COVID-19 vaccines significantly reduce rates of hospitalization and death for those infected with the SARS-CoV-2 virus. Those facing social oppression, including people of color, experience heightened risk for COVID-19 and comorbidities, but are often mistrustful of governmental agencies and initiatives, contributing to low vaccine uptake and a reluctance to access vital health care services. Dialogue-based health literacy interventions may mitigate mistrust and increase access to health services and information, subsequently increasing rates of vaccination and other behaviors that reduce COVID-19 risk.To improve health literacy and reduce COVID-19 disparities, the Westchester County Department of Health, in partnership with two universities, community- and faith-based organizations, and the Westchester County Department of Correction, co-developed a health education program for community members, correctional officers, and incarcerated jail residents in Westchester, New York. Specific objectives are to increase preventative health behaviors, positive attitudes toward use of public health protocols, full vaccination or intentions to vaccinate, health care information understanding, health provider care access, clear communication with health care providers, and personal health care decision-making.Grounded in dialogic learning, the program entails training community-based “trusted messengers” and correctional officers to lead health information sessions in community and correctional settings. During the grant period, the program intends for 80 community-based trusted messengers to receive training from the Department of Health and will be expected to reach a goal of 100 members (N=8000) of their communities. Correctional staff with experience delivering educational programs will be trained to facilitate sessions among 400 correctional facility residents and 600 correctional staff.Pre-post surveys will assess changes in health behaviors, attitudes, and perceptions. The program has been administered in the correctional facility since February 2022, with information sessions expected to cease for correctional staff and residents in June 2022 and November 2022, respectively. An initial cohort of community-based trusted messengers began training in February 2022, and information sessions have been scheduled in various virtual and community settings since March 2022. As of April 2022, the two-pronged health education program has reached 439 correctional officers, 98 jail residents, and 201 community members countywide. Program evaluation findings will be released in future publications after study implementation is complete.Few studies have evaluated the combined effects of training-of-trainers (ToT) and dialogical learning models on behavior and health literacy. As the first known COVID-19–specific dialogue-based health education program that applies a ToT model in the community-based, correctional, and virtual settings simultaneously, this study fills a gap in current knowledge about health literacy and health behavior in marginalized populations. Thus, this evidence-based framework can remedy COVID-19 disparities while also addressing risks for a host of health-related issues at the community level, potentially serving as a best-practice model for future health programs.PRR1-10.2196/37713 Individuals infected with SARS-CoV-2, the virus that causes COVID-19, are significantly less likely to experience death or severe disease when vaccinated . FurtherSociodemographic characteristics correlated with high COVID-19 positivity at the zip-code level include high percentages of people of color, limited English language proficiency, household crowding, and poverty -9. ReasoSocial factors also correspond to low COVID-19 vaccine uptake . Race, eIncarcerated individuals face added dimensions of social vulnerability and COVID-19 disparities due to crowding, poor sanitation, and lack of personal protective equipment . AlthougDespite this disparity, both correctional facility staff and residents demonstrate disproportionately low rates of COVID-19 vaccine uptake . MistrusThese disparities arise from complex issues occurring over long periods of time; as such, addressing these issues at a population level requires long-term structural solutions . HoweverThis protocol outlines the guiding principles and methods used to implement an AHL-funded health education program and evaluation of its effectiveness among priority populations in Westchester County, New York.Educational programs that integrate dialogic learning approaches can give power to learners and acknowledge the value of their experiences and cultures, creating more equitable conditions for sharing information and providing different points of view ,30. StudThe program also applies a training-of-trainers (ToT) framework to equip select individuals with the tools and information necessary to facilitate dialogic health information sessions in various settings. Those selected, referred to as “trusted messengers,” will be individuals who are considered trustworthy in their communities and can lead culturally sensitive, linguistically appropriate COVID-19–focused information sessions in either correctional facilities or community-based settings. Studies have found that enhanced trust between teachers and learners can encourage program participants to engage in constructive dialogue, ask questions that enhance understanding, and put health information into practice ,32-34.Yet, perceived health expertise is also shown to be important for influencing health behavior and enhancing trust ,36. A reHealth education programs led by trusted individuals in correctional facilities have improved behavior intention and attitudes toward risks related to HIV, tuberculosis, and hepatitis C viral infection -40. ThisLessons learned from previous dialogic correctional facility–based HIV programs indicate that “inmate questions and ensuing discussions are an important training ground for applied prevention” . DialogiThe Westchester County Department of Health (DOH) has designed an AHL-funded program that applies ToT and dialogic learning models of education to correctional officers, jail residents, and community members in geographic areas of focus, relying on trusted messengers to lead health information sessions. Trusted messengers receive training on health information delivery and a semistructured lesson plan for leading a 1-hour information session. The sessions themselves intend to be discussion-based, allowing a bidirectional transmission of information between trusted messengers and program participants.There are two parallel branches of this program, entitled Know Better, Live Better (KBLB). The first is based in community settings, engaging community- and faith-based organizations (CBOs), and focusing recruitment efforts in neighborhoods with high social vulnerability and COVID-19–related risk. The second branch partners with the Westchester County Department of Correction (DOC) to address health literacy and COVID-19 among correctional officers and jail residents. We hypothesize that a dialogic learning program, co-developed by CBO partners, will help achieve the overall goals to improve health literacy and reduce COVID-19–related racial and ethnic disparities in Westchester County. After analyzing pre-post survey changes among participants of each information session, we expect increases in preventative health behaviors, positive attitudes toward use of public health protocols, full vaccination or intentions to vaccinate, health care information understanding, health provider care access, clear communication with health care providers, and personal health care decision–making. We will also use demographic questionnaires to gauge any socioeconomic factors mediating program effectiveness, as measured by these objectives.We aim to train approximately 80 trusted messengers to reach a goal of 8000 individuals in the geographic area of focus by the end of December 2022. These areas were selected using the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), which encompasses 4 key domains: socioeconomic status, housing and transportation, minority status and language, and household composition. Program staff identified 55 census tracts ranked with the highest social vulnerability in the county. These census tracts overlap with zip codes with high COVID-19–related morbidity and low vaccine uptake; thus, they constitute the geographic area of focus for this project. These are the areas in which program staff will concentrate efforts to recruit all information session participants, trusted messengers, and CBO partners. However, zip code of residence will not be considered among the exclusion criteria for any partner, trusted messenger, or participant to ensure that program benefits are wide-reaching. As of April 2022, 26 trusted messengers completed training and collectively reached 201 community-based participants.All trusted messengers will be screened through an online form and interviews with DOH staff. Applicants must be at least 18 years old, have access to a computer with internet connection, and have sufficient availability to deliver the program to at least 100 participants in geographic areas of focus. Trusted messengers are also required to be vaccinated for COVID-19 before any health information sessions begin. Preference will be given to bilingual trusted messengers who are comfortable giving presentations in other languages, as well as those with strong connections in Westchester communities. Each trusted messenger will receive a stipend for completing required program activities.Program staff facilitate 6-hour trainings spread over 1 week to provide trusted messengers with information to prepare them for discussion facilitation. This includes COVID-19–related health information, skills related to dialogic learning, and the curriculum outline. Each trusted messenger receives a handbook that contains this information in written form. Trusted messengers will participate in biweekly, 1-hour check-in meetings with program staff to provide opportunities to discuss challenges they have incurred.Community-based information sessions are designed to be either virtual or in person, in order to reach those with limited internet access, and will be limited to 30 individuals to foster productive and engaging discussions ,44. PartThe proposed information sessions cover issues related to COVID-19, such as disease prevention measures and barriers to vaccine acceptance. These topics are contextualized in a broader discussion about health literacy, which includes accessing health care, understanding health information, and making individual health decisions. Trusted messengers will be provided with standardized resources that are necessary for program delivery, including presentation slides and handouts. The information sessions will be piloted with academic partners and CBOs to ensure appropriateness, applicability, and quality.CBOs and DOH program staff will assist trusted messengers with recruitment and locating meeting spaces for in-person sessions. Trusted messengers and/or CBOs are to ensure that recruitment efforts are made before the scheduled session. Trusted messengers and/or CBOs will make initial contact with the participants, depending on who has identified them as an interested participant.For virtual sessions, program staff will provide trusted messengers with a WebEx video conferencing link to share with their intended audience. Registration links will also be made publicly available on the program website. In-person participants may learn about scheduled sessions in any language through personal referral, public notice, and other promotional efforts that DOH program staff and partners make.Because health care professionals who are trusted in their communities can effectively influence health perceptions and behavior, a support team comprised mainly of DOH-employed registered nurses and nurse practitioners will be present for all sessions  as an additional source of support for trusted messengers who lack health expertise.Data will be collected