Background. It is challenging for junior public healthinvestigators who identify as Black, Indigenous, or People of Color (BIPOC) tosecure funding for projects and research. We used a narrative inquiry approachto understand and present the funding cascade from the perspectives of female,junior BIPOC researchers and provide funders with actionable recommendations toadvance their antiracist goals. Approach. We applied a CriticalRace Theory (CRT) framework to guide our narrative inquiry approach. Theparticipants were the four co-authors and we each drafted individual narrativesaround our experience with the funding cascade and subsequently the five stagesof narrative analysis. Results. We created a visualrepresentation of key activities for funders and applicants organized by ourperceived magnitude of inequities in a journey map, an interpreter table thatdescribes common phrases and barriers encountered, and a compositecounternarrative presented as a group text message conversation, elevatingcommon themes including feeling pressured to have our research agendas conformto funders’ interests and receiving limited key information and support in thefunding process. Discussion. We discussed how our findingsrepresented manifestations of White supremacy characteristics like powerhoarding and paternalism. Implications for practice. We offeredspecific antidotes for funding organizations to make their processes moreantiracist and invited leaders of public health funding organizations to join usto further identify antidotes and share lessons learned in Fall 2023. Public health funders often set research priorities—not researchers or practitioners.Members of these funding organizations, including board members, project officers, andgrant reviewers, hold the power to decide which researchers, populations, issues, andmethods receive emphasis and legitimacy. More recently, public health funders haveincreasingly expressed support for equity-focused projects . TheseeIt is challenging for junior public health investigators who identify as Black,Indigenous, or people of color (BIPOC) to secure funding for projects and research. A2011 study of the National Institutes of Health (NIH) external research applicationsfound that among Black and White applicants with comparably top-ranking scores, Blackapplicants were 13 percentage points less likely to be funded than White applicants. A2019 Recent efforts by some organizations to improve equitable funding practices  areneceWe applied Critical Race Theory (CRT) as our framework  to “centFor this study, we used narrative inquiry to explore the lived experiences of female,BIPOC junior researchers pursuing US-based grant funding from federal andnon-federal sources. Narrative inquiry focuses on each participant’s firsthandaccount and how they assign meaning to those events S. R.. We co-cParticipants of this narrative inquiry are the co-authors—all junior publichealth researchers who identify as BIPOC women, some of whom are alsofirst-generation scholars. We leveraged the gendered, racialized, andprofessional statuses we experience to interrogate how systematic differencesoccur along the funding cascade.journey map—wasconstructed iteratively as a group as we built a collective understanding of thejourney toward obtaining research funding. Using the initial iteration of thejourney map, we developed five questions for each co-author to answerindependently in written narratives. Sample questions included “What unspokenrules have you learned along the way?” and “How did your intersectionalidentities affect your experiences seeking research funding?”As a group we began by discussing our individualized experiences with obtainingfederal and non-federal research funding, then two co-authors created a timelinebased on these experiences . This baSupplemental Appendix A). These products were co-created acrossmultiple rounds of review and were informed by the other. The journey map,barriers and facilitators matrix, and composite narrative are presentedbelow.We then followed the five stages of narrative analysis  to move The funding journey map  providesThe journey map depicts our collective perceived magnitude of inequities for eachactivity as low, medium, or high. “Low” activities show little to no patterns ofstructured differential access and has minimal impact on funding outcomes, “medium”activities show some patterns of structured differential access and has a moderateimpact on funding outcomes, and “high” activities show clear differential access byidentity groups and have a large impact on funding outcomes. Most activities weredeemed to have medium or high levels of inequities, with only three activitiesidentified as having low inequities: receiving a funding decision (for applicants)and receiving applications and announcing funding decision (for funders).The interpreter table  describeSupplemental Appendix A) summarizes key moments when BIPOC juniorresearchers may exit academia.Supplemental Materials.Our composite counternarrative is presented as a fictional group text message threadto represent how characters sought funding advice and information through informalchannels. The discussion is initiated by Serena, a new faculty member at a largeresearch (R1) university. She was recently hired as a fixed-term assistant professorfor which she is expected to cover 70% to 90% of her salary through grants andcontracts. The friends depicted are female, BIPOC junior researchers,first-generation academics, and graduated with doctorates within the last 3 years.The group discusses their respective challenges seeking and securing funding –5. See tWhile the authors of this paper have varied research interests and career goals,there are many experiences that we shared as female, BIPOC junior researchersthat we captured in the journey map, interpreter table, and compositecounternarrative above. Some of these shared experiences and feelings includethe following:Feeling our research ideas are undervalued;Hearing that our research, while innovative, does not align withstrategic priorities of funding organizations;Feeling pressured to conform our research agendas to funders’interests;Receiving limited key information during or after the fundingprocess;Watching White and more affluent colleagues navigate academic and fundingstructures more easily;Feeling