consequently reduce the risk of CVD and some cancers. Several medications have shown to reduce visceral and/or subcutaneous fat. Further research is needed to investigate the pathophysiological mechanisms by which visceral obesity may cause both cancer and CVD. The role of visceral fat in cancer and CVD is an important area to advance. Public health policies to increase public awareness about VAT’s role and ways to manage or prevent it are needed. Visceral obesity is a type of body fat deposition in the upper part of the body and within the abdominal cavity. This adipose tissue is located near several organs, such as the liver, stomach and intestines and it can build up in the arteries. Visceral fat is sometimes known as “active fat” because it can actively increase the risk of adverse health problems. Visceral adipose tissue (VAT) is a complex and metabolically active tissue, which can produce different adipokines and hormones responsible for endocrine-metabolic comorbidities. It is associated with increased adipocytokine production, proinflammatory activity and altered blood lipids levels as well as with decreased HDL cholesterol .There is growing consensus that visceral obesity represents an important risk factor for diabetes, cardiovascular disease (CVD) and different types of cancers ,3,4,5 suTherefore, this review aims to highlight the potential shared disease pathways linking visceral obesity to cancer and CVD. In addition, we discuss the shared pharmacological treatments that may mitigate the risk of both conditions.Increases in VAT cause adipose dysfunction and induce chronic local inflammation, which mediates most obesity-related complications . The infChronic inflammation has been linked to the development and progression of cardiovascular diseases  and seve−/−Trp53 in mice maintained in relatively hypoxic conditions (10% O2) have a significantly reduced level of tumorigenesis and improved survival compared to −/−Trp53 mice maintained in standard atmospheric conditions (21% O2) [Along with their role in chronic inflammation, IL-6 and TNF-α also contribute to other mechanistic effects on cancer development. Regarding IL-6, this adipocytokine stimulates angiogenesis, promotes cell proliferation, increases survival of malignant cells and inhibits cancer cell apoptosis, for example, in colon cancer ,25. As f(21% O2) . Moreove(21% O2) .Adipokines are hormones secreted by the adipose tissue, such as adiponectin and leptin that regulate systemic metabolism and inflammation. They have been suggested as a link between obesity and other disorders such as cardiovascular disease and cancer . AdiponeAdiponectin is a protein hormone with vasoprotective properties  and antiAdiponectin attenuates the interaction between leukocytes and endothelial cells by suppressing the expression of E-selectin and vascular cell adhesion molecule-1. This adiponectin-related decrease in expression of adhesion molecules has been demonstrated in an animal model of atherosclerosis. Adiponectin inhibits the expression of adhesion molecules after induction by TNF-α and IL-8, which leads to reduction of monocyte attachment to endothelial cells . AlthougVisfatin is another adipokine and cytosolic enzyme that was originally identified as pre-B cell colony-enhancing factor- 1 (PBEF) and has nicotinamide phosphoribosyl-transferase (Nampt) activity. Visfatin is predominantly produced in VAT. However, it is also produced by immune cells  and induces expression of IL- 1b, TNF-α, and especially IL-6 in human leukocytes . Over thIn addition to the potential indirect role of visfatin in cardiovascular disease through metabolic syndrome and inflammation, visfatin has been demonstrated to induce endothelial dysfunction in vivo, which has a pivotal role in initiation and progress of atherosclerosis . RomachoThe emerging evidence regarding the abnormal expression of visfatin in many types of cancers and also significant correlation between high circulating visfatin levels and increased risk of cancer and cancer-related mortality, suggests visfatin as a potential mediator that contributes to the interconnection of obesity and cancer . VisfatiVisceral adiposity is also associated with metabolic dysfunction, increasing the risk of insulin resistance and hyperglycemia . SeveralHyperinsulinemia may have carcinogenic effects via insulin receptors in the pre-neoplastic cells. It affects the insulin-like growth factors (IGF) axis, which leads to binding of IGF-1 or IGF-2 to the IGF-1 receptor promoting cell proliferation, differentiation and protection from apoptosis . EpidemiIGF-1 level is significantly increased in individuals with obesity and this is a consequence of hyperinsulinemia inhibiting production of IGFBP-1 and -2 . IGF-1 lVisceral fat mass is lower in female than males, but this difference is diminished in elderly people. Therefore, it seems that estrogen signaling plays a major role in sex differences in adiposity . ClinicaClinical studies have provided strong support regarding the association between sex hormones, obesity and cancer, specifically for hormone-dependent cancers such as endometrial, breast, uterine, ovarian, and prostate cancers  and for FGFs comprise a broad family of polypeptides with significant biological roles. They are signaling proteins related to development and metabolism, covering 22 members in the mammalian FGF family. Secreted FGFs control important cellular processes that comprehend positive and negative regulation of proliferation, survival, migration, differentiation, and metabolism. FGFs may indirectly contribute to an inflammatory environment through the synergistic potentiation of inflammatory mediator-induced leukocyte recruitment, intensifying cell adhesion and molecule upregulation . Some FGIn cardiovascular disease, some FGFs are implicated in cardiac remodeling through different mechanisms, which can contribute to heart failure . For exaAlthough FGFs are implicated in both cardiovascular disease and cancer development, different FGF family members are involved in the pathophysiology of these illnesses. In an experimental model with rats, fibroblast growth factor 2 (FGF2), secreted and released by the VAT, stimulated the transformation of skin epithelial cells, primarily in mice fed with a high-fat diet  . This stChanges in DNA methylation is one of the most studied epigenetic modifications at the molecular level . DNA metDNA methylation in visceral adipose tissue has also been the subject of studies in recent years, given that it is an important mechanism that predisposes the development of obesity and metabolic impairment ,95. In aMitochondrial dysfunction can promote various mechanisms during cancer progression. Mitochondrial alterations affect nuclear gene expression for neoplastic transformation. Alteration in the intracellular level of oncometabolites play a critical role in neoplastic transformation and cancer progression. In addition, other suppressors such as hypoxia-inducible factor 1 and p53, alter cellular metabolism . ImpairmThe development of pharmacological agents to reduce visceral obesity is difficult due to various potential side effects . For exaThis ligand-activated transcription factor has critical roles in various cellular functions and glucose and lipid metabolism . PPARγ iPPAR-γ agonists decrease tumor proliferation by lowering circulating insulin and affecting key pathways of the Insulin/IGF axis, such as PI3K/mTOR, MAPK, and GSK3-β/Wnt/β-catenin cascades, which regulate cancer cell survival, cell reprogramming, and differentiation . One metGrowth hormone (GH) treatment is not effective in treating visceral obesity in patients with normal levels but its deficiency leads to obesity or visceral obesity . It has Recombinant human growth hormone (rhGH) has been widely used to treat children with short stature secondary to any medical problems. The experience from many thousands of patients and years of treatment demonstrates a good safety record for rhGH. Nevertheless, the findings from a meta-analysis showed a significant increase in all-cause mortality but no significant increase in the malignancy and CVD mortality. The risk for second neoplasms increases in these patients .A recent meta-analysis evaluated the risk of cancer in adults with and without growth hormone replacement therapy, which suggested that growth hormone replacement therapy could reduce the risk of cancer in adults with growth hormone deficiency .Metformin, a biguanide anti-hyperglycemic agent, is the first line treatment for overweight diabetes patients . It reduMetformin has protective effects on cardiovascular problems in patients with type 2 diabetes which are independent from the glucose-lowering effect . MetformMetformin increases glucose uptake and insulin sensitivity and reduces serum insulin level which results in reduction of pre-neoplastic and neoplastic cell proliferation . MetformElevated levels of cyclooxygenase (COX), a sign of chronic inflammation, is the key connection between cancer and obesity. Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation via COX inhibition which ultimately reduces prostaglandin levels . They alThe results from randomized controlled trials (RCTs) and meta-analyses show that there is a significant increase in risk of heart attack in patients who are taking COX inhibitors compared with placebo . The posAspirin, an irreversible inhibitor of the COX enzyme , is an eStatins, HMG-CoA reductase inhibitors, are the most common lipid-lowering medications and are widely prescribed. They are effective in lowering cholesterol and play a critical role in the prevention of primary and secondary cardiovascular disease . StatinsThere are several meta-analyses on the effect of statins and cancer incidence and also relapse with some showing beneficial effects while others found no effects. A risk reduction has been observed in esophageal , colorecEzetimibe is another lipid-lowering drug which limits the absorption of cholesterol from the gastrointestinal tract epithelial. It blocks the Niemann-Pick C1-like 1 (NPC1L1) protein on small intestine epithelial cells, which leads to reduction of plasma level of cholesterol .There is some evidence suggesting that ezetimibe has an effect on adiponectin and decreases insulin resistance which results in adipose tissue reduction in patients with metabolic syndrome . Adding Ezetimibe in combination with statin, has beneficial effects on the risk reduction of non-fatal MI. However, there is limited evidence about its monotherapy and CVD risk reduction . It has In this review, we discussed some pathophysiological aspects shared between VAT, cardiovascular disease and cancer as well as their shared pharmacological prevention. Chronic inflammation and dysregulated metabolism associated to visceral obesity, such as insulin resistance, hyperglycemia, and dyslipidemia can affect both CVD and cancer development and progression. The shared disease pathways linking visceral obesity to cancer and CVD may offer valuable opportunities for public health interventions to tackle both diseases. Reductions in abdominal and visceral adiposity improve insulin sensitivity, lipid profile and cytokines, which consequently reduce the risk of CVD and some cancer types. In fact, in addition to lifestyle interventions, pharmacotherapy with antidiabetic drugs, PPARγ and recombinant growth hormone may decrease the risk of both visceral obesity and cancer. Several medications have been shown to reduce visceral and/or subcutaneous fat. However, none of them have been approved for use in this context. Further research on the shared pathophysiological mechanisms underlying the association between visceral obesity, CVD and cancer could potentially lead to the discovery of important biomarkers and pathways and development and assessment of effective therapies. New pharmacological treatments that selectively affect the shared pathways, are needed. Long term, well designed RCTs and cohort studies should be conducted to test the hypothesis of targeting shared mechanisms aiming to prevent VAT, cancer and CVD. The role of visceral fat in cancer and CVD is an important area to advance in public health policies. It is also important to increase public awareness about its role and ways to manage or prevent it.