during this project using multiple instruments, as outlined in Immediately following the information session, program staff will distribute a short questionnaire  that asks participants to assess the perceived efficacy of the 1-hour session. The questionnaire consists of 7 Likert items asking whether the session had impact in terms of health information understanding, health information access, and health care decision–making.Participants in the in-person information sessions will be offered paper surveys. Virtual program participants will complete the surveys from an open link from Research Electronic Data Capture (REDCap), a secure, web-based application designed to support data capture for research studies . In-persIn addition to collecting data through surveys, program staff will be present at each information session to track general information about the session logistics. Staff will also use an observation guide to document the broad themes that arise during the facilitated discussions, providing a source of qualitative data.DOH research staff will assess the broader public health influence of the AHL program by monitoring public health surveillance data at the zip-code level, comparing changes in geographic areas of focus to the rest of the county throughout the grant period. These data include COVID-19 positivity rates, calculated using test results reported to the New York State Electronic Clinical Laboratory Reporting System. Data from the New York State Immunization Information System will also track vaccine registration rates across zip codes in the county. Staff will take into account any national, state, or local policy changes, and other potential reasons for changes in COVID-19 positivity and vaccination rates.To evaluate the effect of the AHL program on primary care access, staff will compile a list of primary care providers located in geographic areas of focus. They will request information from a subset of providers on new patient visits and service utilization throughout the grant period on a monthly basis.The use of incentives in research encourages innovation, provides motivation, and promotes strategic decision-making . EvidencIndividuals receiving a financial incentive for immunization were three times more likely to become immunized compared to those not receiving an incentive . Thus, tThe materials and methods of the community-based portion of the project were reviewed and approved by the Mercy College Institutional Review Board  on February 8, 2022.DOH staff will train program officers and instructional officers to educate 400 correctional facility residents and 600 correctional staff, respectively, during the 2-year grant period. While the officers will lead information sessions, DOH program staff will attend to provide administrative assistance and complete informed consent. The training and 1-hour lesson plans will closely resemble those designed for the community-based branch of the AHL program, with further tailoring to meet audience-specific needs, including COVID-19 protocols and special health care resources. As of April 2022, the correctional facility–based education program has reached 439 correctional officers and 98 jail residents.In the correctional facility, there are two sets of discussion leaders, who play the same role as trusted messengers in community-based sessions. Program officers with experience delivering health programs to jail resident comprise the first group. Although they are uniformed officers, the relationships they have with residents are more positive than those of other officers, owing to their roles as program leaders. The second group consists of correctional officers who typically act as instructors for fellow officers during annual training days. Thus, the two sets of learners for the correctional facility–based program are residents and correctional officers. All discussion leaders will be required to be vaccinated for COVID-19.Program staff will provide approximately 6 hours of training to both program and instructional officers. Training sessions will cover COVID-19–related information, AHL program goals, informed consent, and advice for moderating discussions among residents and officers. Like community-based trusted messengers, program and instructional officers will receive necessary resources, including a trainer manual, pilot session recordings, and access to medical support via video conference during the information sessions for any health questions.All correctional facility–based sessions will occur in person at a Westchester County–based jail. The jail consists of the Jail and Penitentiary Divisions. The Jail Division houses individuals aged 18 years and older, including men and women awaiting sentencing and women sentenced to terms of 1 year or less. The Penitentiary Division houses men aged 18 years and older sentenced to terms of 1 year or less. The DOC operates the jail and is accredited by the American Correctional Association with the medical operations accredited by the National Commission on Correctional Health Care.Health information sessions for correctional staff will be held in a training academy classroom during annually scheduled training days. Participating staff members will be asked to voluntarily complete a presurvey immediately before the information session and a postsurvey immediately afterward. A program staff member and a member of the health care professional support team will be virtually present at all sessions.Health information sessions for residents will take place in the housing units’ recreational rooms. Due to COVID-19, there is an anticomingling policy between housing units. Therefore, the program will be offered to each unit individually to ensure complete jail coverage and minimize disease spread. Per DOC request, all residents who would like to participate will be allowed to attend with potential discussion group sizes of up to 40 individuals.The correctional facility–based curriculum, after undergoing CBO partner review, will be tailored to address needs and specific concerns for officers and residents based on recent literature. These tailored versions will be reviewed by a health educator and members of DOC leadership, each with experience delivering programs in correctional facilities. Residents will also receive a list of local health care providers who can be accessed upon release.Correctional officers will participate in KBLB health information sessions as part of their annual “pay back” days, dedicated for training purposes. DOC leadership has dedicated 1 hour of open training time to the KBLB program to increase health literacy and address COVID-19 vaccine resistance among staff.To recruit residents, program officers will provide information about the KBLB program to residents ahead of the scheduled lessons. Per DOC protocols, residents must write their name on a sign-up sheet if they are interested in participating so that the officers may account for all residents during scheduled session times. This also ensures that participants receive their incentive, voluntary presurvey, and informed consent.Data will be collected during the correctional facility–based component of this program using two instruments: the “presurvey” and the “postsurvey.” The presurvey will be distributed prior to the discussion sessions, while the postsurvey will be distributed immediately following the discussion session. Neither is required to participate in the discussion. These surveys are based on the same instruments that were used for the community-based education program .Unlike the community-based branch, the correctional facility branch of the program will combine the 3-month postsurvey with the postdiscussion evaluation. The postsurvey is identical to the presurvey, including all Likert scales, so that pre-post changes can be accurately assessed. Open-ended questions will be used to understand primary concerns regarding COVID-19 vaccines and other public health prevention recommendations before and after the sessions. All surveys will be paper-based and responses will be manually entered into REDCap.Like the community-based component, program staff will complete an observation guide detailing the number of participants in attendance and documenting characteristics of the correctional facility–based discussion session. Staff will record common themes discussed during the sessions, unique features of each session, questions that arise, and discussion topics. The observational guide will include both qualitative and quantitative elements to capture a more complete and detailed depiction of each session.Correctional staff will participate in the program during work hours. They will receive either breakfast or lunch during the session in addition to their regular hourly pay.Incentives for residents will be a US $10 voucher to the jail commissary for food and beverages, or a US $10 prepaid phone card. All participants will receive an incentive regardless of whether they complete surveys.The materials and methods of the correctional facility–based portion of the project were reviewed and approved by the Pace University IRB (Project #1843825-2) on February 11, 2022.t-tests and χ2 analyses for pre-post discussion session changes and a multivariable regression analysis to adjust for covariates such as race, ethnicity, age, and other demographic variables.All survey data will be analyzed with descriptive statistics. Investigators will use t-test. The postsurvey scores will be compared to the individual mean score of the presurvey. The surveys will be analyzed for changes in behavior or behavior intentions, attitudes, and perceptions with the following potential mediator-moderator domains: gender, age, race, ethnicity, zip code, education level, and marital status.Pre- and postsurveys do not include person identifiers and subsequently will not be matched individually. However, as they will be given to a correlated group of individuals, the mean of the pretest variables will be used as a threshold score for the comparison of the post-test variables using a one-sample For item nonresponse, response rates for each question will be stratified by demographic factors to ensure systematic bias is not present due to nonrandom missing variables. If variables are found to be missing at random, imputation of items will occur.The qualitative components of the observational guides completed by program staff will be analyzed for emergent themes using a data-driven thematic coding scheme that will be iteratively developed by the analytic team in accordance with grounded theory analysis ,52.Census tracts comprising the geographic areas of focus, as determined by the SVI, will be mapped to overlapping zip codes. Population counts from the US Census Bureau and data extracted from disease reporting systems will allow for zip code–level computation of outcome rates, vaccination registration rates, and COVID-19 positivity rates. To quantify disparities between zip codes that fall within geographic areas of focus and the rest of the county, a time-trend analysis will be performed, using outcome rates calculated monthly over the course of the 2-year grant period. This will allow assessment of whether changes in outcome rates in the geographic areas of focus correspond to changes in the number of AHL program sessions collectively occurring in those zip codes in a given month, while also comparing rate changes to county zip codes in which information sessions did not take place.The analysis plan for pre- and postsurvey changes and adjustment for covariates will not differ from the analyses performed on community-based surveys detailed above. In addition, the observation guides used for observing correctional facility–based information sessions will not differ from those guides applied to community-based sessions. Therefore, the analysis of all observation guides will also adhere to the same procedures. Analysis of open-ended responses on pre- and postsurveys will follow similar thematic analysis to the qualitative components of the observation guides.While there is a body of literature examining sociodemographic