a large disconnect between community needs and funderrequirements.The funding cascade is made up of multiple systems at play that lead to—andreproduce—systematic differences with regard to funding outcomes.Based on our narrative inquiry, we expand on some of the more salient componentsof White supremacy culture that emerged, grouped in what we saw as clustering ofmutually reinforcing characteristics. This list is not intended to be exhaustiveof the manifestations of White supremacy culture that may appear throughout thefunding cascade.The mechanisms for hoarding power and resources are vast along the path toobtaining grant funding. Grants, especially federal and national,non-federal ones, tend to be awarded to those who have already successfullycompeted for grants. Even grants geared toward junior researchers aretypically framed under the mentorship of those who have successfully joinedthat circular stream of previously funded leading to subsequent funding.This mechanism of allocating funding and power to the same people encouragesthe multigenerational reproduction of the same views on persistent healthissues. This does little to foster innovation, which ironically many RFPsclaim to encourage.Related to power hoarding, we saw that many facets of the funding processshowed classic operationalizations of paternalism. Using Okun’s definitionof paternalism as a facet of White supremacy culture , those iMoving away from a narrow view of how health research should beconducted to foster greater innovation;Expanding representation of who can serve on review boards for opengrants to foster broader perspectives;Increasing access to information for those who are not in positionsof power within decision-making processes.Power hoarding and paternalism are experienced every day in the form of alack of transparency of and noting how funders dictate what is worthy offunding, for how much funding, and the length of funding. For instance,having one-time funding opportunities to improve structural healthinequities will not address the long-standing exclusionary practices thatcaused the disparity in the first place. Rather funders need to shift powerin who is developing the calls for funding to those who have the contextarea expertise health disparities and/or lived experiences of navigatingstructural inequities, be more proactive in the expansion of networks forpotential grantees, and improve transparency across the grants process.There are few places where the sense of urgency has been easier to observethan recent attempts to introduce health and racial equity into fundingportfolios. These RFPs have on average even shorter turnaround times thanother funding opportunities, which do not account for the structuraldisadvantage experienced primarily by women who are often primary caretakersof their families, offer fewer funding dollars, and require unrealistic timeframes for creating structural change that diminish the possibility ofmeaningful engagement with communities most affected by health inequitiesand racism. Moreover, folding restrictive windows of opportunity fromfunding announcement to submission deadline into calls for equity andinclusion is antithetical to the very antiracist programs they seek to fund.Antiracist approaches require additional effort, and therefore additionaltime, to engender inclusive grant development practices that foster trustand collaboration necessary to achieve antiracist goals.Paradoxically, this sense of urgency puts White supremacy tenets ofperfectionism and quantity over quality at odds with one another. Whilethere is an emphasis in grant writing on having as close to perfect a grantproposal as possible for the most competitive application, the need to applyto many grants quickly makes meeting those high standards for qualityexceedingly difficult to attain. As junior researchers, we have all gottenthe messaging that the only way to win grants is to continually apply for asmany as you can. Recent shifts at some institutions, however, have shownthat an increased focus on quality grant development, including structuralsupport for junior faculty, increased researchers’—especially BIPOCresearchers—success in their scholarship endeavors .Allowing more time from announcing an opportunity for grant fundingto when application deadlines are due, particularly for those thatseek to privilege community-engaged methods and knowledge;Including consideration of how research has engaged with, willcommunicate with, and impacts communities most affected by the giventopic under study;Developing guidelines for how funded projects will name, learn from,and leverage inevitable mistakes as they conduct research;Prioritizing proposals that keep sustainability in mind, namelyresearch that impacts health seven generations into the future.The implications of these characteristics of White supremacy include thatinnovative ideas go unsubmitted and thereby unfunded. In addition, BIPOCjunior researchers who are carving out new ideas can experience barrierssuch as the working with a limited scope of what are considered fundablepublic health topics , the need to show preliminary datawhen those data likely do not exist for projects centered on health equity,or trying to navigate exclusionary and segregated systems of informationparticularly for foundation grants, opportunities can be learned fromundefined and exclusionary networks. If we are not aware of and a part ofthese networks, there will always be inequitable access to funding, even ifthe funding opportunities are focused on the communities we are a part ofand work with. As grants funding is an increasingly critical component forjob security and advancement in multiple sectors, substantial change isneeded to address the structural barriers inherently embedded in theprocess. Without informed changes the chutes will continue to grow, makingit harder for BIPOC junior researchers to stay in their researchorganizations and contribute their innovative ideas that push the status quotoward solutions that improve the well-being of communities affected byracism and other structural inequities.We have used the tenets of White supremacy culture in discussing the fundingcascade as an aperture to shine light on ways in which the existing systemswork to disadvantage female, BIPOC junior researchers specifically and