Infants presenting with multiple fractures without a plausible accident history need to be evaluated for child abuse or underlying predisposing conditions such as osteogenesis imperfecta and hypophosphatasia. We present a case of infantile hypophosphatasia with multiple unexplained fractures but otherwise normal radiographs in the setting of biochemical and genetic evidence of hypophosphatasia. Standard screening tests for hypophosphatasia include serum alkaline phosphatase level and genetic testing. Despite the presented case's positive biochemical and genetic testing, the case did not have any other radiologic finding suggesting infantile hypophosphatasia, such as severe bone mineralization deficits and rickets. While patients with hypophosphatasia can have increased bone fragility, this has been reported in the context of radiologic abnormalities of the skeleton. Thus, this case is potentially the first reported infantile hypophosphatasia case presenting with no findings of rickets on radiographs, raising concern that the fractures and especially the radius head dislocation might be due to physical abuse. ALPL gene which encodes tissue-nonspecific alkaline phosphatase, leading to defective bone and teeth mineralization. Hypophosphatasia spans a multitude of clinical manifestations from before birth to early adulthood, and the diagnosis is often delayed. To our knowledge, this case is the first reported case of an infant with biochemical and genetic evidence of hypophosphatasia without classic radiological findings, which was the subject of child abuse evaluation.Unexplained fractures in young children raise concern for child abuse. Although rare, fractures occur in numerous medical conditions. One such condition is hypophosphatasia, a genetic condition caused by mutations in the A previously healthy full-term 6-month-old male infant was brought to the Emergency Department (ED) with an 8-hour history of not moving his right arm and marked fussiness. He had been behaving normally until a brief period when he was left unsupervised with two toddlers as the babysitter went to the kitchen to wash a bottle. Upon arrival, he had tachycardia (169 beats/minute). The rest of his vitals were normal. He could move all his extremities except the right upper extremity. He had a visible deformity of the right arm, and his neurological exam was normal.Radiographs of the right upper extremity revealed an acute spiral right humeral fracture and healed fracture of the right mid-radius and ulna. This prompted a comprehensive child abuse workup. A skeletal survey showed thickened cortex in the mid-shaft of left humerus, radius, and ulna with subtle cortical irregularity, suggestive of healed fractures . The comCOL1A1 and COL1A2 gene testing to evaluate for osteogenesis imperfecta (OI). A next-generation sequencing panel of OI-related genes was performed by an external genetic testing laboratory. The patient was discharged to the parents on hospital day 4, per child protective services (CPS) recommendations.Upon further history, the caretakers reported that four days prior, the patient fell out of bed onto carpeted flooring. He was initially upset but was nursed back to sleep and was at baseline after he woke up. A similar fall happened several months ago, but the patient had returned to his baseline quickly without signs of injury. Developmental history was normal. There was no family history of unexplained or infantile fractures, bone disorders, connective tissue disorders, or bleeding disorders. There was no history of domestic violence in the home. Laboratory evaluation included normal calcium, phosphorus, magnesium, copper, ceruloplasmin, parathyroid hormone, 25-hydroxy vitamin D levels, free T4, and thyroid stimulating hormone (TSH). Urine drug screen was negative for illicit substances. Genetics consultation was conducted with subsequent ALPL gene, a pathogenic variant , and a likely pathogenic variant . To confirm the diagnosis of hypophosphatasia, additional testing was sent and revealed low serum alkaline phosphatase , high serum pyridoxal 5′-phosphate , and high urine phosphoethanolamine . Parental site-specific testing for the two ALPL variants revealed that the patient's mother had the p.Ala40Val variant and his father had the p.Ala176Thr variant. Based on his clinical history and laboratory findings despite the absence of classical radiographic findings, our patient was diagnosed with hypophosphatasia. On subsequent follow-up 10 weeks after discharge, he was growing well and had no new fractures. Enzyme replacement therapy was considered but ultimately not started.OI genetic testing returned negative, but the testing laboratory reported two variants in the Hypophosphatasia is a rare  inherited disorder of bone development caused by deficiency of serum alkaline phosphatase, leading to defective bone mineralization. The clinical presentation of hypophosphatasia is variable with multiple subtypes based on timing of onset of symptoms and presentation: (1) perinatal-onset: infant is born with symptoms, 2) infantile-onset: before six months of age, (3) childhood-onset: between six months of age to less than 18 years of age, (4) adult-onset: over 18 years of age, and (5) odonto-hypophosphatasia: presents at any age with only dental manifestations [ infantilALPL gene [ALPL gene, allowing a diagnosis giving the clinical and biochemical findings.While there are many clinical, biochemical, and radiographic features suggestive of hypophosphatasia, there are no formal criteria for diagnosis –5. FurthLPL gene . The preThere is one case describing an older child with unexplained fractures and otherwise normal radiographs who was found to have biochemical evidence of hypophosphatasia : this caBone diseases, including osteogenesis imperfecta and hypophosphatasia, can be frequently confused with child physical abuse , 8. PatiIt is also important to consider child physical abuse when hypophosphatasia is the working diagnosis, which is not always the practice , 5, 9. SAs a result of these factors, diagnostic considerations in this case may include the following: hypophosphatasia leading to decreased bone mineralization might have caused bone weakness and multiple fractures with minimal trauma. However, the literature shows that asymptomatic children with hypophosphatasia and normal-appearing bones experience fractures anywhere between the ages of 6 months and 18 years of age  . All infThus, this case is the first report of infantile hypophosphatasia presenting with no findings of rickets on radiographs, raising concern that his fractures and especially radius head dislocation might be due to physical abuse.


Cancer immunotherapy has made rapid progress over the past decade leading to high enthusiasm and interest worldwide. Codelivery of immunomodulators with chemotherapeutic agents and radioisotopes has been shown to elicit a strong and sustained immune response in animal models. Despite showing promising results in metastatic and recurrent cancers, the utilisation of immunotherapy in clinical settings has been limited owing to uncertainties in elicited immune response and occurrence of immune-related adverse events. These uncertainties can be overcome with the help of nanoparticles possessing unique properties for the effective delivery of targeted agents to specific sites. Nanoparticles play a crucial role in the effective delivery of cancer antigens and adjuvants, modulation of tumour microenvironment, production of long-term immune response and development of cancer vaccines. Here, we provide a comprehensive summary of nanotechnology-based cancer immunotherapy and radiotherapy including basics of nanotechnology, properties of nanoparticles and various methods of employing nanoparticles in cancer treatment. Thus, nanotechnology is anticipated to overcome the limitations of existing cancer immunotherapy and to effectively combine various cancer treatment modalities. Cancer immunotherapy, which utilises the body’s own immune system to fight against tumour cells, has grown in importance over the past decade. Novel strategies employed to enhance cytotoxic T-cell activation include chimeric antigen receptor T-cell therapy, immune checkpoint blockade (ICB) therapy and neoantigen vaccines –8. CanceNanoparticles are nanoscale materials, usually made up of polymeric, liposomal and metallic formulations . An ideaNanotechnology-based drug delivery system has been utilised to enhance the efficacy of chemotherapy, radiotherapy and photodynamic therapy , 30. TheNanotechnology used in cancer immunotherapy targets not only cancer cells but also lymphocytes and antigen-presenting cells (APCs) in circulation, thereby helping to generate a robust immune response. Hence, a much lower concentration of drug is needed when used in conjunct with immunomodulators . In virt2+, and demonstrated a loading cytosine-guanine oligodeoxyneucleotide (CpG ODN) with the radio-enhanced sodium alginate formulations resulted in strong systemic immune response [Cancer nanovaccines are designed for the effective delivery of tumour-derived protein antigens, or peptide antigens, or nucleic acid antigens to APCs, which, in turn, triggers an immune response . Numerouresponse . Anotherresponse .Protein nanocarriers such as albumin–drug conjugates increase the half-life of drug in blood; potentiate draining to lymph nodes, enhance antigen presentation to APCs and thereby improve antitumour activity . AbraxanNanoparticles also help in the co-delivery of immune adjuvants along with antigens to avoid immune tolerance . The comRadiotherapy has been a vital component of cancer treatment for several decades. With the advent of modern radiotherapy treatment machines and planning systems, the therapeutic ratio of radiotherapy has significantly improved. However, there still exist many challenges that hinder the effective treatment of cancer with radiotherapy. The major limitations of radiotherapy are hypoxic tumours, less radio responsive/radioresistant tumours, increased toxicity to adjacent normal structures and side effects while combining with chemotherapy and immunotherapy. These shortcomings of radiotherapy can be overcome with the help of nanotechnology.90Y, 131I, 199Lu, 186Rh, 89Sr, 32P and 67Cu), alpha emitters  and low-energy electron emitters . Among the three, alpha particles have a high linear energy transfer and are more destructive. However, the therapeutic effect of radioisotopes is largely hindered by rapid renal clearance due to smaller size (5 nm) and opsonisation by mononuclear phagocyte system [et al [111In and 177Lu PEGylated liposomes had a longer half-life in blood compared to 111In-DTPA in mice model. They also improve an intratumoural accumulation of radioisotopes through EPR effect and decrease the dose to surrounding normal structures, thereby improving therapeutic ratio [Radioisotopes used in radioimmunotherapy are broadly grouped into three categories based on the type of emitted particulate radiation. They are beta-emitters  and gadolinium (Z = 64) can act as potential radiosensitizers as dose absorbed by tissue is proportional to Z2 of the material. The study by Zhang et al [In addition to acting as a carrier, few nanomaterials of high atomic number such as gold  contributed in the conception of this review article, literature review and manuscript writing. The second author (DKG) contributed with his suggestions, proofreading and supervision.No organisational grants or support was obtained for writing this manuscript.