predictors of poor health literacy, few studies integrate peer support and dialogic learning models, two evidence-based frameworks that can have sustainable effects on health behavior and knowledge, with COVID-19–focused health education. To our knowledge, this is the first COVID-19–specific dialogue-based education program that applies a ToT model in community-based, virtual, or correctional settings to undergo longitudinal evaluation over multiple months. We hypothesize that pre-and postsurvey analyses for all participants in all settings will demonstrate an increase in the following key outcomes: preventative health behaviors, positive attitudes toward use of public health protocols, full vaccination or intentions to vaccinate, health care information understanding, health provider care access, clear communication with health care providers, and personal health care decision–making improvement.In addition to meeting our outcome objectives, we anticipate that the AHL-funded KBLB program will have several benefits for both community- and correctional facility–based participants. First, engaging CBO partners at multiple stages of KBLB planning and implementation can make participant recruitment efforts more equitable, allow community perspectives to inform an educational approach, and help develop sustainable partnerships that sustain program effectiveness ,54.Trusted messengers can foster a learning environment in which participants feel comfortable being candid and relaying questions or concerns. For attendees with minimal contact with the health care system, access to a member of the health care professional support team may be a rare opportunity to interact with health experts in a setting that is less intimidating than a clinic or private physician practice.The emphasis on dialogic learning also allows attendees to discuss health concerns about COVID-19, discerning reliable health information, and other issues directly to a trustworthy peer. Attendees at information sessions are also encouraged to share knowledge about barriers to health improvement and health care access in their respective communities. The information exchanged during facilitated discussions is expected to illuminate underlying reasons for health-related attitudes and/or behaviors among diverse Westchester residents who, by virtue of geographic location in high-risk zip codes, experience varying levels of social oppression.By having both trusted messengers and health care professionals present at each of the health information sessions, the program may increase the likelihood that participants will share messages learned. Throughout the pandemic, individuals reported stronger intentions to share messages from leaders compared to citizens . TherefoPotential obstacles must be considered during program implementation and evaluation. Studies have shown that dialogic learning approaches are highly dependent on the attitudes of instructors and the physical environment in which learning takes place . ProgramIt will be difficult to recruit a cohort of community-based trusted messengers that is entirely representative of a diverse county population. Hard-to-reach populations may include individuals who prefer languages other than English and Spanish, individuals with disabilities, the deaf community, the LGBTQ community, elderly persons, and others. Without participating trusted messengers, CBOs, or program staff who have existing relationships with these subpopulations, participation recruitment may lack breadth; as a result, health information sessions may lack critical perspectives.Health departments and other agencies that coordinate community-based participatory health interventions may encounter administrative obstacles during program planning and implementation phases. For instance, ToT models and CBO partnerships generally require formal agreements between funders, awardees, and partners. Grassroots organizations lacking legal departments and other administrative support may not have the capacity to properly vet proposed agreements, afford liability insurance, or provide other types of documentation that government agencies may require. Similar challenges are present for informal groups and associations that are organized by community members rather than formal institutions. Such barriers can slow down onboarding processes and delay program implementation. Monthly CBO workgroups may act as resource-sharing opportunities for large, well-equipped organizations to assist more resource-limited groups.Some challenges specific to the correctional facility setting are related to special restrictions and policies that may interfere with best practices for health program delivery. For example, due to the COVID-19–related anticomingling policy, informational sessions for residents must take place in housing units of 35 to 40 people. Depending on the number of voluntary participants per housing unit, discussion group sizes may exceed the recommended maximum size of 30 learners per unit. To ensure that quality of the discussion is maintained, program officers who are experienced in leading larger discussions among residents will lead health information sessions. Similarly, correctional officers leading discussions for fellow officers are accustomed to instructing large groups in this setting. Finally, because the rate of vaccine uptake among correctional officers is generally low, it is a challenge to recruit discussion leaders who support vaccination and other health measures that are emphasized in the program curriculum.Despite these challenges, program implementation may have lasting effects that result in long-term health improvement and subsequent cost savings. For example, establishing trust and understanding can aid effective health communication and resource-sharing in future health emergencies. In addition, investing in programs that motivate health literacy skills through dialogue can lead to more preventive health behaviors at the population level, reducing the potential costs associated with emergency services utilization . Finding


Dear Editor,1 Therapeutic options for advanced pancreatic cancer patients are still chemotherapy drugs with limited outcomes to improve patient survival and life quality.2 New insights into developing safe and effective drugs for this lethal disease are urgently needed. Elemene (Ele) is a sesquiterpene natural product extracted from the Chinese herb Curcuma wenyujin. Developed with the guidance of “molecular compatibility theory”,3 it is formulated as elemene liposome emulsion and approved by China’s Food and Drug Administration for treatment of some common cancers, including lung, liver, gastric, colorectal cancer and pancreatic cancer.5 More interestingly, studies reported that elemene produces combinative effects with some chemotherapies,7 such as oxaliplatin, gefitinib. Therefore, systematic exploration of the combined application of elemene with oncology drugs to achieve better therapeutic effects is of great clinical significance given the grim reality of pancreatic cancer treatment.Pancreatic cancer* is one of the deadliest cancers, with an overall 5-year survival rate of less than 10% unchanged over the last 40 years. Approximately 80–85% of patients are diagnosed as advanced stage, which are not eligible for curative surgery.In this study, systematically searching for the potential combination agent with elemene was performed with high-throughput screening of approved oncology drugs in pancreatic cancer cells to identify the drugs that synergize with elemene. A class of proteasome inhibitors was identified, with the combination effect rank: bortezomib >ixazomib >carfilzomib (Supplementary Fig. To further confirm above findings, the antitumor efficacy of bortezomib in combination with elemene was examined in a pancreatic cancer xenograft model. Compared with the control group, bortezomib or elemene alone inhibited the tumor growth to a certain extent, while the combination treatment significantly enhanced the antitumor activity relative to bortezomib alone assessed by tumor growth curve and endpoint tumor weight Fig. , suggestTo explore the potential downstream mechanism for elemene’s synergism with bortezomib in inhibiting cell growth, a proteomic assay was first performed in PANC-1 cells treated with a single agent or their combination. Most of differentially regulated proteins are enriched in the common signaling pathways upon proteasome inhibition, including proteasome degradation, cell cycle, apoptosis and translation (Supplementary Fig. To validate whether elemene works synergistically with bortezomib in inhibiting cell growth by enhancing bortezomib’s action via proteasome inhibition, cellular proteasome activity was examined by Cell-based Proteasome-Glo Assays. Compared to the bortezomib group, addition of elemene significantly increased bortezomib-associated proteasome inhibition activity in both PANC-1 and BxPC-3 cells Fig. , whereas8 In line with enhanced proteasome inhibition demonstrated above, elemene dramatically promotes bortezomib-induced cell cycle arrest and apoptosis-related cell death toward pancreatic cancer cells (Fig. 9 All the concatenated computational and experimental data suggests the role of elemene in producing the synergistic antitumor effects by enhancing proteasome inhibition probably through the molecular patch mechanism, and promoting resultant cell cycle arrest and apoptosis through downstream regulatory proteins (Fig. As a potent proteasome inhibitor, bortezomib’s antitumor mechanism of action is through proteasome inhibition to disturb cell cycle regulation and apoptosis process. The proteasome is a multi-subunit complex that is responsible for the degradation of the majority of intracellular proteins in eukaryotes, and plays a critical role in the regulation of proteins that control cell cycle and apoptosis process.lls Fig. . Some prlls Fig.  and IHC lls Fig. . Differeins Fig. .10 Herein, we have found this novel combination to be effective and practical, and propose the sensitization mechanism of action, by which elemene reinforces the antitumor efficacy of bortezomib against pancreatic cancer cells both in vitro and in vivo probably via molecular patch mechanism. As a proof of concept study, this provides the rationale of their combination in pancreatic cancer treatment. Extensive efficacy and toxicity of this combination deserves further evaluation in both preclinical and clinical setting. It is expected that this novel combination strategy could provide the benefit in enhancing antitumor efficacy and thus possibly minimizing the toxicity of bortezomib. The proposed “molecular patch” mechanism demonstrates the mechanism of action for such a tiny and simple compound as elemene, may provide clues for understanding, optimizing, and ultimately designing of molecular-patch-based low-molecular-weight drugs.To summarize, elemene is an anticancer drug known for its broad-spectrum antitumor effects and lower toxicity in patients, and has been widely used as adjuvant therapy for cancer treatment in clinic. Bortezomib is the first-generation proteasome inhibitor that was approved for multiple myeloma and mantle cell lymphoma. However, its long-term use may be limited by treatment-related toxicities, including neurological, hematological and gastrointestinal complications as the most common side effects.Clean Supplemental Material