allknowledge creation efforts more broadly. In doing so, we hope to catalyzeengaged parties in conceptualizing, designing, and implementing thestructural changes necessary to move the field of health research towardactively antiracist funding modes of operation.In an effort to transform the funding cascade, we invite public health funders tojoin us for a series of virtual convenings in Fall 2023 hosted by the UNCGillings School of Global Public Health so that funders can collectively:Identify problematic practices using Identify potential solutions and antidotes;Forecast resources needed to enact these changes and potential barriersto change;Crowdsource technical assistance or support.https://bit.ly/antiracistfunding. In the meantime, we ask thatfunders internally reflect on action items 1 through 4 above and hold themselvesaccountable to making the funding cascade more antiracist. While the focus ofthese results and recommendations is funders, there are also many instanceswhere other institutions  limit the potential of BIPOC researchers. We encouragemembers of these other systems reflect on individual and collective practicesthat must be transformed to drive toward equity.To receive updates about these convenings, to invite a funder to the convening,or to submit a comment to the co-authors, please fill out this form: We share the perspectives of female, junior BIPOC researchers navigating the grantslandscape. The funding cascade is filled with barriers that maintain the status quoand are reflective of continued normalization of White supremacy culture. Structuralbarriers to the grants process require structural solutions as a means of improvingequity in the workforce, equity in research being conducted, and improved equity inpublic health.Click here for additional data file.Supplemental material, sj-jpg-1-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-10-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-11-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-2-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-3-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-4-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-5-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-6-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-7-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-8-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion PracticeClick here for additional data file.Supplemental material, sj-jpg-9-hpp-10.1177_15248399221129864 for Examining theWhite Supremacist Practices of Funding Organizations for Public Health Researchand Practice: A Composite Narrative From Female, BIPOC Junior Researchers inPublic Health by Elizabeth Chen, Deshira Wallace, Cristina Leos and YeseniaMerino in Health Promotion Practice


Extracellular vesicles (EVs) are highly promising as drug delivery vehicles due to their nanoscale size, stability and biocompatibility. EVs possess natural targeting abilities and are known to traverse long distances to reach their target cells. This long-range organotropism and the ability to penetrate hard-to-reach tissues, including the brain, have sparked interest in using EVs for the targeted delivery of pharmaceuticals. In addition, EVs can be readily harvested from an individual’s biofluids, making them especially suitable for personalized medicine applications. However, the targeting abilities of unmodified EVs have proven to be insufficient for clinical applications. Multiple attempts have been made to bioengineer EVs to fine-tune their on-target binding. Here, we summarize the current state of knowledge on the natural targeting abilities of native EVs. We also critically discuss the strategies to functionalize EV surfaces for superior long-distance targeting of specific tissues and cells. Finally, we review the challenges in achieving specific on-target binding of EV nanocarriers. Extracellular vesicles (EVs) are membranous nanosized particles produced by nearly all cell types, including eukaryotic and prokaryotic cells, and they carry their parent cell’s cytosolic components in their lumen, including RNA and various proteins. EVs can be broadly classified into three types by their biogenesis pathway: exosomes, microvesicles (ectosomes) and apoptotic bodies. Exosomes have attracted the most attention in the drug delivery field due to their unique composition and their ability to deliver messenger proteins and genetic components to distant sites. Exosomes are 30 to 150 nm in diameter and their generation starts with receptor-mediated endocytosis at the cell’s plasma membrane. The endocytosed contents are directed towards the endosome which later matures into a multivesicular body (MVB) filled with intraluminal vesicles. Upon fusion of the MVB with the plasma membrane, these intraluminal vesicles are released into the extracellular space as exosomes. Microvesicles directly pinch off the cell’s plasma membrane. While they are less commonly researched for their drug delivery capabilities, microvesicles from specific cell types, especially red blood cells, are promising delivery tools due to their scalability. Apoptotic bodies are released by dying cells and are outside the scope of this review.EVs’ natural capacity to penetrate hard-to-reach tissues is only matched by a limited number of highly advanced synthetic nanocarriers. For example, EVs have a unique ability to cross the blood-brain barrier (BBB)—a major challenge faced by traditional therapeutics. The mechanism behind this is poorly understood, but exosomes are hypothesized to be transported to the brain via vesicular transport, known as transcytosis . EVs alsFurther, EVs are believed to be more likely to have extended circulation times compared to synthetic nanoparticles due to their stability and ability to evade the immune system. The phospholipid surface of EVs is negatively charged, potentially making it easier for them to evade macrophages and cells of the mononuclear phagocyte system (MPS), which are also negatively charged ,6. AdditUnlike synthetic carriers, EVs from certain cell types possess intrinsic therapeutic qualities that may supplement the effects of the incorporated drugs. This is particularly true for stem cell-derived exosomes. For example, EVs derived from mesenchymal stem cells (MSC) have anti-inflammatory and protective