Widespread transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in a global coronavirus disease 2019 (COVID-19) pandemic that is straining medical resources worldwide. In the United States (US), hospitals and clinics are challenged to accommodate surging patient populations and care needs while preventing further infection spread. Under such conditions, meeting with patients via telehealth technology is a practical way to help maintain meaningful contact while mitigating SARS-CoV-2 transmission. The application of telehealth to nutrition care can, in turn, contribute to better outcomes and lower burdens on healthcare resources. To identify trends in telehealth nutrition care before and during the pandemic, we emailed a 20-question, qualitative, structured survey to approximately 200 registered dietitian nutritionists (RDNs) from hospitals and clinics that have participated in the Malnutrition Quality Improvement Initiative (MQii). RDN respondents reported increased use of telehealth-based care for nutritionally at-risk patients during the pandemic. They suggested that use of such telehealth nutrition programs supported positive patient outcomes, and some of their sites planned to continue the telehealth-based nutrition visits in post-pandemic care. Nutrition care by telehealth technology has the potential to improve care provided by practicing RDNs, such as by reducing no-show rates and increasing retention as well as improving health outcomes for patients. Therefore, we call on healthcare professionals and legislative leaders to implement policy and funding changes that will support improved access to nutrition care via telehealth. The ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has triggered the coronavirus disease 2019 (COVID-19) pandemic and caused a significant strain on medical institutions, particularly in the acute care setting. This disruption of healthcare services has multiple contributing factors: limited availability of adequate personal protective equipment (PPE), the need for defined populations to stay at home, and the high risk of infection spread among patients and healthcare professionals at care sites , adoptioWhile the terms “telemedicine” and “telehealth” are sometimes used interchangeably , our papAbout 11% of US consumers used telehealth in 2019 compared to an estimated 46% of consumers in 2020 that were often used to replace in-person visits . OpinionWith the onset of the COVID-19 pandemic, the US Department of Health and Human Services (HHS) declared a public health emergency that temporarily relaxed the existing restrictions on telehealth care . For exaNotably, telehealth services have also been applied to providing nutrition care for patients ,14,15,16Launched in 2013 by the Academy of Nutrition and Dietetics (Academy), Avalere Health, and other stakeholders, the MQii has established and supported a Learning Collaborative among more than 290 US hospitals and clinics to implement and disseminate best practices for malnutrition care ,19,20,21With telehealth identified as a way to comply with physical restrictions and provide safe nutrition care for COVID-19 outpatients, we developed and disseminated a second qualitative, structured survey via email between 24 August and 11 September 2020. In this survey, we sought to obtain more information about how RDNs and teams were using telehealth to continue providing quality nutrition care to all patients  during the pandemic. The 20-question survey see  was emaiWe received responses from 22 RDNs . Twenty of the hospitals had treated COVID-19 patients (with a case range of 90 to 1000) and two had not treated COVID-19 patients. Of the 22 respondents, 14 worked in academic medical centers and 8 worked in community hospitals. The size of the hospitals ranged from 34 to 1400 beds, with the majority having between 400 and 900 beds. All were general acute care hospitals with one exception of a rehabilitation facility. Twelve hospitals were in urban settings, one in a rural environment, and seven in a combination of urban and rural or suburban. All but two hospitals were part of integrated health systems. Nutrition educationNutrition counselingNutrition care plan developmentNutrition assessmentRecommendations for nutrition supplementationNutrition discharge planningNutrition screeningSix respondents reported that their hospitals had provided nutrition care via telehealth prior to the pandemic, 15 had not provided nutrition care via telehealth, and one did not know. During the pandemic, 20 respondents reported their hospitals are now providing nutrition telehealth services and 2 are not. The 20 RDNs and/or teams currently utilizing telehealth reported using it to provide the following services: Respondents reported using various telehealth modalities—live video conferencing, phone calls, web-based portals, and remote patient monitoring—during the COVID-19 pandemic. The largest increase in telehealth use by individual RDNs during COVID-19 occurred in telephone calls (15 RDNs).Responses offered insights into positive perceptions, areas for improvement, and potential solutions for future support of nutrition care delivery via telehealth . RDN resWhile it is too early to know the long-term impacts of the COVID-19 pandemic on the US healthcare delivery system, our survey results give us early information about how telehealth can enhance nutrition care. Although the number of our responses was small, we were able to draw on the reported experiences of the MQii Learning Collaborative hospitals and other clinicians to identify opportunities that may help promote quality nutrition care via telehealth and better prepare for future challenges to their practice. The COVID-19 pandemic of 2020 has expedited the adoption of telehealth by many health systems. Information from our survey indicates that telehealth can be an acceptable alternative to in-person clinic and even inpatient visits. In fact, telehealth can enable healthcare providers to maintain usual caseloads and provides patients with uninterrupted healthcare access. Furthermore, telehealth offers opportunities for evaluation and education that might not exist in the face-to-face visit system. For example, telehealth visits have given RDNs the opportunity for longer assessment time with patients and the ability to “look in” their home environments to potentially observe their refrigerators and pantries, allowing further examination of their diet and nutrition habits. In other studies, telenutrition interventions have improved weight loss outcomes in cardiovascular disease patients in a pilot randomized controlled trial  and imprEven before the current COVID-19 pandemic, Kelly et al. called for expanded use of telehealth for nutrition care and diet-related consultations for people living with a wide range of conditions, such as type 2 diabetes, cardiovascular disease, obesity, cancer, chronic kidney disease, and mental health conditions . Their rMehta et al. specifically evaluated ways to apply telehealth-based nutrition care during the COVID-19 pandemic, including using telehealth for one-on-one RDN visits with existing outpatients . They foAnother potential benefit of telehealth nutrition care is that it increases access to medical nutrition therapy (MNT) by removing barriers related to limited finances, travel, time, and physical function. More than 10 years ago, Busey and Michael identified a role for “new and growing electronic technologies” to make healthcare services more accessible and less costly to a wider range of patients . Today, Several barriers to telehealth for patients must still be overcome. Our respondents identified lack of access to needed technology and connectivity issues as limitations. Similarly, results of other studies have identified technical/connectivity issues and limited telecommunication skills as common patient barriers to telehealth . While hAdditional barriers for providers still need to be addressed. Ready support from an IT team can promote learning and trouble-shooting for new applications, incorporation of video (rather than audio-only) for more effective telehealth consultations, and increased provider training for electronic communication . Our surPerhaps the most critical need to continue expanding access to nutrition telehealth services is advocating to policymakers that MNT is essential for comprehensive and effective patient care. Discussions about healthcare reform need to consider all aspects of care that can be delivered effectively through telehealth means both during and beyond the COVID-19 pandemic. Medicare telehealth requirements that existed prior to the pandemic only covered nutrition services via live-video conferencing and under specific circumstances regarding the patient’s and practitioner’s physical locations. With the onset of the COVID-19 pandemic, CMS has lifted many of these restrictions , resultiTo help address the barriers practitioners face in using telehealth and to share their learning, some organizations are already offering practical guidance on adopting telehealth practices while working within evolving regulatory frameworks. For example, the Academy of Nutrition and Dietetics launched its Telehealth Quick Guide for RDNs practicing via telehealth during the COVID-19 pandemic . The MQiOur survey respondents reported positive experiences as well as challenges to using telehealth; they also shared recommendations that underscore a need for continued exploration of the patient, provider, economic, and policy implications of telehealth use. It is still unknown how the rapid and drastic switch to telehealth services during the pandemic will affect providers, payers, and patients financially as well as the percentage of visits that will ultimately return to in-person format. To advance health information technology policies and practices, further research should investigate how nutrition services via telehealth compares to other telehealth services as well as how to overcome barriers and identify the best path forward for providing effective and efficient nutrition care. This can ensure the appropriate patients have ready access to the care they need, regardless of where they reside. Continued research should also explore patient preferences and options for improving their reception to telehealth as well as determining the optimal applications and means for integrating with in-person visits for facilitating transitions of care. We call on healthcare professionals and legislative leaders alike to work together to extend policy and payment changes that will support nutrition care provided via telehealth as appropriate throughout and beyond the COVID-19 pandemic.