Cold atmospheric plasma (CAP) resembles a physical state of matter, best described as ionized gas. CAP has demonstrated promising anti-cancer effects. Despite their relevance for the treatment of solid tumors, effects of CAP on tumor vessels and tumor-blood-circulation are still insufficiently investigated. CAP exposure reduced the vessel network inside the tumor and increased vascular leakiness, leading to an elevated tumor cell death and bleeding into the tumor tissue. These effects highlight the potential of CAP as a promising and yet underrated therapeutic modality for addressing the tumor vasculature in the treatment of solid tumors.Cold atmospheric plasma (CAP) has demonstrated promising anti-cancer effects in numerous in vitro and in vivo studies. Despite their relevance for the treatment of solid tumors, effects of CAP on tumor vasculature and microcirculation have only rarely been investigated. Here, we report the reduction of vessel density and an increase in vascular permeability and tumor cell apoptosis after CAP application. Solid tumors in the chorioallantoic membrane of chicken embryos were treated with CAP and evaluated with respect to effects of CAP on embryo survival, tumor size, and tumor morphology. Furthermore, intratumoral blood vessel density, apoptotic cell death and the tumor-associated microcirculation were investigated and compared to sham treatment. Treatment with CAP significantly reduced intratumoral vessel density while increasing the rate of intratumoral apoptosis in solid tumors. Furthermore, CAP treatment increased vascular permeability and attenuated the microcirculation by causing vessel occlusions in the tumor-associated vasculature. These effects point out the potential of CAP as a promising and yet underrated therapeutic modality for addressing the tumor vasculature in the treatment of solid tumors. RegardTo further investigate the influence of CAP on vascular permeability and subsequent intratumoral hemorrhage, we evaluated vascular permeability by intravital microscopy in an explorative setting. Comparing repetitive images and video sequences of intravital fluorescence microscopy of tumor-associated blood vessels demonstrated an increased extravasation of TRITC-dextran (70 kDa) in addition to multilocular vessel occlusions after CAP treatment d. In conAntitumoral effects of CAP treatment on malignant cells have been elucidated by various working groups , howeverIn this study, significant changes in the vascular network within and surrounding the tumor were observed after CAP treatment of solid tumors. Beyond a reduced intratumoral vessel density, an increased vascular permeability, reduced blood flow and hemorrhages emphasizea profound effect of CAP on tumor vessels. Additionally, CAP resulted in an increased apoptosis of tumor cells at the tumor surface, indicating the direct hazardous effects of CAP on tumor cells.Contrary to preliminary studies proclaiming CAP treatment was considered non-genotoxic and safe for clinical use, severe adverse effects of CAP treatment were observed when using the CAM assay as an experimental model. These effects were characterized by a significant reduction of chicken embryo viability a. FurtheTumor angiogenesis is a pivotal component tumor growth and nutritional supply . Hence, By a reduction of tumor vascularization, which subsequently limits tumor progression by restricting the supply with oxygen and nutrients, CAP treatment may be utilized to facilitate antitumoral effects.In accordance with our findings, Haralambiev et al. recently published data on the inhibition of endothelial cell migration and tube forming after CAP treatment, using an in vitro model . ContrarThe induction of apoptotic cell death by CAP, as demonstrated in our experiments, has also been described by other working groups for malignant cell lines in vitro and in vivo ,9. CAP iIn rodent models, other working groups reported a reduction of tumor volume after CAP treatment ,22,69,70p = 0.03) this increase in tumor size is likely to be attributed to intratumoral hemorrhage rather than actual growth of the tumor after treatment. As demonstrated in Ultrasonography has recently been demonstrated to be suitable for the measurement of tumor size in the CAM assay . Since vThe assumed vascular damage resembled by intratumoral hemorrhage is further supported by our observation of an increased TRITC-dextran extravasation after CAP exposure. Following CAP treatment, tumor-associated blood vessels of the CAM demonstrated an extensive extravasation of TRITC-dextran (70 kDa). Although a minimal extravasation was detectable after sham treatment in tumor-adjacent vessels, the extent of extravasation was extensively higher after CAP treatment, as demonstrated in ®) are comparatively low [These effects are likely to be facilitated by the ability of CAP to induce pore formation in the cell membrane . Furthervely low ,41. Thervely low ,90,91. Wvely low ,93,94.A strong initial decrease in flow was detectable immediately after CAP treatment. While some vessels resumed to a normal velocity of blood flow, others completely occluded over time, indicating an influence of CAP on microcirculation . FurtherThe influence of CAP exposure on blood flow and vascular permeability of tumor-associated vessels has not been previously described. Yet, synergistic effects of nanoparticulate drugs or chemotherapeutics with CAP treatment in vitro and in vivo have been reported by other working groups ,98,99. TThough some publications suggest a positive influence of CAP on tumor metastasis by regulating epithelial-mesenchymal transition  and downHence, considering the very mild local side effects of CAP treatment in clinical practice , furtherCAP has been demonstrated to reduce vascular density in solid tumors while increasing intratumoral apoptosis. CAP further increased the vascular permeability and attenuated the microcirculation by causing vessel occlusions in the tumor-associated vasculature. These effects further promote CAP as a promising augmentative treatment modality to systemic treatment approaches of solid tumors.Although these findings were obtained in an explorative setup, the data obtained point out the potential of CAP as a promising and yet underrated therapeutic modality for addressing tumor vasculature in cancer therapy.Further studies are urgently needed to evaluate and standardize plasma therapy in clinical practice. Therefore, the influence of vascular damage resulting in synergistic effects of CAP treatment with established and novel cancer therapies should be further investigated.


The lymphatic system is part of the circulatory system and it is indispensable for life. In physiological conditions, the main functions assigned to the lymphatic system are the maintenance of the interstitial fluid homeostasis, immune surveillance and the absorption of dietary fat in the intestine . HoweverBrown et al. summarizes potential pharmacological strategies for the treatment of lymphedema caused by lymphatic injury during cancer treatment. They highlight the current treatment options for these patients, most of them being palliative in nature rather than considering the root cause of this disease. Traditional approaches rely mostly on compression garments and manual lymphatic drainage to decrease fluid accumulation. However, recent advances and discoveries in the field have identified potential alternatives, such as lymphangiogenic cytokine delivery, anti-inflammatory medications, and anti-fibrotic strategies. Likewise, these novel options may be used in combination with traditional methods or as adjuncts to surgical management.Primary (or genetic) and secondary (or acquired) lymphedema are characterized by skin and tissue edema, chronic swelling, inflammation and fibro-adipose tissue accumulation in the extremities due to abnormal lymphatic fluid clearance . ApproxiPal et al. summarize the evidences and potential mechanisms of drug-induced lymphedema. They describe how pharmacological regular medications for cardiovascular diseases, such as anti-arrhythmic agents , vasodilators and KATP channel openers might contribute to the formation of lymphedema by impairing lymph flow as an off-target effect. Of note, calcium channel blockers are able to disrupt the cyclic contraction and relaxation of lymphatic vessels by modifying the physiological activity of calcium channels. The attenuation of the cyclic influx of calcium through L-type calcium channels in lymphatic smooth muscle cells impacts lymph flow and promotes the development of lymphedema. Following the same line, anti-diabetic agents such as the thiazidolinediones may also impair lymphatic function and contribute to the development of drug-induced secondary lymphedema. Additionally, chemotherapeutic agents such as anthracycline drugs (particularly doxorubicin), taxanes and corticosteroids co-administered with chemotherapy significantly contribute to lymphedema risk in cancer patients. However, on the other hand, other pharmacological treatments that include diuretics, hyaluronidase, ion channel modulating agents, anti-inflammatory and immunosuppressive agents are being administered to lymphedema patients with comorbid conditions to alleviate the symptoms of the disease. Up to date, there are no FDA-approved pharmacological agents to treat or prevent lymphedema. This work provides new guidance on potential therapies that may cause or reduce lymphedema, and therefore how patient medications can be managed to reduce lymphedema-related symptoms.Even if secondary lymphedema is usually a post-cancer treatment complication, common drugs administered to treat cardiovascular diseases and metabolic disorders can also promote the development of drug-induced lymphedema . In theiClinical studies have shown that both, obesity and metabolic syndrome, are linked to lymphatic dysfunction and are a significant risk factor for the development of secondary lymphedema . Lee et Castorena-Gonzalez performed an interesting study that shows, for the first time, that lymphatic valve dysfunction could be a critical regulator of obesity-induced lymphedema, in association with the metabolic alterations induced by the western diet. To this end, Castorena used a diet-induced obesity model in mice and applied a methodology recently developed in his lab to quantitatively assess lymphatic valve function. First at all, obesity was induced in wild-type C57BL/6J mice by feeding a western diet for 14 weeks, which elevated plasma glucose and cholesterol levels when compared to controls. Then, valve function in isolated popliteal and mesenteric collecting lymphatic vessels from control and western diet-induced obese wild-type C57BL/6J mice was quantitatively assessed and compared, revealing that the function of lymphatic valves in popliteal lymphatics was not affected by diet-induced obesity, while back-leak of pressure, and leaky valves were detected in the mesenteric lymphatics. However, he also shows that globally deficient Plasminogen Activator Inhibitor-1 (PAI-1) mice, previously shown to be protected against the metabolic effects of a high fat diet, fed with a western diet were protected against metabolic dysfunction and displayed functional mesenteric lymphatic valves.In the context of obesity and lymphatic vessels, Louie et al. shows the crucial role of lymphatic function in the transport of tumor-associated antigens to B cells in the tumor draining lymph node to enhance B cell maturation. They also unravel how regional and systemic drug delivery to the tumor draining lymph nodes might affect the immune regulation. Louie and colleagues analyze how tumor growth reconstructs lymph node conduits and subcapsular sinus macrophages to ensure a more effective entry of tumor-associated antigens into the germinal center, thus promoting B cell activation and maturation. Furthermore, they find that regional delivery of clodronate liposome specifically depletes subcapsular sinus macrophages in the tumor draining lymph nodes, increases germinal center formation and induces tumor growth.In addition to new potential roles of lymphatic vasculature dysfunction in obesity, the impact of lymphatic vessels in cancer immunotherapy is also gaining increasing attention . InteresOverall, the articles building this special issue highlight the importance of the lymphatic vessels in health and disease, and how lymphatic vessel morphological or functional abnormalities are linked to numerous disorders. They also nicely summarize the current and potential future lymph-focused therapeutic approaches for lymphatic dysfunction and emphasize, not only the urgent need for developing more effective medical strategies to combat lymphatic dysfunction, but to careful evaluate the impact that regular pharmacological treatments for different pathologies could have on lymphatic function.