properties similar to their parent cells. Multiple studies have shown the regenerative potential of such EVs ,11,12,13Finally, when stored at −80 °C, EVs remain stable and retain clinical usability even after five months of storage ,18. ThisEVs have shown enough promise as drug delivery vectors to become the subject of several high-value pharmaceutical deals. In particular, the unique ability of EVs to cross the blood-brain barrier has attracted over CAD 1 billion of investments from Eli Lilly into central nervous system (CNS)-targeting exosomes, which could be loaded with RNA interference (RNAi) and antisense oligonucleotide (ASO) therapeutics. The addition of guiding ligands will enhance CNS targeting. While there is a definite focus on exosomal nucleic acid delivery , adult stem cell companies also show considerable interest in EVs ,20. It iClinical trials are continuously initiated to assess EVs’ suitability for various therapeutic applications. Dendritic-cell (DC)- and MSC-derived EVs are the most common types of EVs used in clinical trials. A phase II/III clinical trial showed that the use of EVs derived from MSCs improved kidney function in patients with chronic kidney disease and did not produce significant side effects . A phaseThe clinical use of EVs as delivery vehicles for various therapeutics is currently being tested. For example, a phase II trial sought to treat hard-to-manage malignant ascites and pleural effusion in cancer patients by administering various chemotherapeutic drugs packaged into cancer EVs . The results of this trial are, however, unknown. Another ongoing study will investigate the ability of plant-derived exosomes packaged with curcumin to deliver their contents to normal colon tissue and colon tumours .Recently, there has been a surge of interest in using EVs to treat COVID-19. Currently, eight ongoing and two completed clinical trials are registered on ClinicalTrials.gov, which use exosomes as a treatment option for COVID-19. Two ongoing studies (phase I and phase II) are investigating the safety and efficacy of CD24-exosomes, which can potentially suppress the cytokine storm in patients with moderate or severe COVID-19 . Another two trials (phase I and II) are looking into the safety and efficacy of bone marrow MSC-derived exosomes in severely ill patients hospitalized with COVID-19 .Given the amount of dedicated effort and investment into EV-based therapeutics, it is vital to ensure that they are targeted to the tissues of interest to maximize their medicinal action and minimize off-target effects. This review will focus on EVs’ natural targeting abilities and the bioengineering strategies to target specific cells. We will also discuss the challenges and future perspectives of EV-based therapeutics.EVs are nature’s delivery vehicles, as their surface is decorated with numerous molecules, such as tetraspanins, integrins and cell-specific proteins, which serve as native targeting moieties . These mLong-range organotropism of cancer EVs is well-documented. Cancer EVs are known to travel far from their original tumour sites and alter the healthy tissues, thus preparing the ‘soil’ for metastatic ‘seeds’ to be planted ,25,26,27The targeting abilities of EVs originating from non-cancerous cells have also been explored. For example, EVs derived from immune cells appear to preferentially target immune cells. For instance, exosomes originating from T cells target antigen-presenting cells for unidirectional microRNA transfer . This exA study comparing the in vivo distribution of EVs originating from cancer cells vs. non-cancerous cells have shown that cellular origin plays a role in the fate of exogenously administered EVs. Thus, in a mouse model, melanoma-derived EVs were shown to target the gastrointestinal tract more than those from non-cancerous cells . On the In addition to choosing the appropriate parent cell type, altering the route of administration can be used to increase the targeting of EVs towards the tissue of interest. In a mouse model, intravenous (iv) injection resulted in the highest accumulation of EVs in the liver compared to intraperitoneal (ip) and subcutaneous (sc) injection (~60% vs. ~30%) . Ip and Despite the evidence discussed above, the ability of unmodified EVs to specifically target cells and tissues in vivo remains controversial. A study by Jung et al. demonstrated that exosomes derived from MDA-MB-231 human breast cancer cells only targeted hypoxic cancer cells in vitro, but failed to do so in vivo . FurtherEVs can be decorated with surface molecules to enhance their targeting abilities. This can be accomplished by directly attaching targeting moieties to the EV surface or modifying EV-producing cells See . A very Modifying parent cells is a common method to obtain EVs with particular targeting properties and is superior to direct modification of exosomal surface in terms of the stability of the targeting moiety. In this method, a gene encoding the targeting proteins is inserted into donor cells, and the cells then release EVs carrying those proteins via the natural biogenesis pathways. If certain targeting moieties are not naturally found on EV membranes, cells can be made to express the desired moiety fused to an EV membrane component.Lysosomal-associated membrane protein 2b (Lamp2b) is one of the most commonly used exosomal pedestals to attach guiding moieties ,48,49,50The designs of protein-targeting constructs that get incorporated into therapeutic EVs can become rather complicated. Ohno et al. used cloned tumour-targeting peptides  into pDisplay vector, which already contained hemagglutinin, myc-tag and platelet-derived growth factor receptor (PDGFR) . Human eBesides targeting peptides, antibodies and nanobodies have been installed on EV surfaces to improve targeting. In one study, EV-producing cells were transfected with a vector encoding for anti-EGFR nanobodies fused to glycosylphosphatidylinositol (GPI) peptides to target cancer cells . Lipid rWhile peptides and antibodies/nanobodies are the most popular choices for EV target guidance, other more imaginative approaches have also been employed. For example, pseudotyping—a method to change the tropism of viruses by packaging the genetic components of one virus into the envelope proteins of a different virus—has been applied to