Liquid biopsy is a convenient, fast, non-invasive and reproducible sampling method that can dynamically reflect the changes in tumor gene expression profile, and provide a robust basis for individualized therapy and early diagnosis of cancer. Circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs) are the currently approved diagnostic biomarkers for screening cancer patients. In addition, tumor-derived extracellular vesicles (tdEVs), circulating tumor-derived proteins, circulating tumor RNA (ctRNA) and tumor-bearing platelets (TEPs) are other components of liquid biopsies with diagnostic potential. In this review, we have discussed the clinical applications of these biomarkers, and the factors that limit their implementation in routine clinical practice. In addition, the most recent developments in the isolation and analysis of circulating tumor biomarkers have been summarized, and the potential of non-blood liquid biopsies in tumor diagnostics has also been discussed. Early detection of cancer can significantly improve the therapeutic outcomes and patient prognosis. However, large-scale screening for early stage tumors is still not possible due to lack of suitable techniques. Although tissue biopsy is the gold standard of tumor detection and diagnosis, it is limited by the difficulties in obtaining tissue samples, poor sensitivity and accuracy, high procedural costs, inability to distinguish between heterogeneous tumors and invasiveness ® CTCs capture system has also been approved by the FDA for diagnosing metastatic prostate, breast and colon cancers i, new generation sequencing technology (NGS) CtDNA was approved by FDA as a diagnostic marker for lung cancer and for screening colorectal cancer (CRC) in 2016 In this review, we have summarized the diagnostic and prognostic value of liquid biopsies in various cancers, the recent developments in the isolation of cancer biomarkers, potential clinical applications, and the limitations. In addition, the possibility of using body fluids other than blood, such as urine, salivary, cerebrospinal fluid (CSF), stool, sputum and lacuna liquid such as pleural effusion, as tumor-derived biomarkers has also been discussed.Circulating protein markers are the most established diagnostic tools for cancer, and include prostate specific antigen (PSA) for screening prostate cancer + T cells function by inducing the immunosuppresive PD-L1 on macrophages + dendritic cells (DCs) was an independent prognostic factor for reduced OS in pancreatobiliary cancer, and increased prevalence of CD68+ and CD163+ tumor- associated macrophages (TAMs) were significantly associated with poor OS in periampullary adenocarcinoma patients The extracellular matrix (ECM) molecules, such as matrix metalloproteinases (MMPs), MMP- degraded collagens, collagen oligomeric matrix protein (COMP) and fibronectin, are released into the bloodstream from solid tumors, and have therefore emerged as promising surrogate markers of tumor development or clearance ® EGFR Mutation Test v2 (Roche Diagnostics), the first ctDNA-based diagnostic test used in clinics, was approved by FDA in 2017 for monitoring the response to epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) in non-small cell lung cancer patients harboring EGFR-TKI sensitizing mutations ®, a FDA-approved screening test for CRC, is based on the methylation pattern of the SEPT9 gene promoter Circulating or extracellular tumor nucleic acids are secreted from primary or metastatic cancer cells following apoptosis or necrosis MicroRNAs are a class of small non-coding RNAs that regulate gene expression and are critical in several biological and pathological processes, including cancer initiation and progression. Several preclinical studies have reported circulating miRNA as tissue-specific cancer biomarkers that can not only monitor a prognosis but also determine the origin of tumor metastases ® EGFR test Currently, ctDNA analyses are based on PCR or next-generation sequencing (NGS). Allele-specific PCR was the earliest approach used in ctDNA detection However, ctDNA detection has several limitations, such as low sensitivity at the early stages of cancer. The incipient tumors shed very low levels of ctDNA, which decrease the MAF and may escape detection ® system captures epithelial cells from the blood using EpCAM-coated magnetic beads, which are then identified using fluorescently-labeled antibodies against cytokeratins . There are several hitherto non-approved systems as well that detect stem-like, mesenchymal-like and hybrid CTC subpopulations, which are clinically significant since CTCs show partial or complete epithelial- mesenchymal transition (EMT) and some even acquire stem cell-like characteristics Ex vivo expansion of CTCs from individual patients can enable personalized drug screening, and assist in making more effective treatment decisions based on the unique tumor mutation profiles and drug sensitivity patterns in vitro culture of CTCs has important guiding value for clinical tumor treatment, this approach is fraught with several limitations. For instance, pre-sample processing, enrichment and sorting, and improper culture conditions can cause irreversible damage to the CTCs. Furthermore, long- term in vitro culture and multiple passages may alter the CTCs genetically and epigenetically, such that they no longer represent the phenotype of the original tumor. Therefore, it is essential to develop a more effective CTC sorting and enrichment system, as well as improve the in vitro culture conditions. In addition, establishing co- cultures of CTCs with immune cells and other blood cells can improve our understanding of the survival mechanism of CTCs in the peripheral blood. This in turn can help develop new intervention strategies and further promote the clinical usage of CTCs as an important tool for liquid biopsy. The isolated CTCs can be genetically analyzed using qPCR, dPCR-based mutational spectroscopy technology, target NGS and genome-wide sequencing technologies During malignant progression, the primary tumor masses shed a significant number of cells that invade adjacent tissues, and migrate to distant sites to establish metastatic clones and also regenerate blood vessel walls to support neo-angiogenesis ® is based on enriching the EpCAM+ cells + depletion TM® assay ®CTC enrichment and detection methods are broadly classified as biological, physico-chemical and functional based on the specific CTC properties that are utilized. The biological methods of capturing CTCs depend on the expression of surface biomarkers; for example, CellSearchChargaff and West discovered back in 1946 that removal of the pelleted plasma fraction after high- speed centrifugation inhibited plasma clotting EVs, especially the exosomes, mediate cell-cell communication by transporting cargo like proteins, DNA, mRNAs and miRNAs from the donor to target cells The proteins and RNAs present in the lumen and membrane of EVs are potential cancer biomarkers that can allow early tumor diagnosis. Typical exosome- enriched proteins include members of the tetraspanin family , members of the endosomal sorting complexes required for transport TSG101 and Alix), and heat-shock proteins   and Alixet al. in situ immunoassay EVs are released by several cell types, including B and T lymphocytes, dendritic cells, mast cells, intestinal epithelial cells, neurons, tumor cells and MSCs Compared to ctDNA and CTCs, the clinical translation of EVs is hampered due to the technically challenging isolation methods, low analytical sensitivity and poor stability. On the other hand, the amount of circulating EVs is significantly higher compared to that of CTCs In addition to proteins, DNA, glycans, lipids and metabolites are also present on the surface of EVs, and are potential biomarkers for EV enrichment Calverley et al. were the first to observe significant differences in the platelet genomic profiles of cancer patients and healthy individuals. They found that 197 platelet-associated genes were down- regulated in patients with metastatic lung cancer, and multiple genes were also spliced differentially between the control and patient groups It has been 150 years since Ashworth first discovered CTCs, and now various liquid biopsy platforms and techniques have been developed for screening, detection, and diagnosis of tumors Figure . During However, although liquid biopsy typically refers to utilization of blood samples, almost all body fluids, including but not limited to urine, saliva, sputum, feces, cerebrospinal fluid and lacuna liquid such as pleural effusion, are reliable cancer biomarkers suitable for liquid biopsies ii for repetitive prostate biopsies in case of a negative first diagnosis ® Prostate (IntelliScore)iii test can detect the expression levels of three exosome-associated RNAs in the urine with high sensitivity and specificity. Thus, urine analysis can obviate the need for invasive prostate tissue biopsies and digital rectal examination.For genitourinary tumors such as prostate, the bladder and cervical cancer, urine is the ideal liquid biopsy for early diagnosis and treatment, and can be easily collected and analyzed for biomarker proteins, ctDNAs or EVs. Progensa® PCA3 Assay was approved by FDA in 2012Salivary biomarkers include ctDNA, miRNAs and EV-associated miRNAs, and have significant clinical value in diagnosing head and neck squamous cell carcinoma and early oral cancers Liquid biopsies provide a cost-effective, fast, reproducible and non-invasive source for early cancer diagnosis and prognostic monitoring. In addition, analysis of circulating tumor-derived factors or the tumor circulome in the liquid biopsies can capture the clonal heterogeneity of these tumors unlike tissue biopsies. Various liquid biopsy samples can be combined to improve the chances of cancer diagnosis, and sequential real-time biopsies will further aid in the early identification of therapy-resistant tumors. Furthermore, detection and characterization of minimal residual disease after initial therapy can also be improved by analyzing liquid biopsies. Automated chip-based devices are particularly fitting for the high throughput analysis of biomarkers from whole blood and other body fluids, and obviates time consuming and costly purification steps. However, the lack of standardized pre-analytical and analytical variables is a significant limitation in this field, and has stymied large-scale clinical applications of liquid biopsies. In conclusion, liquid biopsies can be a powerful tool for cancer diagnosis, monitoring, prognosis and individualized treatment, and can completely change the current paradigms of cancer management. However, considerable research and development are still needed to improve the isolation, enrichment and downstream analysis of circulating biomarkers.


The evolutionary arms race between host and pathogen has resulted in the ability of many human viruses to alter the host gene expression profile during infection, in order to redirect cellular resources towards viral gene expression and inhibit cell-intrinsic host immune responses. In particular, multiple viruses globally reduce host gene expression in a process termed “host shutoff.” Multiple mechanisms of host shutoff exist, including translational and transcriptional shutoff, but several viruses carry out host shutoff by encoding ribonucleases (RNases) that degrade host messenger RNAs (mRNAs). Viral host shutoff RNases include the influenza A virus polymerase acidic-X (PA-X) , the herAll host shutoff RNases cause global decreases in host mRNA abundance, revealed by transcriptome-wide studies –15, and For influenza PA-X, the selectivity for mRNAs (and other transcripts of RNA polymerase II) is linked to RNA splicing, which is tightly connected to RNA polymerase II transcription . SplicedIn contrast, all the herpesviral nucleases selectively target mRNAs because they are actively translated ,17. HSV In an interesting case of convergent evolution, all the host shutoff RNases described so far are endoribonucleases and cut mRNAs in fragments rather than initiating degradation from an mRNA end ,17,23–25Multiple studies show that the activity of the HSV RNase vhs is modulated by other viral proteins. As the “virion host shutoff” name suggests, vhs is a component of the virion and inhibits gene expression immediately after release from the entering virions . HoweverIn contrast to vhs, gamma-herpesviral RNase activity is not restricted to the early part of the replication cycle. Nonetheless, the EBV protein kinase BGLF4 has been proposed to inhibit activity of the EBV RNase BGLF5 . The mecWhy do these viruses encode both RNases and inhibitors of the RNases? As mentioned previously, herpesviral host shutoff RNases can degrade viral as well as cellular mRNAs. In fact, HSV vhs is thought to degrade early viral mRNAs and contribute to the switch between early and late herpesviral gene expression . Moreovevhs is primarily located in the cytoplasm , whereasImportantly, the functionally relevant localization of the RNases matches well with that of their cellular cofactors. For example, vhs-interacting proteins are cytoplasmic proteins involved in translation initiation, whereas PA-X-interacting proteins are nuclear proteins involved in RNA processing. Thus, correct localization presumably allows the RNases to interact with the correct cellular proteins and degrade the intended RNA targets.Eukaryotic proteins commonly undergo co- and posttranslational modifications, such as phosphorylation, ubiquitination, and acetylation, which can regulate protein localization, stability, and function. So far, few modifications have been identified on host shutoff RNases. Although 3 differentially phosphorylated forms of HSV-1 vhs have been identified , it is uHost shutoff is a key feature of many viral replication cycles that profoundly alters the host gene expression profile. It plays important roles in viral pathogenesis by suppressing host immune responses and redirecting cellular resources to viral gene expression. This warrants the detailed understanding of host shutoff mechanisms and regulation in different viruses, especially because the expression of viral mRNAs and key host mRNAs and/or ncRNAs must be preserved for replication to occur. Particularly, determining the host and viral interacting proteins of the RNases and characterizing the functional consequences of these interactions will shed new light on their target selection mechanism and wider roles in viral replication. Together with a better characterization of posttranslational modifications, it will give us a better understanding of the regulation of these potent viral factors and provide new targets for potential therapeutic interventions.