Chronic kidney disease (CKD) affects ~10% of the adult population . The newPreservation of kidney function can be achieved through both non-pharmacological strategies and CKD-targeted pharmacological interventions . For decLuckily, nephrology is a fast-moving science. The novel obesity and diabetes pandemic has created the conditions for rapid knowledge generation. An example of the new knowledge is offered by the new treatments of diabetic kidney disease (DKD). Until recently, prevention of DKD progression was based around strict blood pressure (BP) control, using renin–angiotensin system blockers that simultaneously reduce BP and proteinuria, adequate glycemic control and control of cardiovascular risk factors. New drugs which modify intrarenal haemodynamics (such as renin–angiotensin (RAS)–aldosterone pathway modulators and sodium–glucose cotransport inhibitors (SGLT2i)) can preserve the kidney from damage by decreasing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents  offer kidney protection in proteinuric patients through their antifibrotic mechanisms. The new guidelines have now included as a first-line therapy the use of SGLT2i in addition to RAS inhibition, and as an additional risk-based therapy, glucagon-like peptide 1 receptor antagonists (GLP1-RA) and non-steroid MRA .In addition, a couple of years ago, the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial  demonstrWhile studying the implementation of the new guidelines, and trying to understand the new threshold for residual risk in DKD, a number of new treatments, derived from the basic research pipeline, are likely to be soon proposed. Recent progress in the understanding of mechanisms leading to CKD has shown that nephron loss is associated with inflammation, myofibroblast activation, tissue hypoxia, cell loss by apoptosis and senescence and extracellular matrix (ECM) deposition. Upregulated Nox expression and the decreased Nrf2 expression result in oxidative stress. The injured renal resident cells upregulate NLRP3 inflammasome, MAPK, PI3K/Akt and RAAS signaling and release proinflammatory chemokines to recruit immune cells such as macrophages from bone marrow which multiply the inflammatory effects. Targeting these pathways is expected to ameliorate outcomes and further extend basic and clinical investigation in CKD .N)-derived catabolic products and delay uremic symptoms and in patients with CKD. Restriction in fruits and vegetables to prevent hyperkalemia has been one of the cornerstones of CKD nutritional approach. More recently, it has become clear that targeting patients’ nutrition is a necessary approach to prevent malnutrition, CKD complications and, possibly, disease progression. Recent cohort observational studies suggest that plant-dominant low-protein (PLADO) diets offer a better approach to nutritional treatment of CKD. The benefits of PLADO include increased fibre intake with reduced production of uraemic toxins by the gut microbiota, anti-atherogenic effects, better correction of metabolic acidosis and of CKD progression, and better control of hyperphosphataemia. The current concept is that restriction of plant foods as a strategy to prevent hyperkalaemia or undernutrition needs to be individualized to offer the benefit of PLADO without incurring hyperkalemia. However, proteins contained in plants are less anabolic than animal proteins and their constituent amino acids may be in part oxidized; therefore, amino acids contained in plant proteins may not completely be used for protein synthesis. Although PLADO has a preventive effect on the associated risk factors and influences CKD progression this anabolic potential may be low if used under protein-restricted regimens [In addition to the recent breakthroughs in the treatment of disease progression, new science is being developed for the treatment of CKD complications. During its course, CKD is characterized by the progressive development of a series of complications, such as hypertension, left-ventricular hypertrophy (LVH) anemia, hyperkalemia, hypervolemia, hyperphosphatemia with mineral and bone disorders (CKD–MBD), metabolic acidosis, hyperuricemia and wasting; all of these complications have been shown to be associated with adverse outcomes, and can contribute either individually or in association to the morbidity and mortality observed in CKD. New treatments are available for many of these complications. One of the new concepts regards the importance of lifestyle modification strategies for primary and secondary CKD prevention. Maintaining a healthy body weight, physical activity, avoiding tobacco smoking, moderating alcohol consumption and healthy diets  can prevent kidney disease . Dietaryregimens ,12. TherAnother new issue is on the treatment of metabolic acidosis. Small-scale trials in patients with CKD 3–5 have shown that hypobicarbonatemic metabolic acidosis promotes progression of CKD. Accordingly, the 2012 KDIGO guideline suggests base administration to patients with CKD when serum bicarbonate concentration is <22 mEq/L. However, recent observations in eubicarbonatemic patients with CKD suggest that also in these subjects, base administration ameliorates disease progression. If proven true, such knowledge would trigger a paradigm shift in the indication for alkali therapy in CKD .Journal of Clinical Medicine Special Issue. We hope the readers will enjoy and benefit from new insight.Overall, these are only a few examples of the fast-moving issues in the treatment of CKD and of its complications. Several of the issues dealing with the prevention and treatment of CKD are addressed in this volume. We thank the MDPI staff for their leadership in producing this


As one of the most cutting-edge and promising polymer crosslinked network nanoparticle systems. Polymer nano-sized hydrogels (nanogels) have been a hot topic in the biomedical field over the last few decades. Due to their unique characteristics, which include their relatively high drug encapsulation efficiency, ease of preparation, high tunability, low toxicity, high stability in serum and responsive behavior to a range of stimuli to facilitate drug release. Nanogels are thought to be the next generation of drug delivery systems that can completely change the way that drug delivery systems have an impact on patients’ lives. Nanogels have demonstrated significant potential in a variety of fields, including chemotherapy, diagnosis, organ targeting, and delivery of bioactive molecules of different dimensions. However, the lack of substantial clinical data from nanogels becomes one of the major barriers to translating the nanogel concept into a practical therapeutic application for many disease conditions. In addition, nanogel safety profiles have been the major concern that hinders it advancement to the clinical trial phase. This review aims to emphasize the unique properties of nanogels as delivery systems for a variety of bioactive molecules over other nano-delivery systems. Also, this review attempts to give insight into the recent progress in nanogels as a carrier in the field of nanomedicine to overcome complex biological barriers. Relevant scientific data and clinical rationale for the development and the potential use of nanogel as a carrier for targeted therapeutic interventions are discussed. Finally, the concluding points of this review highlight the importance of understanding the long-term toxicity profile of nanogel within the biological system to fully understand their biocompatibility. Over the years, multidisciplinary studies have demonstrated the role of nanomedicines and nano-based drug delivery systems as an alternative therapeutic strategy in the management, prevention, diagnosis, and treatment of diseases ,2,3. Par2H, –NH2, –CONH2, –CONH, and –SO2H are common in the synthesis of nanogels .,14.13,14Physically crosslinked nanogels, also known as pseudo gel/ supramolecular particles, are formed by weaker interactions between the polymer reactive groups in an aqueous medium under mild conditions. These interactions, including van der Waals forces, hydrogen bonding, and electrostatic interactions, can initiate the self-assembly of polymer material into nanogels depending on the functionalities grafted onto the polymer backbone see B 16,17],1716,17]The most common and multipurpose technique for preparing highly stabilized nanogel is via chemical cross-linking . Different chemical cross-linking strategies that have been reported in the literature in recent years will be discussed briefly and with relevant examples in the following sections.3O4 (NCGs)] with magnetic properties were successfully synthesized using the IEP technique with good structural integrity in the presence of N, N’-bis(acryloyl) cystamine (BAC) as the cross-linking agent [The IEP method has been used to produce kinetically stable monodisperse solutions of emulsion (water-in-oil [W/O]) with the desired size. Reviews have been published summarizing recent works reporting on nanogel synthesis using the IEP technique . This meng agent . Both stThe reversible addition–fragmentation chain transfer (RAFT) process is the other most-used polymerization technique for engineering complex polymeric nanostructures for drug delivery, and it is common in the synthesis of nanogels. For example, Photo-RAFT-mediated polymerization-induced self-assembly (photo-RAFTPISA) of poly(N-acryloyl glycinamide) (PNAGA) using N,N′-methylene bis(acrylamide) as a crosslinker and poly(oligo(ethylene glycol) methyl ether acrylate) as both a stabilizer and a macromolecular chain transfer agent were used to prepare thermosensitive nanogels. Under UV irradiation and low temperatures (3 °C), very stable, spherical nanogels with narrow polydispersity were generated within one hour . Yang, ZClick chemistry is the most instrumental approach in creating materials with highly controlled structures in high yields under mild conditions for a short period of time. It has been extensively explored in nearly every field of modern chemistry, from drug discovery to materials science . This apAlternatively, photochemistry is another crosslinking technique used to form functionalized stable polymer assemblies via either polymerizable or dimerizable units upon exposure to specific photo irradiation . SimilarCovalent disulfide bond (S-S) linkages are formed by the oxidation of sulfhydryls (SH) groups found in natural peptides and proteins ,15. ThesAmine-based cross-linking is another attractive approach commonly used in the development of nano DDS including nanogel because of the high reactivity of amine groups towards several chemical moieties such as carboxylic acids, activated esters, isocyanates, iodides, and others . The nanThe technique of creating an item from a digital file known as 3D printing can be accomplished by subtractive or additive manufacturing . This teNanogels, like most nanocarriers, can be engineered with biomaterials that are responsive to specific microenvironmental stimuli (endogenous or exogenous) in order to facilitate intra or intercellular drug release . The genSome disease sites such as tumors and inflammation are characterized by elevated temperatures ranging from 