engineering targeted exosomes . Meyer eAn interesting direction in EV targeting is to use targeting moieties that also have a therapeutic effect. Jiang et al. induced overexpression of tumour necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) in the membranes of donor cells which subsequently got incorporated into exosomes loaded with an anti-cancer agent triptolide . In thisSupplying EVs with targeting properties via genetic modification of parent cells is an effective approach. However, it is not suitable for personalized medicine applications as it is difficult to apply this approach to patients’ own cells. It is also time-consuming, hard to scale for mass production and limiting as only genetically encodable targeting moieties may be used. Moreover, some targeting moieties tend to be expressed incorrectly and are quickly degraded in producer cells, affecting the resulting EVs’ targeting efficiency .Direct chemical modification of EVs allows for a wider selection of targeting ligands and is more suited to personalized medicine applications, as EVs can be isolated from patient’s own body fluids and later decorated with chosen guiding moieties. Further, targeting ligands can be attached to isolated EVs in a very controlled manner which is not achievable with the parental cell modification approach.Targeting peptides and antibodies/nanobodies are most commonly used to achieve efficient targeting of EVs post-isolation. An interesting approach was suggested by Ye et al., who used a multifunctional peptide to target EVs to glioblastoma cells . The pepAnti-EGFR nanobodies fused to lactadherin, which bind to the phosphatidylserine in EVs post-isolation, have been used to target EGFR-positive tumour cells . SimilarMore out-of-the-box approaches to direct modification of EVs for targeted drug delivery have also been tested. For instance, both DNA and RNA aptamers (single strands of nucleic acid that can bind to specific targets) have been used to direct EVs towards tumours. Cholesterol, naturally present in EV membranes, was used to conjugate AS1411, a DNA aptamer with a high affinity to nucleolin typically overexpressed in breast cancer cells . AS1411-Even actual magnets have been used to direct exosomes towards tumours. Qi at al. decorated transferrin receptors of blood-derived exosomes with magnetic nanoparticles and then guided them towards murine tumours using external magnets . A niche and underexplored method for functionalizing EVs with targeting moieties is their fusion with liposomes decorated with targeting peptides or antibodies . For exaOverall, the direct EV modification approach allows for a wider selection of targeting ligands and greater freedom in choosing chemical tools for their conjugation. These targeting moieties often have therapeutic and even diagnostic modalities that amplify the effect of loaded cargo drugs. Still, direct modification of EVs is challenging as the reaction conditions must be adapted to preserve EV membranes, prevent aggregation and ensure sufficient density of targeting ligands on EV surfaces.EVs have many characteristics that make them an obvious choice as drug delivery vehicles, such as biocompatibility, stability, low immunogenicity, etc. However, the use of EVs as nanocarriers in their natural form remains challenging due to insufficient natural targeting abilities. Multiple attempts have been made to target EVs to specific cells by modifying the producer cells or attaching targeting moieties to EVs post-isolation. While these approaches enhance the interaction of EVs with their target, they do not cancel out EVs’ natural homing abilities and do not prevent off-target effects. Therefore, artificial targeting moieties must be carefully selected to complement EVs’ intrinsic homing abilities. This is a non-trivial task due to the inherent heterogeneity of EV subtypes, which may have different natural targeting ligands, and the absence of standardized testing of EV-based pharmaceuticals. Thus, separating EV subtypes remains a major hurdle for achieving efficient targeting and preventing batch inconsistencies.While there is an abundance of research on targeting EVs to specific cells, few studies have investigated the ultimate fate of those EVs. EVs are taken up by cells via different routes, including receptor-medicated endocytosis, micropinocytosis and membrane fusion. Furthermore, a large proportion of them may be degraded in the lysosome. More research into EV uptake mechanisms is necessary to ensure they reach the cytosol, and this requires overcoming the current microscopy limitations. Advantage should be taken of EV subtypes that directly fuse with the cellular membrane delivering their contents straight to the cytosol as they do not face the problem of endosomal escape.Making EV pharmaceuticals commercially and practically viable remains challenging. First, scaling up targeted EV production for pharmaceutical applications is problematic, especially when working with primary cells due to relatively low EV yields. In addition, when modifying EVs post-isolation, the complexity of EV composition may affect the efficiency of conjugation reactions. Creating personalized EV-based medicines is also a highly inefficient process. The time required for the manufacturer to isolate EVs from the patient’s body fluids or primary cells, load them with a drug and perform all the required quality control checks may be considerable, and in the meantime, the patient’s condition may worsen.Due to the practical difficulties associated with commercializing EVs as drug delivery vehicles, their advantages must be warranted. For many applications, EVs do not offer a substantial advantage over traditional drug delivery vehicles, such as liposomes and polymeric nanoparticles. However, EVs’ unique composition makes them ideally suited to several niche applications. First, EVs’ capacity to deliver therapeutics to hard-to-reach tissues makes them ideal for drug delivery to the brain or the cochlear sensory hair cells. Second, EVs that naturally possess medicinal qualities, such as stem cell-derived EVs, could be used to amplify the therapeutic effect of loaded pharmaceuticals. Third, unlike liposomes and polymeric nanoparticles, EVs are uniquely suited to personalized medicine applications as they could be derived from patients’ own body fluids or cells.Importantly, care should be taken when selecting producer cells for therapeutic EVs. While there is an abundance of studies on cancer EVs as drug delivery tools due to their natural tumour-targeting abilities, such EVs raise safety concerns as they could potentially transform healthy cells, making them more susceptible to metastasis invasion and resistant to therapy ,71,72.Neisseria meningitidis that have been licensed for clinical use [Looking to the future, a highly promising but underexplored source of targeted therapeutic EVs is bacterial cells. Bacterial EVs can naturally transfer resistance genes and virulence factors to host cells, but their targeting mechanisms are currently poorly investigated. Bacterial EVs have been successfully loaded with siRNA, gold nanoparticles and antibiotic gentamicin . Importaical use . Furtherical use . The abiical use . Howeverical use . Thus, tFurther, in addition to delivering therapeutics and vaccines, EV-targeting techniques can also be used for imaging and diagnostics. To achieve this, both genetic engineering of parent cells , gLuc, etc.) and direct incorporation of dyes  into the EV membrane have been used . For exaUltimately, coordinated effort from EV researchers and start-up owners is necessary to create standardized manufacturing and testing protocols for targeted EV-based therapeutics to ensure their effectiveness, safety and commercial success.EVs possess natural targeting abilities that facilitate cell-to-cell communication and deliver molecules to distant sites. EVs can also penetrate brain tissues and the cochlear sensory hair cells, a task that represents a challenge for most synthetic nanocarriers. To translate these findings into clinical applications and utilize EVs as an efficient and reproducible nanocarrier system, the functionalization of EV surfaces with unique targeting ligands is required. This can be achieved by genetically modifying EV producer cells or directly functionalizing the EV surface post-isolation. Both approaches have advantages and should be chosen with the desired application in mind. Notably, the natural targeting properties of EVs should not be disregarded when engineering targeted EVs. Instead, their effect should be amplified further by artificial modifications. The future of targeted EV-based therapeutics lies in combining their natural targeting and medicinal capabilities with designer targeting elements and therapeutic and diagnostic cargo, thus producing a multifunctional biomedical device.


While great progress has been made in transplantation medicine, long-term graft failure and serious side effects still pose a challenge in kidney transplantation. Effective and safe long-term treatments are needed. Therefore, evidence of the lasting benefit-risk of novel therapies is required. Demonstrating superiority of novel therapies is unlikely via conventional randomized controlled trials, as long-term follow-up in large sample sizes pose statistical and operational challenges. Furthermore, endpoints generally accepted in short-term clinical trials need to be translated to real-world (RW) care settings, enabling robust assessments of novel treatments. Hence, there is an evidence gap that calls for innovative clinical trial designs, with RW evidence (RWE) providing an opportunity to facilitate longitudinal transplant research with timely translation to clinical practice. Nonetheless, the current RWE landscape shows considerable heterogeneity, with few registries capturing detailed data to support the establishment of new endpoints. The main recommendations by leading scientists in the field are increased collaboration between registries for data harmonization and leveraging the development of technology innovations for data sharing under high privacy standards. This will aid the development of clinically meaningful endpoints and data models, enabling future long-term research and ultimately establish optimal long-term outcomes for transplant patients. While short-term survival rates of transplanted grafts and patients have improved in past decades, progress of long-term graft survival is still limited. In addition to the highly specialized surgery, long-term immunomodulatory treatment is needed to prevent rejection and allograft failure . The aveDemonstrating superiority of novel therapies and strategies in the long-term is challenging in conventional randomized controlled trial (RCT) settings. This is due to statistical challenges presented by the requirement to demonstrate benefits with long-term follow-up and large sample sizes. Resulting in increased operational risks  for sponsors, they also pose a high operational burden on patients and physicians. The need for shorter term, clinically meaningful endpoints that are predictive of longer-term outcomes has been extensively described –7.Whereas regulatory hurdles limit opportunities for novel therapeutics in RCTs to demonstrate improved graft and patient survival in the short-term , studies in real-world (RW) treatment settings offer new possibilities to generate evidence. With generalizable cohorts, RW settings have a broader relevance and efficiency compared to RCTs; provided that data elements relate to accurately recognized clinical phenomena and are comparable across settings –7.To expand the scientific understanding of innovative evidence generation in kidney transplantation, a scientific discussion was initiated by Novartis in 2020, including a panel of leading nephrologists, scientists, transplant registry experts, and drug development professionals. Participants were invited based on clinical research in kidney transplantation and/or experience in registry and real-world data (RWD)Long-term data is needed to understand patient outcomes beyond the one-to-three-year time-point usually considered in RCTs. Currently there is limited follow-up data available from clinical trials for kidney transplants, particularly in later years post-transplant, partly due to the high number of complex data elements  One of the issues are the high discontinuation rates (15–30%) observed in the first year of many immunosuppressive drug trials. Examples of this can be found in recent immunosuppressive drug RCTs in which the main reasons for patient discontinuation were AEs, severe refractory rejection