The goal of this review was to summarize reported studies focusing on cellular reductive stress-induced mitochondrial dysfunction, cardiomyopathy, dithiothreitol- (DTT-) induced reductive stress, and reductive stress-related free radical reactions published in the past five years. Reductive stress is considered to be a double-edged sword in terms of antioxidation and disease induction. As many underlying mechanisms are still unclear, further investigations are obviously warranted. Nonetheless, reductive stress is thought to be caused by elevated levels of cellular reducing power such as NADH, glutathione, and NADPH; and this area of research has attracted increasing attention lately. Albeit, we think there is a need to conduct further studies in identifying more indicators of the risk assessment and prevention of developing heart damage as well as exploring more targets for cardiomyopathy treatment. Hence, it is expected that further investigation of underlying mechanisms of reductive stress-induced mitochondrial dysfunction will provide novel insights into therapeutic approaches for ameliorating reductive stress-induced cardiomyopathy. Itmyopathy . TFEB exmyopathy .Nrf2 is a master regulator of many cytoprotective genes . Nrf2 inIn this review, we have summarized studies published mainly between 2014 and 2019, which accounts for more than four-fifth of all the citations. Further investigations should focus on identifying more reductive stress indicators as the risk assessment and prevention of developing heart damage as well as exploring more targets for cardiomyopathy treatment. Although there are still some ambiguous statements, such as the paradox between mitochondrial morphological abnormalities and mitochondrial dysfunction, we firmly believe that studying mitochondria is the critical step to reveal more unknowns. Therefore, it is expected that future investigation of underlying mechanisms of reductive stress-induced mitochondrial dysfunction will provide novel insights into therapeutic approaches for ameliorating reductive stress-induced cardiomyopathy.


Adverse experiences during childhood are among the most prominent risk factors for developing mood and anxiety disorders later in life. Early-life stress interventions have been established as suitable models to study the neurobiological basis of childhood adversity in rodents. Different models such as maternal separation, impaired maternal care and juvenile stress during the postweaning/prepubertal life phase are utilized. Especially within the limbic system, they induce lasting alterations in neuronal circuits, neurotransmitter systems, neuronal architecture and plasticity that are further associated with emotional and cognitive information processing. Recent studies found that astrocytes, a special group of glial cells, have altered functions following early-life stress as well. As part of the tripartite synapse, astrocytes interact with neurons in multiple ways by affecting neurotransmitter uptake and metabolism, by providing gliotransmitters and by providing energy to neurons within local circuits. Thus, astrocytes comprise powerful modulators of neuronal plasticity and are well suited to mediate the long-term effects of early-life stress on neuronal circuits. In this review, we will summarize current findings on altered astrocyte function and hippocampal plasticity following early-life stress. Highlighting studies for astrocyte-related plasticity modulation as well as open questions, we will elucidate the potential of astrocytes as new targets for interventions against stress-induced neuropsychiatric disorders. Adverse events causing feelings of emotional strain are part of our daily life. Usually, our system adapts well to such stressors. However, when stress endures or is too intense, then adaptation can fail, and stress-induced psychopathologies emerge. However, the levels of stress endurance and intensity that cause a maladaptation are highly individual. Indeed, even after experiencing a potentially life threatening, traumatic event, only a minority of people will develop a long-lasting pathological stress response such as posttraumatic stress disorder (PTSD) . PTSD isIndeed, in response to new events, neural circuits constantly change in order to adapt their function to new environmental requirements, a process called plasticity, which occurs on different temporal scales. These changes can be expressed as an altered short-term (millisecond-to-minutes) adaptation to a multisensory input, the formation of short-forms of memories or sustenance of working memory -adaptive plasticity. Thus, we can identify current gaps in knowledge and themes for further research regarding the putative mechanisms of a lasting astrocytic modulation of plasticity after early-life stress.While astrocytes comprise the second largest cell population in the central nervous system and are the predominant glial cell type besides oligodendrocytes and microglia, they have only received a modest degree of attention in studies of neurobiological processes in health and disease. In gray matter, protoplastic astrocytes are widely distributed and form highly ramified processes which permeate the extracellular space between neuronal cells and contact neuronal cell bodies, blood vessels and synapses, in order to metabolically support neurons, regulate brain homeostasis and also modulate neuronal signaling by releasing neuromodulatory factors or regulating neurotransmitter concentrations at synaptic sites  phosphorylation and support of LTP induction [Another metabolite that affects long-term memory and LTP formation is lactate, that sustains neuronal energy demands during neuronal activity. Astrocytes store metabolites for the TCA cycle in the form of glycogen, thereby providing a local source for the energy used by synapses that can be released upon enhanced neuronal activity . In the nduction . Such a nduction . Accordinduction ,87.One functionally important feature of astrocytes is their connection with each other via hemichannels formed by a hexameric ring of connexin proteins (Cxs). When hemichannels between neighboring astrocytes face each other, they form “gap junctions”, supporting direct intercellular communication via the exchange of ions and small molecules within the astrocytic network, thereby enabling crosstalk with neuronal networks over a wide range . The maiConsidering the tight interaction of neurons and astrocytes in the establishment and induction of synaptic plasticity, further studies are needed to understand the role of astrocytes in the long-term adjustment of synapse strength, and might help to unravel the astrocytic role in memory storage. In this way, new therapeutic targets for the treatment of stress-induced memory impairments and associated neuropsychiatric disorders such as anxiety and depression could be identified. Animal models are indispensable tools to investigate the neurobiological traces of early-life stress in the adult brain. Several procedures have been developed in rodents to mimic an adverse childhood. One of the most prominent models concentrating on the preweaning life phase is maternal separation (MS). Typically, rats and mice are weaned off their mothers at the age of PND 21; the repeated separation of pups from their mothers during their first two postnatal weeks can evoke increased anxiety- and depression-like behavior later in life. However, outcomes vary greatly depending on the exact age of the separated pups, the duration of the separation sessions and whether pups we kept alone or grouped during separation sessions ,9. MoreoFollowing all these models of early-life stress, long-term changes in plasticity were observed and are particularly well studied in the hippocampal formation. It is now well-established that the dorsal and ventral portions of the hippocampus show differential anatomical connectivity and support diverging functions . While tAnother hippocampal region that functions as the gatekeeper of the hippocampus is the dentate gyrus (DG) . SeveralIn contrast to the studies investigating the impact of MS on hippocampal physiology, the differential impact of stress during the postweaning/adolescence period on VH vs. DH plasticity has been investigated more extensively. We and others have consistently shown that stress exposure (PND 27–29 or PND 28–30) during juvenility prompts the induction and maintenance of LTP at the ventral SC-CA1 synapse, while decreasing it somewhat in the dorsal counterpart later in adulthood PND 60–120) ,119,120. ,119,120Taken together, stress during this sensitive period affects bidirectional plasticity in the “cognitive” DH and “affective” VH in a contrasting fashion. Such an opposing impact may induce diverging synaptic scaling/homeostatic plasticity in brain regions with differential functional and anatomical connectivity to VH or DH ,123.As stated above, astrocytes can modulate plasticity at the tripartite synapse in multiple ways. The majority of studies investigating the impact of early life stress on astrocytes have focused on the expression of astrocyte-specific markers, such as glial fibrillary acid protein (GFAP) and the calcium binding protein S100ß in brain areas involved in emotional behavior control, while only a handful have assessed specific astrocytic functions .Within the DH of adult rats, preexposure to MS reduced GFAP expression ,125 or tstratum radiatum, the layer of SC synapses in CA1 [Together, instead of general markers of astrocytes, the analysis of specific astrocytic proteins may hold greater potential to reveal functions of astrocytes as sequelae of stress. While such studies are still ongoing for models of preweaning early life stress, we started to investigate the key players of astrocyte-neuron interactions after variable 3-day JS. We found that preexposure to JS reduced the expression of GLT-1 and GAT-3 in the granule cell layer of the dorsal DG in adulthood. These changes were associated with an increased paired pulse inhibition, a form of STP. Increased PPI was pharmacologically mimicked by blocking of GAT-3 in stress-naive rats. Thus, the reduced uptake of GABA into astrocytes appears to increase inhibition in local dorsal DG circuits as a long-lasting consequence of JS . Interess in CA1 . Both stStress early in life is one of the most important risk factors for developing psychopathologies in adulthood, like depression and anxiety disorders. Studies in humans and rodents have demonstrated that early-life stress shapes how individuals respond to stress later in life ,137,138.Indeed, as summarized above and by others, astrocytes are powerful modulators of neuronal plasticity, but neuronal activity itself shapes the interaction of neurons and astrocytes at the tripartite synapse as well ,22,23. PTo date, most of the studies investigating the lasting consequences of stress across different life phases on astrocytes have merely assessed the expression of astrocytic markers such as GFAP, finding, overall, a reduction see . One majGiven the functional complexity of astrocyte–neuron interactions, an altered neurotransmitter uptake and metabolism as a consequence of early life stress may not be the only astrocytic functional domain contributing to stress-induced changes in LTP and STP. For example, metabolic coupling and lactate shuttling might be affected, or the release of other gliotransmitters such as ATP or D-serine could be affected as well. Another as yet unresolved question is whether early-life stress has stable long-term effects on astrocyte structure and interactions via gap junctions. First insights from adult stress models underline the modulative capacity of stress on astrocytes. Acute adult stress appeared to induce an astrocytic hypertrophy and an increase in astrocytic microdomain calcium levels, while the expression of connexin proteins was reduced . Other sMoreover, instead of assessing isolated astrocytic factors that could be potentially altered following stress, transgenic animal models are available that allow cell-type-specific metabolic tagging of newly synthesized proteins to be performed that discriminate between neuronal and glial proteomes, and thereby make possible the identification of global astrocyte specific changes following stress ,140. UsiAs the findings from the JS studies demonstrate, there is a high regional specificity in the impact of stress on hippocampal plasticity see also . IncreasIn summary, identifying the relevant molecular mechanisms targeted by early-life stress in astrocytes would make it possible to identify possible pharmacological targets that attenuate stress-induced alterations in astrocytes; thereby, new therapeutic avenues for the treatment of stress-induced psychopathologies such as anxiety disorders and depression could be established and tested in translational settings.