40–45 °C ,67. ThesSeveral studies have explored the potential of pH-sensitive biomaterials in the design of DDS to achieve a site-specific and controlled drug release with respect to changes in pH levels at the disease site ,73. The + laser promoting intracellular heat generation by NGs, which resulted in selective and non-invasive cancer photothermal therapy. This indicated that light-sensitive nanogels with metal NPs could be used for both drug delivery and release and localized heating for thermal therapy . A. A116]. While passive targeting remains the standard mechanism by which most DDS deliver the drug to the targeted site, active targeting has been the alternative strategy to improve the targeting ability of some nonresponsive DDS that depend solely on the EPR effect . Like moThe ligand binding targeting approach has been used quite extensively to treat cancer-infected tissues while minimizing exposure of the cytotoxic drug to healthy cells . Folic aPeptides are well-known for their low immunogenicity and biological functions that closely resemble or outperform natural proteins ,132. As Apart from using small molecules or peptides, surface conjugating with antibodies for targeting purposes is also another alternative strategy used to improve the interaction with particular cancer cells while limiting side effects on healthy tissue ,138. SurCell membrane coating technology is a method for reproducing cell membrane features in a biomimetic manner, and it is currently a hot topic in nanoscale biomedicine. Cell membrane surface-decorated nanoparticles (NPs) are one of the ways cell membrane properties are merged with NPs’ properties to achieve superior therapeutic outcomes . Coated Nanogels attracted a lot of attention as nanoscopic drug carriers, especially for delivering bioactive mediators to specific sites or at certain times. The versatility of polymer systems and the ease with which their physicochemical properties can be changed have resulted in versatile nanogel formulations. Nanogels offer exceptional stability, drug loading capacity, biological consistency, strong penetration ability, and the ability to respond to environmental stimuli. Nanogels have shown great potential in the field of nanomedicine as a superior DDS, particularly in gene and chemotherapeutic drug delivery, diagnostics, organ targeting, and in many more applications. Designing an effective drug delivery vehicle for many malignancies such as cancer is still met with many challenges related to the body’s system complexity. However, significant progress has been made in developing “smart” DDS with unique properties, particularly nanogels for the delivery of small therapeutic agents for a range of disease conditions ,152. Sev950-2 demonstrated a slow intracellular release within 8 h which further translated to excellent anticancer activity against tumor cells [Another study published in 2017 by Luan et al. demonstrates the pH-responsiveness of hyaluronic-acid-based nanogels for tumor-targeted Dox delivery. A similar trend from the above study was also observed with an accelerated Dox release under acidic simulated tumor conditions. The Dox-loaded nanogels displayed much higher in vitro cytotoxicity than free Dox. Confocal microscopy indicated that tumor cells cultured with pH-sensitive Dox-loaded nanogels from 3 to 12 h had a substantial increase in Dox in their nucleus. The increased anticancer effectiveness of Dox-loaded pH-sensitive nanogels was confirmed using in vivo treatment trials on mice, in which tumor volume evolution was recorded and tumor tissue cell death and proliferation were studied . Recentlor cells .Several biotherapeutics, such as proteins and DNA, are employed as medicines and have their target inside the cell. However, challenges facing their delivery to specific areas within cells have been associated with enormous molecular size, difficulty passing through cellular membranes, and susceptibility to enzymatic and chemical destruction. Nanogels, because of their flexible three-dimensional polymer network structure, became a suitable carrier for this type of delivery, since they can accommodate all sizes of biotherapeutics, proving a safe passage through the cell membrane and a shield from degradation and allowing for cell internalization.Several disease conditions, including cancer, autoimmune illnesses, and metabolic disorders, are also being treated with therapeutic proteins. Reduced stability and short circulation half-lives following parenteral injection are two major issues that restrict the efficacy of protein therapies . High doGene treatment introduces foreign genomic material into specific host cells to acquire a therapeutic benefit by repairing existing dysfunctions or sustaining individual cells with new functions . Due to Even though the available data on cancer therapy highlights the potential of nanogels as a versatile drug delivery system, it is still presented with some limitations, which suggests that currently, there is a lack of efficient treatment available for cancer. Indeed, it is impossible to achieve a desirable outcome with a single therapeutic approach because of this disease’s biological complexity. Even though several studies have reported delivery systems delivering a specific drug or gene/macromolecules to improve their efficacy, they are still faced with some restrictions that delay their clinic application. A considerable number of studies have indicated the need to develop an alternative system to improve the inadequate suppression of any disease condition by single-drug delivery systems. Compared to a single-drug method, a co-delivery system has proven to be a promising strategy for enhancing the target response or achieving a synergistic/combined impact.Cancer is still considered one of the leading causes of death across the globe with limited treatment options. Combination therapy has been adopted as one of the alternative treatment approaches to fight cancerous disease with some successful clinical applications in patients with breast and ovarian cancers . The suc2), which causes oxidative stress in cancer cells, inducing apoptosis [Phototherapy has been proven to be an effective therapy for treating primary tumors since the 20th century. It differs from conventional chemotherapy, radiotherapy, and gene therapy because of its non-invasiveness, ease of operation, low drug resistance, high temporal–spatial resolution, and low adverse side effects ,162,163.poptosis . Despitepoptosis ,165. DuePhotothermal therapy alone has been associated with uneven hyperthermia distribution, leading to incomplete tumor ablation, whereas chemotherapy can develop serious side effects and drug resistance . TherefoA combined chemo-photothermal therapy based on nanomaterials has shown superior therapeutic effect over single cancer treatment. Since nanomedicine can selectively accumulate into the tumor site, the co-delivery of cytotoxic drugs and hyperthermia can produce a synergistic effect to improve cancer treatments . This coPhotodynamic therapy (PDT) is considered a minimally invasive treatment and is currently employed as an alternate treatment for cancer control in clinics ,172. PDTChemotherapeutic failure to eliminate cancer may be attributed to fast mutations within tumor cell subgroups that avoid cytotoxic medicines. The presence of lymphocytes within the tumor microenvironment causes the suppression of anti-cancer immune responses, allowing them to grow, develop, and metastasize more easily ,176. HowNanotechnology’s application in medicine, particularly for drug delivery, is growing rapidly, and more biomaterials are being introduced, especially for cancer therapy ,180. HowNanogels are new and promising drug-delivery technologies which can play a significant role in addressing clinical issues associated with classic and current therapies or formulations, such as targeted cellular uptake, toxicity-related issues and the development of drug resistance. In this review, we have highlighted different methods of preparation, characterization, properties and biomedical applications of nanogels. The currently reported studies on nanodelivery systems suggest that there is no universal delivery system that can address all the needs of current and future medicine. However, nanogels present some key unique features, including but not limited to stability, biocompatibility, and stimuli responsiveness which can widen their clinical applicability. Nanogel’s superiority as a nanocarrier is highlighted by its capacity to encapsulate and deliver a range of biomolecules of different dimensions. In addition to high encapsulation efficiency, layer-by-layer surface-functionalization can aid in receptor-mediated targeting and subsequent spatiotemporally and sequentially controlled drug release. Nanogels are thought to be the next generation delivery system to improve quality of life based on preclinical data reported in the literature. However, there is still a need for conclusive research demonstrating the potential of nanogels through in vitro and in vivo evaluation. Also, toxicity concerns related to the degraded gel residue, immunogenicity, pharmacokinetic differences between rodent and human models, and regulatory challenges need further exploration. Finally, several researchers have examined the efficacy and safety of nanogel formulations and reports on their long-term accumulation and breakdown characteristics are scarce. However, nanogels as bioactive delivery carriers have a lot of promise for improving medical care efficiency and patient benefit. Therefore, more experimental demonstration is encouraged, from the design to application to better understand the potential of nanogels as the next generation of drug delivery system to fight and eliminate emerging and long standing disease conditions.


Social exclusion is a serious problem that can lead to diminished well-being, health problems, premature death and increased societal costs. Depending on the definition used, 10 to 30% of the older adults experience social exclusion, and many have been confronted with prolonged isolation during the pandemic. Constructing measures for social inclusion and exclusion is a challenging yet important endeavor, and various approaches exist. For example, EU-policy makers define social exclusion mainly in terms of poverty and lack of labor market participation However, a too narrow definition of social exclusion leaves large groups of people unattended leading to sub-optimal understandings of social exclusion and ineffective interventions. This symposium brings together scholars from different cultures. The first paper discusses newly developed social and well-being scales, that more adequately address cultural notions of exclusion and discrimination experienced by older Māori . Based on unique data from time-diaries kept by older women from several European countries and the U.S, the second speaker discusses how increased time spend alone is key factor behind widows’ reduced well-being. The last study finds a northwest to southeast gradient in objective exclusionary states, with the rates in southeast Europe to be pronounced among older women.