or ineligibility , 12.Classical RCT settings are unlikely to fulfil needs for long-term outcome data as they require large sample sizes leading to an operational and financial burden, resulting in very few patients, physicians, and sponsors  being willing to participate in studies that require long years of clinical follow-up . RCTs alThe current standard of care (SoC) provides excellent short-term outcomes in suitable donor-recipient combinations; therefore, it is difficult to exceed SoC outcomes in RCTs of novel treatments. The currently accepted endpoints by regulatory authorities  provide mostly short-term outcomes, rather than long-term results . There aThe authors believe that studies of sub-groups , and non-ideal donor-recipient combinations, could demonstrate superiority of novel treatments in situations where SoC is not yet sufficient. There is also little inclusion of non-immunological aspects of kidney transplantation that should be considered  . Higher There is a need to improve the relevance and inclusion of patient-centric and patient reported outcomes in future research, as outlined by the Standardised Outcomes in Nephrology (SONG) initiative . Few triA common understanding on surrogate endpoints in kidney transplantation is required to improve the comparability of data as these do not directly measure clinical benefits, but rather predict the likelihood of a clinical benefit . Some suKidney transplant biomarkers were categorized by Mannon et al. as either pre-transplant, early post-transplant and late post-transplant markers . One preFinding accurate predictors depends on the immunological response, which can be highly variable due to immunosuppression therapies, comorbidities, and lifestyle factors. Transferring surrogate markers to new “surroundings” is also challenging as the predictive performance may not be the same and cross-validations may be necessary. For example, biomarkers evaluated in calcineurin inhibitor (CNI) based immunosuppression may not necessarily be valid in non-CNI protocols. The cost of immunosuppressive drugs and availability of follow-up visits also differ significantly across healthcare systems. Keeping these differences in mind will improve and ensure the comparability of treatment outcomes across geographies and treatment situations .Both RWD and RWE refer to patient related data not collected through a RCT . “The diInnovative clinical trial designs, such as those using external comparators (ECs), harness the power of RWD derived from patients treated in RW settings . ECs, alThe potential of RWE was seen in research by Friends of Cancer Research, where several RW clinical endpoints in patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors were compared to results of RCTs . SimilarThere are two examples of kidney transplant studies, which followed a similar approach to an EC using extension studies , 33. TheThe second clinical trial is the tricontinental mycophenolate mofetil (MMF) kidney transplantation extension study, which initially recruited 503 patients that received a deceased donor kidney, and were randomized in equal groups to receive azathioprine (AZA) or MMF in combination with cyclosporine and steroids , 33. WitRWE is increasingly required by regulators to demonstrate generalizable comparative insights, notably for: market authorization applications, line extension and post-authorization safety studies etc, . The nonFurthermore, RWD can be used to support the validation and test the predictive nature of short-term surrogate endpoints, as clinically meaningful surrogate endpoints that are predictive of final outcomes can be used and are needed for shorter term studies as well. Once such surrogate endpoints are validated, they could be used in clinical trials or other RW study designs. Specific transplant data  should be considered for consistent inclusion across registries, for example from diagnostic databases and biobanks, to expedite validation requirements.The potential advantages of using RWD must outweigh concerns of quality and consistency . Not manA global literature search assessment was conducted by the authors in 2020, using a standard methodology described in Ekman et al., , to idenWhilst the five sources fully or partly met data requirements to assess treatment patterns, burden of disease, and validated predictive surrogate endpoints , they represent less than 10% of the kidney transplant sources identified. Hence, the assessment concluded that few kidney transplant RWD sources routinely capture data needed to derive predictive markers  in greater clinical depth  36). En. En36). Identifying outcomes available across many sources, standardizing and enhancing data collection, will improve cross-source comparability to generate robust assessments. For example, more consistent glomerular filtration rate (GFR) measures would support definition of relevant surrogate endpoints for graft loss, and whilst this would likely require a shift from eGFR to standardized measured GFR assessments, this may be feasible with capillary samples and mathematical models. Ensuring such data breadth and completeness requires common definitions and sufficient time to implement changes that enforce required data quality.Lastly, technology innovations such as Natural Language ProcessingSeveral practical challenges exist in implementing large multinational registries with enough granularity and validated contemporary data for RWE studies. First, such a resource would be costly, and would require innovative design to start and maintain such a registry. Some examples exist however, where regulatory authorities are involved together with the industry, in funding and initiating a wide network of RWD, such as the EU-wide DARWIN . AnotherAnother major hurdle for registry collaboration comes from ownership of data and data sharing policies, especially within the EU with the current General Data Protection Regulations (GDPR). Although GDPR should be EU-wide, individual countries have adopted very different policies for defining concepts of data transfer, making international collaboration sometimes challenging. One possible solution to this problem could be federated data models, described above, which allow for the generation of cohorts from different datasets without requiring data to leave.Sub-optimal