Many patients with cancer suffer from anemia, depression, and an impaired quality of life (QoL). These patients often also show decreased plasma tryptophan levels and increased kynurenine concentrations in parallel with elevated concentrations of Th1 type immune activation marker neopterin. In the course of anti-tumor immune response, the pro-inflammatory cytokine interferon gamma (IFN-γ) induces both, the enzyme indoleamine 2,3-dioxygenase (IDO) to degrade tryptophan and the enzyme GTP-cyclohydrolase I to form neopterin. High neopterin concentrations as well as an increased kynurenine to tryptophan ratio (Kyn/Trp) in the blood of cancer patients are predictive for a worse outcome. Inflammation-mediated tryptophan catabolism along the kynurenine pathway is related to fatigue and anemia as well as to depression and a decreased QoL in patients with solid tumors. In fact, enhanced tryptophan breakdown might greatly contribute to the development of anemia, fatigue, and depression in cancer patients. IDO activation and stimulation of the kynurenine pathway exert immune regulatory mechanisms, which may impair anti-tumor immune responses. In addition, tumor cells can degrade tryptophan to weaken immune responses directed against them. High IDO expression in the tumor tissue is associated with a poor prognosis of patients. The efficiency of IDO-inhibitors to inhibit cancer progression is currently tested in combination with established chemotherapies and with immune checkpoint inhibitors. Inflammation-mediated tryptophan catabolism and its possible influence on the development and persistence of anemia, fatigue, and depression in cancer patients are discussed. Cancer is a leading cause of death and disability worldwide with an increasing prevalence. Patients with malignant diseases often have sustained systemic immune activation, which is linked to tumor progression and a poor clinical outcome , 2. InitIn fact, enhanced Trp breakdown, reflected by decreased Trp and elevated kynurenine (Kyn) concentrations in the peripheral blood, is often observed in cancer patients and related to tumor progression, poor clinical outcome  and an iHigher neopterin concentrations mostly coincide with increased IDO-activation as reflected by a higher Kyn/Trp ratio , 89, 90 Trp is essential for the growth and proliferation of all kinds of cells; therefore, local inflammation-induced Trp depletion is initially a defense mechanism of the immune system to limit growth of microbes but also of proliferating malignant cells . HoweverApart from an activated immune system and enhanced Trp breakdown, patients with malignancies frequently suffer from anemia . Anemia This review discusses the current knowledge on and consequences of immune activation and Trp breakdown for the development and persistence of anemia, fatigue, and depression in cancer patients. Moreover, it gives an overview of possible therapeutic options for the treatment of comorbidities. At the beginning, a brief depiction of Trp metabolism and its relations to immune activation will be given.Trp is an essential amino acid that is required for protein biosynthesis. Therefore, it is essential for the growth and proliferation of cells. Trp must be supplied by diet or obtained from protein degradation, since it cannot be synthesized by human cells. The required daily amount for adults lies between 175 and 250 mg. Yet, the average daily intake for many individuals lies between 900 and 1,000 mg , 103. Th+. These metabolites are mainly generated by two different biochemical pathways.Trp is also an important precursor for several bioactive metabolites including tryptamine, serotonin, melatonin, kynurenine (Kyn) and quinolinic acid (QUIN) and kynurenic acid (KYNA) as well as for the coenzyme NADFirst, Trp can be catabolized by the enzyme tryptophan 5-hydroxylase (TPH) to 5-hydroxytryptophan (5-HTP) . 5-HTP iAlthough only 1% of the available Trp is converted by the Trp/5-HT pathway in healthy individuals, decreased Trp availability is associated with decreased serotonin concentrations and consequently with neuropsychologic disorders . In the + and NADP+ being necessary for energy production   . IDO1 exop (reg) –121 as wop (reg) . Contrarop (reg) , 124. Liop (reg) . Similarop (reg) . Interesop (reg) . IFN-γ aop (reg) .An immunologicaly privileged milieu with a decreased reactivity to allogeneic (non-self) antigens is found in certain parts of the human body . This immune tolerance prevents fetal rejection and immune responses against immunogenic sperms. An enhanced expression of TDO, IDO1, and IDO2, with a subsequent accumulation of Trp metabolites, is found in several parts of the human body including the placenta , 129, mareg) in naive CD4+ T cells  cells. Furthermore, they induce apoptosis of these cells probably mediated by oxygen free radicals  inhibition might be due to an immunosuppressive tumor microenvironment based on IDO1 activation within macrophages . This suIn human patients, epacadostat monotherapy was not effective , 164, whUntil now, IDO2 has been investigated far less than IDO1. Although IDO2 is expressed by cancer cells, it does not contribute to the accumulation of Trp metabolites to the same extent as IDO1 , 171. HoRecent studies revealed that TDO may also be involved in tumor immune-escape. It was demonstrated that TDO is expressed in various tumors including glial tumors , breast Also, KMO activity may be involved in tumor immune tolerance. Recent studies have shown that its overexpression is related to rapid cancer progression and a poor prognosis , 180. SiCancer related fatigue (CRF) is a complex multi-dimensional phenomenon that affects physical, cognitive and emotional activity, and behavior . It is aPatients with lung cancer and moderate or severe fatigue are presented with lower Trp and hemoglobin concentrations, but with higher inflammatory markers . They fuA recent study in patients with solid tumors excluded patients with known depression or antidepressant treatment or established infection . Again, It is of importance that treatment with corticosteroids or anti-inflammatory drugs like celecoxib reduces fatigue in patients with advanced cancer , 195, suFatigue is one of the main symptoms of depression, which is another common comorbidity in subjects suffering from malignancies, affecting ~20% of the patients –101. DepRecently, correlations between inflammation markers (neopterin and CRP) and depression scores in a population of patients with solid tumors were reported, and particularly in male patients, lower Trp levels were associated with higher depression scores and stronger fatigue .This clinical data fit well with results from animal experiments: Depressive-like behavior related to immune activation was demonstrated to be associated with an upregulation of IDO1 –207 as wDepression is also related to enhanced Trp breakdown and immune activation in patients with HIV-infection , 213, asImmune activation probably affects the development of CRF and depression also by other mechanisms: Pro-inflammatory cytokines, for one thing, directly affect basal ganglia and dopamine function and, for another, activate sensory nerves. This results in production of pro-inflammatory cytokines and prostaglandins by microglia in the CNS, which then affect the functionality of neurons, thereby contributing to fatigue . Immune There are several pathophysiological mechanisms, which might explain how Trp metabolites cause CRF or neurobehavioral symptoms related to CRF such as depression.Trp is a crucial amino acid in brain homeostasis and a precursor for serotonin and melatonin synthesis. It can cross the blood-brain barrier; therefore, reduced Trp availability may contribute to serotonin dysregulation and neurobehavioral manifestations , 218. HoQUIN, which is primarily produced by monocytes/macrophages and microglia, generates free radicals, causes structural changes, and is a selective agonist at the glutamate receptor sensitive to N-methyl-D-aspartate (NMDA receptor) . Its accAlthough immune system activation frequently coincides with fatigue or depression in cancer patients, it has to be kept in mind, that fatigue or depression also can develop isolatedly in patients with other predisposing conditions . Probably the development of neuropsychiatric disturbances and depression is alleviated in the presence of an activated immune system and accelerated Trp breakdown, but it must not necessarily lead to depressed mood. Maybe the handling of bad news is impaired if Trp and thus serotonin availability is low.Additionally, also other factors, like psychosocial aspects including demographical factors , behavior/well-being  but also functional status  contribute to the development, severity, and duration of CRF and depression. Moreover, an imbalance in the autonomic nervous system, disturbances in the hypothalamic-pituitary-adrenal axis and circadian rhythm as well as hypoxia or anemia are key players in the pathophysiology of CRF and depression , 229. ThExperiments in mice demonstrated that the IDO pathway modulator indoximod inhibits depressive-like behavior  without altering the infectious immune response , 230. MoInhibition of KMO also seems to be a possible therapeutic approach in the treatment of fatigue and depression by shifting Kyn metabolism toward the enhanced production of neuroprotective KYNA while decreasing production of neurotoxic QUIN. A recent mice trial revealed that KMO gene deletion substantially reduces 3-HK and QUIN concentrations while elevating KYNA concentrations . It was Another recent study showed decreased IDO1 and KMO expression in the murine brain as well as decreased IDO1 and IDO2 expression in human peripheral blood mononuclear cells as a consequence of antidepressant treatment , 245. ThMonoaminergic antidepressants and also omega-3 fatty acids were demonstrated to reduce neurotoxic effects related to Trp breakdown . Omega-3In fact, diet and the gut microbiome may influence inflammation and Trp metabolism by several ways : MicrobiA recent review by Weber et al. proposed that preclinical and several clinical studies argued for the use of a ketogenic diet (KD) in combination with standard therapies in patients with cancer : KD had Significant differences regarding Trp metabolism were reported between a low-glycemic load dietary pattern  and a diet high in refined grains and added sugars on inflammation and energy metabolism pathways . In lineAs cancer cells are very vulnerable to nutrient deprivation , fasting or fasting-mimicking diets (FMDs) might be another effective strategy to generate environments that can reduce the capability of cancer cells to adapt and survive and thus improve the effects of cancer therapies . FurtherLactobacillus acidophilus and rhamnosus) improved CRF, irritable bowel syndromes and QoL significantly in a double-blind placebo-controlled study  production by activating AhR . AhR comInterestingly, in patients with different malignant diseases, increased Kyn/Trp and neopterin concentrations also coincided with lower hemoglobin values . Also, rAlso, QUIN was shown to inhibit EPO production  by stimuIn patients with myelodysplastic syndromes, a fundamental role for Trp metabolized along the serotonin pathway in normal erythropoiesis and in the physiopathology of MDS-related anemia was demonstrated recently: Decreased blood serotonin levels were related with impaired erythroid proliferating capacities, and treatment with fluoxetine, a common antidepressant, was effective in increasing serotonin levels and the number of erythroid progenitors .Low serotonin concentrations are also associated with the development of depression. Vulser et al. actually showed a considerable association between anemia and depression in otherwise healthy adults . IncreasThese findings show that impaired Trp availability but also accumulation of Trp metabolites, may affect erythropoiesis. In cancer patients, tumor cells produce TDO and IDO1, and both are equally capable of producing Kyn . HoweverInflammation-induced Trp breakdown in cancer patients is considered to play a key role in the pathophysiology of tumor immune tolerance. Accumulation of Trp metabolites as well as impaired Trp availability suppress the tumor immune response and may also greatly contribute to the development of comorbidities such as fatigue, depression, or anemia, which are all common in patients with malignancies. Although anemia is primarily caused by the enhanced immune response itself, inflammatory-induced Trp degradation may also be involved strongly. Studies have shown that inhibition of Trp breakdown might be a promising therapeutic option in cancer patients to counteract the immunosuppressive tumor microenvironment. Especially cancer patients with no response to immune checkpoint inhibitors might benefit from an additional IDO1 inhibition. Moreover, there is evidence that inhibition of IDO1, TDO, and KMO or other interventions targeting Trp metabolism (like diet or probiotics) may further improve neurobehavioral manifestations including CRF or depression. Further studies investigating the effects of IDO1, TDO, or KMO inhibition on tumor immune response should also take the impact on neurobehavioral manifestations into consideration.LL and KK wrote the manuscript. PK, EE, WW, DF, and GW critically read and revised the paper. All authors listed approved the submitted 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.