JCI, Mottis et al. report that tetracyclines induced disease tolerance against influenza virus infection, expanding their protection potential beyond resistance and disease tolerance against bacterial infections. The authors dissociated tetracycline’s disease-resistance properties from its disease-tolerance properties by identifying potent tetracycline derivatives with minimal antimicrobial activity but increased capacity to induce an adaptive mitochondrial stress response that initiated disease tolerance mechanisms. These findings have potential clinical applications in viral infections.Several classes of antibiotics have long been known for protective properties that cannot be explained through their direct antimicrobial effects. However, the molecular bases of these beneficial roles have been elusive. In this issue of the  ICU patients with sepsis often present dramatically different outcomes despite having had a similar initiating pathogen or pathogen load, or even having completely eliminated the original infection. The contrasting outcomes may be explained by the need for two different but interdependent and evolutionarily conserved defense strategies to survive a severe infection: resistance, which relies on effector mechanisms to reduce pathogen load, and disease tolerance, which provides host tissue damage control and limits disease severity irrespective of pathogen load . ResearcPhysicians have known, and empirically used for decades, several classes of antibiotics that seem to better resolve an infection than would be expected from their direct antimicrobial efficacy alone, comparing favorably with other classes that have similar antimicrobial spectra. In addition, for example, macrolides have extensively documented clinically beneficial roles in chronic inflammatory pulmonary disorders , 12, andAntibiotics, like most other drugs in clinical use, have varying degrees of off-target effects that may account for undesirable side effects. Unexpectedly, some of these off-target effects induce low-level core cellular function perturbations in the host, which may constitute a critical signal to initiate both resistance and disease tolerance mechanisms. For example, quinolones that target the bacterial enzymes DNA gyrase and DNA topoisomerase IV cause low levels of DNA damage to the host, potentially leading to the induction of IFN-stimulated genes (ISGs), as in the case of aminoglycoside antibiotics . AdditioJCI, Mottis and colleagues take these observations further to demonstrate that tetracyclines also induce disease tolerance (In this issue of the olerance  to influolerance . Using ctert-butyl doxycycline (9-TB), retained, and in fact substantially superseded, the effects of the parental doxycycline on induction of mitochondrial unfolded protein response (UPRmt). 9-TB was also much more potent than doxycycline at inducing a mitochondrial stress response  and inducing ISGs in BMDMs. Doxycycline and 9-TB were effective at increasing survival in a lethal IFV infection model when given preventively. They did not affect the viral titers, a fact that points to their capacity to induce disease tolerance, not resistance mechanisms. Critically, while doxycycline affected the gut microbiome as expected, decreasing its bacterial species diversity, 9-TB did not affect the microbiome composition. Moreover, 9-TB was also capable of decreasing the severity of infection and delaying mortality when administered therapeutically (To avoid the antibacterial effects of tetracyclines on the host microbiome, Mottis et al.  identifiutically . The aututically  because mt. This possibility is based on the recent finding that ATP is a strong hydrotrope with the ability to prevent the formation of, and dissolve already formed, protein aggregates (Going forward, many exciting questions remain. One is how core cellular function perturbations leading to resistance or disease tolerance are sensed. In the case of tetracyclines it is tempting to speculate that inhibiting mitochondrial protein synthesis perturbs the ETC and decreases ATP concentration, potentially leading to the initiation of UPRgregates . AlternaThe study by Mottis et al.  substant


Periodontal infections are noncommunicable chronic inflammatory diseases of multifactorial origin that can induce destruction of both soft and hard tissues of the periodontium. The standard remedial modalities for periodontal regeneration include nonsurgical followed by surgical therapy with the adjunctive use of various biomaterials to achieve restoration of the lost tissues. Lately, there has been substantial development in the field of biomaterial, which includes the sole or combined use of osseous grafts, barrier membranes, growth factors and autogenic substitutes to achieve tissue and bone regeneration. Of these, bone replacement grafts have been widely explored for their osteogenic potential with varied outcomes. Osseous grafts are derived from either human, bovine or synthetic sources. Though the biologic response from autogenic biomaterials may be better, the use of bone replacement synthetic substitutes could be practical for clinical practice. This comprehensive review focuses initially on bone graft replacement substitutes, namely ceramic-based  and autologous platelet concentrates, which assist in alveolar bone regeneration. Further literature compilations emphasize the innovations of biomaterials used as bone substitutes, barrier membranes and complex scaffold fabrication techniques that can mimic the histologically vital tissues required for the regeneration of periodontal apparatus. The holy grail of periodontal therapy is the regeneration of the attachment apparatus lost due to periodontitis. This noncommunicable chronic inflammatory disease of multifactorial origin is known to cause damage to soft tissue and induce destruction of the periodontium . The losThe successful outcome of periodontal regeneration in combination with various therapeutic modalities  are evident in the literature . HoweverBone grafts can be broadly classified as autografts, allografts, xenografts and alloplasts (synthetic). Among them, bone replacement synthetic grafting procedures are more pragmatic even though autologous bone grafts provide a better biological response. There are a few disadvantages, such as additional surgical time and donor site morbidity, that are overthrown by artificial bone substitutes. Osseous grafts are derived from either human, bovine or synthetic sources. The human or animal sources may have issues related to ethics or disease transmission. Hence, there is a demand for artificial/synthetic bone substitutes, with biological stability, biocompatibility and negative immune response having similar or better efficiency, which could be procured less expensive than allogeneic and xenogeneic substitutes ,7.The synthetically developed bone substitutes used in clinical practice are broadly classified as polymers, metals and ceramics. However, these bone substitutes exhibit few drawbacks related to poor mechanical properties, low biocompatibility and poor adhesion to human tissues . In ordeHydroxyapatite (HA) is the most commonly used calcium phosphate bone graft material across the world. Its structure and composition are comparable to native bone . Van MeeTCP is a resorbable form of bone substitute broadly classified into two phases, i.e., α and β, which are chemically similar but tend to perform differently based on their functional environment . ConsideBiphasic calcium phosphate ceramics: These are a combination of two different CaP phases; a more stable phase (HA), which is more common, and a more soluble phase (β-TCP) in different proportions. Degradation of bone grafts is an important factor in bone formation. In order to increase biodegradation, biphasic calcium phosphate was developed for osseous defects. It is a bioceramic available in different formulations such as powders, granules and blocks for regenerating bony defects and is widely used across the world . Wang et®, which can be used solely without the use of a barrier membrane, with lesser surgical time and cost. All these features make it preferable for adjunctive use as regenerative material. Thus, clinical reports describe it as an alternative to nonresorbable membranes (e-PTFE), which are known to be time consuming [The literature records the use of calcium sulfates predominantly in the orthopedic specialty. However, in two different papers, Dreesmann and Peltier reported that calcium sulfates can be used effectively to fill and treat osseous defects ,26. Calconsuming . A mixtuonsuming . Micro- onsuming .2 (46.1 wt.%)), sodium oxide (Na2O (24.4 wt.%)), calcium oxide (CaO (26.9 wt.%)) and phosphorus pentoxide (P2O5 (2.6 wt.%))), and the molecular proportions of calcium and phosphorus oxides are similar to natural bone. A recent comprehensive review on bioactive glass applications deduced that the most common bioactive glass compositions  are versatile replacement materials, and their availability in different designs enhances their use in the treatment of human defects among clinicians [Several biomaterials have been introduced over the years. In the late 1960s, Hench and coworkers developed a group of surface-reactive glass ceramics, including bioactive glass, which gained popularity in periodontal and implant surgeries . The keyinicians .Schepers and Ducheyne coined the term ‘osseostimulation’ to describe the process of bone formation in bioactive glass . De novoResearchers have developed many regenerative procedures over the decades to treat periodontitis . HoweverClinical trials conducted in the field of regenerative medicine use allografts, xenografts, alloplasts and/or their combinations in view of the evidence related to their regenerative potential. Nevertheless, these mentioned bone graft resources have a major drawback of foreign body reaction or negative immune response, which impairs their use in periodontal defects . ConsideInitially, Serroni et al. conducted a clinical trial to study the additional benefit of leukocyte-platelet-rich fibrin (L-PRF) to autogenous bone graft compared to autogenous bone graft and open-flap debridement alone. The results of the study showed a better outcome with L-PRF for degree II furcation management . In anotDifferent variants of PRF appeared in due course through variations in centrifugation protocols. This was originally prompted to investigate the intensified release of growth factors. One such development was advanced platelet-rich fibrin (A-PRF) introduced by Choukroun (2014), obtained by low centrifugal speed , which stirred the leukocytes to the bottom of the test tube for a more even distribution of neutrophils and unbound fibrin matrix. The neutrophils present in PRF have soft and hard tissue regenerative capabilities to direct monocytes to phagocytosis and produce proteases such as MMP9 for the wound healing process . AdditioFurther development in PRF was the elimination of silica in glass tubes required for the formation of platelet aggregation and fibrin. Few health risks caused due to the presence of silica in these glass tubes were discussed . Hence, Regarding the stability of the PRF membrane, its ability to release cytokines was explored, and results showed a 28-day release rate within a biological environment . HoweverTechnological advances of the past decade have fueled innovations in biomaterial design and architecture for periodontal tissue engineering. Application of nanotechnology, with a particle size of less than 100 nm, closely mimics the native structure and architecture of tissues with improved biological properties and bioactivity, leading to a significant increase in regenerative capability ,79,80,81The advent of bioprinting has led to biomaterials of a customized three-dimensional structure specific to the defect requirements, which can enhance the form and function of biomaterial. Newer fabrication techniques have enabled biomaterials of different structures and characteristics to be arranged as composite entities that can mimic different kinds of tissues for regeneration of histologically complex anatomies such as periodontal attachment apparatus. Moreover, the incorporation of such materials into a single construct has given rise to composite biomaterials that can release drugs and growth factors, where the release can be controlled in space and time. This section summarizes the novel applications and advancements in ceramics, polymers, metals and composite biomaterial constructions used for periodontal regeneration. .Egg shells contain 90% calcium and can be