In Kenya, pre-exposure prophylaxis (PrEP) for HIV prevention is almost exclusively delivered at HIV clinics. Developing novel PrEP delivery models is important for increasing the reach of PrEP. Delivery of PrEP through pharmacies is one approach utilized in the US to improve accessibility. Retail pharmacies are commonly used as a first-line access point for medical care in Kenya, but have not been utilized for PrEP delivery. We conducted a collaborative consultative meeting of stakeholders to develop a care pathway for pharmacy-based PrEP delivery in Kenya.In January 2020, we held a one-day meeting in Nairobi with 36 stakeholders from PrEP regulatory, professional, healthcare service delivery, civil society, and research organizations. Attendees reviewed a theory of change model, results from formative qualitative research with pharmacy providers and clients, and anticipated core components of pharmacy-based PrEP delivery: counseling, HIV testing, prescribing, and dispensing. Stakeholders participated in small and large group discussions to identify potential challenges and solutions. We synthesized the key findings from these discussions.Stakeholders were enthusiastic about a model for pharmacy-based PrEP delivery. Potential challenges identified included insufficient pharmacy provider knowledge and skills, regulatory hurdles to providing affordable HIV testing at pharmacies, and undefined pathways for PrEP procurement. Potential solutions identified included having pharmacy providers complete the Kenya Ministry of Health-approved PrEP training, use of a PrEP prescribing checklist with remote clinician oversight and provider-assisted HIV self-testing, and having the government provide PrEP and HIV self-testing kits to pharmacies during a pilot test. A care pathway was developed over the course of the meeting.PrEP delivery stakeholders in Kenya were strongly supportive of developing and testing a model for pharmacy-based PrEP delivery to increase PrEP access. We collaboratively developed a care pathway for pilot testing that has the potential to expand PrEP delivery options in Kenya and other similar settings.The online version contains supplementary material available at 10.1186/s12913-020-05898-9. Maximizing access and reaching at-risk populations are key priorities for optimizing the public health impact of pre-exposure prophylaxis (PrEP) for HIV prevention , 2. PrEPIn Kenya and many other resource-constrained countries, retail pharmacies fill an important gap in the health care system, providing access to treatment of urgent conditions , monitoring of chronic conditions , point-of-care testing , and preventative care  –16. PharTo develop a model for pharmacy-based PrEP delivery for pilot testing in Kenya, we convened a meeting of stakeholders with diverse professional backgrounds and roles in PrEP delivery to collaboratively design a pathway that aligns with Kenya’s national PrEP and HIV prevention guidelines , 26. In In Kenya, PrEP is currently being delivered at most health facilities. In 2019, nearly 2000 public HIV clinics in Kenya were offering PrEP and approximately 63,000 individuals were on PrEP , with ovWe convened a consultation of individuals from different regulatory, professional, healthcare service delivery, civil society, and research organizations in Kenya . We inclThe one-day stakeholder meeting in Nairobi, Kenya featured presentations from stakeholders and researchers, as well as small and large group discussions. Two facilitators  with expertise in PrEP and implementation research oversaw the meeting. The meeting — including group discussions — was audio-recorded for purposes of note-taking.Representatives from Kenya’s National AIDS & STI Control Program (NASCOP) and Pharmacy & Poisons Board (PPB) opened the meeting with presentations on the role of PrEP in Kenya’s national HIV prevention plan. Next, members of our research team presented a theory of change for how pharmacy-based PrEP delivery may overcome barriers to PrEP access and delivery and outlined the anticipated core components of pharmacy-based PrEP delivery in Kenya . A mock care pathway for the delivery of these components was presented, based on a pharmacy-based PrEP delivery model ongoing in the US .Following presentations, stakeholders were divided into three small groups to discuss the potential for pharmacy-based PrEP delivery to address the barriers to PrEP access and delivery presented in the theory of change model. Stakeholders were grouped purposefully to equally distribute different perspectives  across the groups. To help guide discussion, each group received worksheets (organized by the anticipated core components of pharmacy-based PrEP delivery) on current practices and potential barriers to pharmacy-based PrEP delivery  and poteWe received ethical approval to conduct formative research, including engagement with stakeholders during a one-day meeting, from institutional review boards at the Kenya Medical Research Institute and University of Washington.Both NASCOP and PPB gave introductory statements that were strongly supportive of developing models for pharmacy-based PrEP delivery in Kenya. The organizations acknowledged the limitations of clinic-based PrEP delivery and stressed the need for evidence that alternative models of PrEP delivery work. Both organizations emphasized their commitment to working with researchers to support the development of such models and outlined key questions related to the development of pharmacy-based PrEP delivery. Their questions centered around the minimum criteria pharmacies should meet to deliver PrEP, capacity-building needs among pharmacy providers,acceptable modalities of PrEP delivery at pharmacies , data for tracking pharmacy-based PrEP delivery, and the role of NASCOP and PPB in the process.In our theory of change model, Fig. Following presentation of our theory of change model, we presented the anticipated core components of pharmacy-based PrEP initiation and refills: counseling, HIV testing, prescribing, and dispending, with oversight by a remote clinician and referral to a health facility when needed, Fig. During small and large group discussions, stakeholders identified a number of challenges and solutions, both for the pilot study of pharmacy-based PrEP delivery and for larger scale-up in Kenya. Findings from these discussions are summarized in Table Anticipated challenges primarily centered on pharmacy provider knowledge and skills to deliver PrEP. To ensure that the pharmacy providers in the pilot study have sufficient skills to deliver PrEP, stakeholders suggested training using existing NASCOP PrEP materials and guidelines. For future pharmacy PrEP scale up, stakeholders suggested that the Kenya MOH establish training requirements specifically for pharmacy providers and that NASCOP PrEP training materials be customized to fit the retail pharmacy setting. Stakeholders agreed that the pilot study should have pharmacy providers use a stakeholder-approved checklist to guide PrEP prescribing and a remote clinician available for consultation (via both the phone and WhatsApp). If this model is successful in a pilot setting, stakeholders expressed interest in testing this model at scale  and, in the future, having PPB consider rescheduling PrEP medications so that is available without a prescription .Other anticipated challenges to pharmacy-based PrEP delivery included lack of guidelines for PrEP delivery in pharmacies, including whether and how pharmacies can advertise PrEP, test for HIV, procure and price PrEP, and document PrEP delivery. Stakeholders noted that, currently in Kenya, the PPB does not allow retail pharmacies to publicly advertise name-brand medicines. To attract PrEP clients during the pilot study, stakeholders advocated for pilot pharmacy providers to use word-of-mouth referral, offer PrEP to clients seeking services indicative of HIV risk behavior , and obtain permission to display PrEP posters within the confines of the pharmacy. Stakeholders also suggested that, for future pharmacy-based PrEP scale-up, the PPB could revise pharmacy advertising restrictions to include a PrEP exemption, the MOH could implement a national awareness campaign, and NASCOP could create standard PrEP promotional materials for pharmacies.With respect to HIV testing, stakeholders noted that retail pharmacies are not currently allowed to sell or perform rapid HIV tests but that they are allowed to sell and assist clients with HIV self-testing. For the pilot study, stakeholders felt that only provider-assisted HIV self-testing should be permissible, but that long term solutions for pharmacy-based PrEP scale-up could include developing MOH guidelines for the delivery of rapid HIV testing at pharmacies (including modifying permissions as to who can conduct rapid HIV tests).With respect to PrEP procurement and pricing, NASCOP and MOH representatives committed to providing the PrEP drugs and HIV self-tests for free to the pharmacies in the pilot study and suggested that pilot pharmacies acquire their PrEP and HIV self-tests through nearby health facilities so that this inventory can be tracked using those facilities’ Master Facility List (MFL) codes. The cost of PrEP to pilot study participants would, therefore, be just a service fee for counseling, and dispensing, but not for the HIV self-test or PrEP drug itself. When asked how PrEP procurement and pricing might be handled in a scale-up situation, stakeholders felt that pharmacy providers could work with non-branded drug manufacturers to procure PrEP and HIV tests, or the MOH could consider giving retail pharmacies their own MFL codes for direct procurement through the Kenya Medical Supplies Agency (KEMSA).Based on stakeholder feedback and consensus, we revised and finalized the care pathway for pharmacy-based PrEP delivery to pilot test, Fig. This collaborative meeting, including a wide cross-section of stakeholders, aimed to spearhead the first national effort to create a formal pathway for pharmacy-based PrEP delivery that bridges the public and private sectors , 28. ThiIn its 2017 framework for PrEP implementation, the Kenya MOH identified research on the feasibility of integrating PrEP into pharmacies as “high priority” . At thisExpanding the scope of retail pharmacy practice to include interventions traditionally delivered at healthcare clinics is not new for Kenya. For years, retail pharmacies have delivered family planning methods  that are available for free at public family planning clinics . The phaSimilarly, this model — if successful — may prompt the Kenya MOH to reconsider HIV testing guidelines. According to guidelines by Kenya Medical Laboratory Technicians and Technologists Board, only trained laboratory technologist and technicians are legally allowed to conduct rapid provider-completed HIV testing in Kenya. Under these guidelines, the ongoing rapid HIV testing being conducted by nurses at health facilities and retail pharmacy providers is not permissible. For these reasons, we limited HIV testing in our pharmacy-based PrEP delivery pilot study to provider-assisted HIV self-testing, which was made permissible when HIV self-tests were introduced in Kenya in May 2017 . There eDocumentation of PrEP dispensing was another key concern raised during the stakeholder meeting because implementing partners at the MOH facilities set PrEP targets for health facilities that could potentially disincentivize facilities from referring PrEP clients to retail pharmacies. For the pilot study, it is important that PrEP dispensing records complement — and do not compete with — facilities’ PrEP dispensing targets. For this reason, the PrEP dispensed at pilot pharmacies was recommended to be under the MFL code of a nearby health facility so that it can count toward that facility’s target PrEP numbers. Accurate completion of NASCOP’s PrEP dispensing records (including the drugs that will be donated to the pilot pharmacies) is important for future PrEP procurement, including continued support from international organizations such as the United States President’s Emergency Plan for AIDS Relief, United States Agency for International Development, Global Fund, and others. A number of electronic drug dispensing tools have already been developed by the Pharmaceutical Society of Kenya and the Clinton Health Access Initiative for use in the Kenyan context, so we plan on modify existing tools to record pharmacy-based PrEP delivery in our pilot study.This study has some limitations that are important to note. First, the pharmacy PrEP stakeholders who attended this Nairobi-based meeting were a highly selective group of individuals who had contributed, in some way, to the recent introduction and scale up of PrEP in Kenya. While an alternative group of stakeholders may have designed a different care pathway for pharmacy-based PrEP delivery, we believe the experiences of the stakeholders in this group helped informed the design of a care pathway with the greatest likelihood of success, particularly for the setting. Second, the pharmacy-based PrEP care pathway designed from this collaborative process does not include creatinine testing for PrEP initiation. In Kenya, creatinine testing is not formally required for starting PrEP if doing so would limit initiation . AdditioThrough a collaborative stakeholder consultation process, we were able to successfully develop a care pathway for pilot testing of pharmacy-based PrEP delivery in Kenya. Despite the availability of highly effective HIV prevention interventions, high levels of population-level HIV incidence persist in many sub-Saharan African settings . Novel sAdditional file 1:Appendix I. Stakeholder organizations in attendance at the January 2020 meeting.Additional file 2:Appendix II. Pharmacy-based PrEP delivery – Worksheet #1.Additional file 3:Appendix III. Pharmacy-based PrEP delivery – Worksheet #2.Additional file 4:Appendix IV. Pharmacy PrEP prescribing Checklist.


Lastly, we summarize completed and ongoing TTFields clinical trials on a variety of solid tumors.Despite extraordinary advances that have been achieved in the last few decades, cancer continues to represent a leading cause of mortality worldwide. Lethal cancer types ultimately become refractory to standard of care approaches; thus, novel effective treatment options are desperately needed. Tumor Treating Fields (TTFields) are an innovative non-invasive regional anti-mitotic treatment modality with minimal systemic toxicity. TTFields are low intensity (1–3 V/cm), intermediate frequency (100–300 kHz) alternating electric fields delivered to cancer cells. In patients, TTFields are applied using FDA-approved transducer arrays, orthogonally positioned on the area surrounding the tumor region, with side effects mostly limited to the skin. The precise molecular mechanism of the anti-tumor effects of TTFields is not well-understood, but preclinical research on TTFields suggests it may act during two phases of mitosis: at metaphase, by disrupting the formation of the mitotic spindle, and at cytokinesis, by dielectrophoretic dislocation of intracellular organelles leading to cell death. This review describes the mechanism of action of TTFields and provides an overview of the most important  The paradigm of standard care for cancer treatment has dramatically changed in the past two decades due to a greater understanding of tumor development and treatment resistance to more classical therapies  includinin vitro investigations. Finally, we provide an up-to-date summary of approved and ongoing clinical studies highlighting the multifaceted applications of TTFields.TTFields are applied to the localized tumor using an array of ceramic applicators powered by a portable 3 lb battery pack. These fields are believed to exert their inhibitory effect on dividing cells by inducing a disruption of cytokinesis during mitosis, leading to cell cycle arrest and cell death . This reWith a basic understanding of Gauss's law and Coulombic attractions between oppositely charged particles, one can visualize electric fields through a thought experiment involving a parallel plate capacitor connected to a battery. By definition, an electric field produces a voltage difference in space . When thin vitro. Similarly, these effects were observed in vivo in two different animal models, resulting in a significant tumor growth reduction  impairment of mitotic spindle microtubule formation; and, (2) the dielectrophoretic effect, in telophase/cytokinesis, which compromises organelles and biomolecules impairing chromosomal segregation and cell division. These mechanisms have been suggested to result in cancer cell death, offering a therapeutic effect by reducing tumor growth.The cell cycle is an essential process consisting of four phases, G1, S, G2, and M linked to cell division resulting in two daughter cells. The first three phases, known as interphase, are associated with cellular growth and genetic material duplication, ultimately segregated to daughters. Mitosis (M), is a multi-step process, orchestrating dense DNA compaction into chromosomes that are evenly distributed among daughters, culminating in their separation from the parent cell. The macromolecular machine segregating chromosomes among the two daughter cells during mitosis is known as the mitotic spindle. Its main components, the microtubules, are formed from α- and β-tubulin dimers. Microtubules are in a dynamic state of polymerization/depolymerization which is important for the cytoskeleton remodeling during mitosis –15.in vitro phenocopied defects in the mitotic spindle and in some cases caused cells to undergo mitotic catastrophe or a form of cell death-linked to grossly abnormal mitosis. Further analyses of TTFields-treated tumor cells showed disruptive mitotic spindle formation in vivo and a prolonged mitosis. Detailed cell cycle analysis of exposed cells revealed that there was significant accumulation of cells in M phase (compared to untreated cells) and the majority of treated cells underwent a caspase-mediated apoptosis  in the majority of tumors has been observed and believed to contribute to genomic instability through chromosome mis-segregation errors . Many cain vitro studies conducted on human cancer cell lines have reported the non-mitotic effects of TTFields  or adenocarcinoma cells (CT-26) and TTFields-treated exhibit a significant tumor growth inhibition compared to non-treated tumors  and median OS was 20.9 vs. 16.0 months (P < 0.001), both in favor of the TTFields-TMZ combination. Systemic and neurologic adverse events and health-related life quality were similar, but mild-to-moderate skin toxicity underneath the transducer arrays occurred in 52% of patients who received TTFields-TMZ , for newly diagnosed GBM patients  for patients treated with TTFields with inoperable and previously untreated mesothelioma in combination with pemetrexed and cisplatin or carboplatin . FDA appAdditional clinical trials in other histologies have also evaluated the efficacy of TTFields. In the LUNAR trial, unresectable advanced NSCLC were treated with TTFields in combination with pemetrexed and showed treatment tolerability with no adverse reactions , and 1- and 2-years survival of 53 and 27%, respectively . Based oTTFields treatment against other solid malignancies, such as ovarian cancer and pancreatic adenocarcinoma, were examined in INNOVATE and PANOVA phase II clinical trials, respectively. The INNOVATE was a single arm trial testing the efficacy of TTFields combined with paclitaxel in patients with recurrent ovarian carcinoma. The 6-months and 1- year survival rates were 90 and 61%, respectively . The PANThe movement from initial laboratory observations to the implementation of several clinical trials have shown the significant strides TTFields have made as a promising therapeutic agent for the treatment of different solid cancers. Likely through the disruption of cell proliferation and tumor growth by curtailing mitotic activity, TTFields show promise as an innovative, non-invasive anti-cancer treatment modality. However, there remain questions regarding exactly how TTFields exert anti-cancer effects on cancer cells. Mathematical modeling suggests TTFields do not produce strong anti-mitotic effects through microtubule disruption but instead induce changes in cell membrane potential causing deleterious downstream effects during cell separation at the cleavage furrow. Additionally, several other open-ended mechanistic questions remain to be answered. The action of TTFields in each phase of the cell cycle and the link between TTFields, DNA repair pathways and mitotic catastrophe remain to be characterized. One promising area of investigation could evaluate whether TTFields exert their function selectively on tumor cells by affecting microtubule biology through centrosomes. Surely, gaining more insights into TTFields mechanisms will pave the way for further innovative clinical trials. With six completed clinical trials to date, and 14 ongoing at different phases, a deeper understanding of TTFields biology is crucial to identify novel vulnerabilities in specific malignancies that might be efficiently targeted by TTFields, either as monotherapy or in combination with other therapeutics.FC and PT conceived the structure and content. FC wrote the initial draft document, designed, and produced the figures. CS, IS, and LK reviewed the document. PT corrected and edited the document. All authors contributed to the article and approved the submitted version.in vitro studies investigating the efficacy of TTFields and inhibition of centrosome clustering. PT has served as a consultant for RefleXion Medical, Inc., Noxopharm, and Janssen-Taris Biomedical and has research grant support from RefleXion Medical, Inc., Astellas Pharmaceuticals, and Bayer Healthcare. The remaining 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.FC has received research funding from Novocure for