used to extract hydroxyapatite for bone regeneration . This biStrontium-doped hydroxyapatite showed increased osteoblast proliferation and differentiation ,90.Staphylococcus aureus [Zinc-doped hydroxyapatite induced differentiation of mesenchymal stem cells to osteoblasts, migration and proliferation of endothelial cells and antimicrobial activity against s aureus ,92.Silver-doped hydroxyapatite demonstrated enhanced antibacterial activity and osteoblast adhesion when silver was used in low concentrations; higher concentrations of silver had a negative effect on osteoblast cell proliferation ,94,95.Silicon-doped hydroxyapatite showed significantly greater bone in-growth and bone implant coverage than undoped hydroxyapatite .Recently, in an attempt to improve the mechanical and biological properties of hydroxyapatite, few studies investigated the effect of replacing the calcium, phosphate or hydroxyl ions of apatite crystal with different trace metal ions. Comprehensive findings of these experiments revealed:All these observations indicated that ion-doped hydroxyapatite crystals have enhanced biological properties and can be a promising alternative to pure hydroxyapatite-based bone substitutes.Magnesium is a highly bioresorbable metal with excellent biocompatibility. The magnesium–strontium alloy exhibited favorable characteristics when used as a bone substitute, considering its mechanical properties that resembled natural cortical bone. This alloy had good cytocompatibility and antibacterial and physical properties compared to existing bone graft materials indicating its potential for use as a bone defect filler in stress-bearing areas .Carbon nanotubes are elongated cylindrical nanostructures with a hexagonal honeycomb lattice. Their structure and scale simulate the collagen fibers present in the connective tissue . These nTitanium is a highly biocompatible metal with extensive applications in biomedical devices. Porous titanium granules offer several advantages as a bone defect filling material, such as superior physical properties for better osseoconduction, high porosity facilitating absorption of blood  and highGuided tissue regeneration (GTR) membranes are used for selectively excluding the epithelium and the connective tissue from the periodontal defects, which allows the periodontal ligament cells to proliferate and repopulate the root surface.Electrospinning is a technique to produce nanoscale diameter fibers from a polymeric solution. The polymeric solution is loaded into a syringe pump and will be ejected from a blunt tip needle (spinneret), producing a droplet at the tip of the needle. On application of a high-voltage current, the shape of the droplet changes to a cone shape (Taylor cone); an electrified jet of polymer is ejected out, which solidifies into fine threads that are then collected on the grounded collecting plate ,109,110.Electrospun poly /poly  membranes showed superior physical properties, optimum degradation rate and excellent cell occlusion properties, both in vitro and in vivo . RecentlS. mutans and A. actinomycetemcomitans [A. actinomycetemcomitans and P. gingivalis [Streptococcus sanguinis and Porphyromonas gingivalis, control of inflammation and promoted periodontal ligament cell migration in rat periodontal defects [Recently, GTR membranes with added antimicrobial functions have been fabricated and evaluated for periodontal regeneration. Expanded polytetrafluoroethylene (e-PTFE), collagen and glycolide fiber membranes loaded with tetracycline or amoxicillin showed less adhesion and penetration of comitans ,119. Elecomitans . Doxycycngivalis . Amoxici defects .Functionally graded membranes have multiple layers; each layer is fabricated to be closely associated with a specific type of tissue in order to control and dictate its behavior, facilitating guided tissue regeneration. Recently, a novel trilayered chitosan membrane with varying concentrations of bioactive glass among the layers was prepared and evaluated. The lower layer, which was designed to interface with the bone, was porous, hydrophilic and had the highest concentration of bioactive glass; this layer showed osteoblast and fibroblast cell adhesion and proliferation. The upper layer, designed to interface with the connective tissue and the epithelium, was nonporous, hydrophobic and had no bioactive glass and showed no cell adhesion and proliferation . SimilarThe periodontal attachment apparatus is an anatomically and histologically complex zone containing different types of tissues integrated together for the purpose of supporting the teeth in the jaws: the periodontal ligament (a fibrous tissue) connects the bone to the cementum of the tooth root; the entire complex is covered by epithelium and connective tissue of the gingiva. To be able to regenerate the periodontal complex in its entirety, there is a need to customize biomaterials that contain different parts or zones that would mimic and regenerate each type of tissue. The construction of such complex scaffolds has become a reality due to the application of novel biomaterials, innovative engineering solutions and fabrication techniques that can combine different biomaterials.An in vitro study conducted in 2017 evaluated a nanocomposite hydrogel scaffold with three distinct layers; each layer was designed to regenerate a specific type of tissue in the periodontium. The cementum layer was made of chitin-poly (lactic-co-glycolic acid) (PLGA) hydrogel scaffold with nano-bioactive glass ceramic and cementum protein-1; this layer faces the root surface. The alveolar bone layer that faces the bone surface was made of a chitin-PLGA hydrogel scaffold with nano-bioactive glass ceramic and platelet-rich plasma (PRP). The middle layer attempting to regenerate the periodontal ligament fibers was made of the same chitin-PLGA hydrogel scaffold but contained fibroblast growth factor (FGF). The three layers were assembled together to form a biocompatible composite scaffold, which induced differentiation of human dental follicle stem cells into osteoblasts, cementoblasts and fibroblasts . The impA sandwich complex with three layers was fabricated into which gingival fibroblasts were seeded on both sides of a collagen membrane and cultured for 3 days to create a tissue-engineered membrane. This membrane formed the central layer of the sandwich. The outer layers were formed by a layer of the intestinal mucosa (porcine jejunum) seeded on one side by gingival fibroblasts; they were cultured and placed in a mineralization induction medium to form a mineralized membrane. These mineralized membranes formed the outer layers on both sides of the tissue-engineered membrane to form the sandwich construct. The mineralized membranes attempted to regenerate the hard tissues (bone and cementum), and the tissue-engineered membrane attempted to regenerate the periodontal ligament. The implantation of these sandwich constructs led to complete regeneration of the periodontal defects in beagle dogs’ experiment; histological analysis confirmed the formation of new bone, cementum and periodontal ligament within 10 days .Three-dimensional (3D) printing technology was used to assemble a poly-caprolactone-hydroxyapatite scaffold in three distinct phases: Phases A, B and C were designed with 100 μ, 600 μ and 300 μ microchannels incorporated with PLGA microspheres encapsulating amelogenin (to regenerate cementum/dentin), connective tissue growth factor (CTGF)  and bone morphogenetic protein-2 (BMP-2), (for bone regeneration). This multiphase scaffold was then seeded with dental pulp stem cells (DPSCs) and cultured in vitro before implanting them subcutaneously in immunodeficient mice. After 4 weeks of implantation, histological analysis showed mineralized tissue formation on Phases A and C; Phase B contained collagen fibers inserted into mineralized tissues and fibroblast-like cells along with blood vessels. The PLGA microspheres were used to deliver biological growth factors for stem cell differentiation; the release of the growth factors was controlled in time over 6 weeks .A chitosan scaffold containing alginate microparticles loaded with insulin-like growth factor-1 (IGF-1) and PLGA nanoparticles loaded with bone morphogenetic protein-6 (BMP-6) was fabricated to study the temporal sequence of drug release. The results exhibited initial rapid release of the alginate microparticles, and since PLGA nanoparticles have a longer degradation rate, they release BMP-6 in a sustained manner. Hence, this system was used to control the temporal sequence of drug release in a phased manner. Results showed enhanced proliferation and differentiation of cementoblasts and increased extracellular matrix (ECM) synthesis in vitro . A 2015 Hu et al. (2018) developed a novel immunomodulatory biomaterial containing interleukin-4 (IL-4) for switching proinflammatory M1 macrophages to proresolving M2 macrophages in a diabetic rat model. Heparin-modified gelatin nanofibers were self-assembled into a microsphere into which IL-4 was loaded. Heparin binds to IL-4, protecting it from degradation and sustaining its release. When injected into a rat fenestration defect model, it caused switching of macrophages to proresolving M2 phenotype and resolved the inflammation; there was enhanced osteogenic differentiation and new bone formation. This study presented a strategy of host-modulation of periodontal regeneration using biomaterial-controlled release of anti-inflammatory cytokines .A temperature-sensitive, shape-memory biomaterial was synthesized using cross-linked poly-caprolactone with hydroxyapatite nanoparticles loaded with BMP-2 . This laOur current understanding of the wound healing and resolution of inflammation in periodontal tissues is inadequate to successfully manage and treat periodontitis. A complete and thorough understanding of the etiopathogenesis of the disease along with the healing mechanisms are key for engineering biomaterials for periodontal regeneration.One of the most important problems in managing periodontitis is regenerating the lost tissues in horizontal/supra-alveolar bone defects. In spite of advances in biomaterial engineering, there is a lack of solutions in sight for regenerating tissues in horizontal bone defects that are non-contained and lack spatial control of biomaterials. Newer biomaterial engineering approaches need to emerge to successfully exclude the epithelium and connective tissue from the horizontal bone defect and to spatially orient the biomaterials in the defect area.An important tenet for the success of periodontal therapy is regenerating all three types of tissues  in the periodontal defect. Even though composite multilayered biomaterial constructions have successfully demonstrated the formation of all three types of tissues in vitro and in experimental periodontal defect models in animals, their efficacy needs to be evaluated in humans. Currently, platelet concentrates show promise in delivering autologous growth factors directly to the periodontal defect. However, the scientific literature reveals numerous protocols for different types of platelet concentrates. Periodontal regeneration is a rapidly evolving, dynamic field with an enormous potential for research.With advances in biomaterial science and growing interest in tissue engineering strategies, the future displays possibilities for complete rehabilitation and regeneration of the periodontium. Taken together, the combination of bone graft substitutes and stimulatory effects of bioactive materials  provide a better outcome in terms of tissue and bone regeneration. The success of tissue-engineered bone regeneration is influenced by various factors that include the use of appropriate scaffolds/constructs for harvesting cells at the defect site, suitable cell type, adequate vascularization, signaling molecules for osteogenic differentiation, etc. Hence, a multidisciplinary approach will be required to develop newer graft materials that possess enhanced properties to obtain more desirable results.Advancements in scaffold fabrication technologies such as 3D printing, multiphase scaffold, smart biomaterials, etc., have been developed with attempts to regenerate different tissues of the periodontium. Several in vitro studies using these constructs incorporated with nanohydroxyapatite, immunomodulatory biomaterial, gingival fibroblasts, growth factors, etc., have yielded beneficial results. However, clinical trials are required to assess the safety and efficacy of these biomimetic materials for periodontal tissue engineering and bone regeneration purposes in humans.