long-term graft survival highlights the need for novel therapies and ways to demonstrate their long-term benefit-risk ratio for patients. Demonstrating superiority of novel therapies is unlikely in conventional RCT’s due to the financial and logistical burden of long-term follow-up. However, innovative designs have the potential to facilitate improved longitudinal transplant research by harnessing RWD sources to demonstrate both effectiveness and safety of treatment in a non-invasive, effective, and affordable way. Nonetheless, for innovative designs to bring more value to patients, a common understanding, definition, and agreement on surrogate endpoints predictive of final outcomes in kidney transplantation is required. For this to be possible, harmonization among registries via the alignment of definitions is crucial to improve the comparability and wealth of usable data across clinical practice, RCTs and registries.The authors recognise that efforts are needed to strengthen the RWD infrastructure, thus also encourage developing studies of sub-populations and non-immunological aspects, as we believe these can demonstrate short and long-term benefits in situations where it may be methodologically hard to demonstrate superiority versus SoC in the general transplant population. Nonetheless, registry collaboration and data harmonization are considered key steps in demonstrating long-term beneficial outcomes of new therapies in kidney transplant patients . Finally


There are 15·4 million children who are HIV-exposed and uninfected worldwide. Early child development crucially influences later academic and socioeconomic factors. However, the neurodevelopmental outcomes of HIV-exposed uninfected (HEU) children in the era of maternal antiretroviral therapy (ART) remain unclear. We aimed to examine the effects of in-utero exposure to HIV and ART on child neurodevelopment.For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, Africa-Wide Information, PsycInfo, and Global Health databases from inception to May 27, 2020, for studies from the past two decades reporting neurodevelopment of HEU children aged 0–5 years compared with HIV-unexposed (HU) children (aim 1), and effects of different maternal ART regimens on neurodevelopment of HEU children (aim 2). We did narrative syntheses for both aims, and a random-effects meta-analysis of high-quality studies comparing HEU children and HU children, to obtain weighted pooled estimates of effect sizes. This study was registered with PROSPERO, CRD42018075910.We screened 35 527 records and included 45 articles from 31 studies. Overall, 12 (57%) of 21 studies comparing HEU children and HU children found worse neurodevelopment in HEU children in at least one domain. Study design and methodological quality were variable, with heterogeneity across populations. Meta-analysis included eight high-quality studies comparing 1856 HEU children with 3067 HU children at ages 12–24 months; among HEU children with available data, 1709 (99%) of 1732 were exposed to ART. HEU children had poorer expressive language  and gross motor function  than HU children, but similar cognitive development , receptive language development , and fine motor skills . Results suggested little or no evidence of an effect of specific maternal ART regimens on neurodevelopment; study heterogeneity prevented meta-analysis.HEU children are at risk of subtle impairments in expressive language and gross motor development by age 2 years. We found no consistent effect of maternal ART regimens analysed, although evidence was scarce. We highlight the need for large high-quality longitudinal studies to assess the neurodevelopmental trajectories of HEU children and to investigate underlying mechanisms to inform intervention strategies.Wellcome Trust and Medical Research Council. HIV are HIV-exposed and uninfected. There are an estimated 15·4 million HIV-exposed uninfected (HEU) children worldwide, comprising over 20% of annual births in some high HIV-burden countries. Disparities in early-life mortality and morbidity are evident between HEU children and HIV-unexposed (HU) children, and concerns have been raised regarding the effects of HIV and ART exposure on neurodevelopment.2Widespread access to antiretroviral therapy (ART) in pregnancy has substantially reduced vertical HIV transmission, meaning most children born to mothers with Sustainable Development Goals recognise the importance of child neurodevelopment, since the early years are foundational for brain development.Early child development forms the basis of future academic achievement and socioeconomic outcomes.Existing literature suggests that HEU children might be at risk for adverse cognitive, language, and motor outcomes compared with HU children. However, previous systematic reviews describing neurodevelopmental delay include multiple reports from before widespread access to ART and few studies from countries with generalised HIV epidemics.Evidence before this studyChildren who are HIV-exposed and uninfected represent a growing global population. The neurodevelopmental outcomes of this group of children in the era of antiretroviral therapy (ART) remain unclear; however, evidence is emerging from recent studies. Further information is needed to understand the nature of early neurodevelopment in this population to inform provision of care to improve outcomes. On searching the literature, we identified two meta-analyses but these were limited by the low number of included studies, including some with high risk of bias, thereby leaving a gap in our understanding of the neurodevelopmental outcomes of HIV-exposed uninfected (HEU) children in regions of high HIV prevalence. Individual studies were often limited by sample size and although previous reviews have been done, the majority have included studies from before widespread access to ART or have few studies from sub-Saharan Africa where the highest burden of HIV exists. We are unaware of any systematic reviews that have assessed the effect of different maternal ART regimens or examined imaging and head circumference alongside neurodevelopmental assessments. There is a need for an updated and focused synthesis of data for HIV and ART exposure on neurodevelopment in the ART era.Added value of this studyOur systematic review included 45 articles (from 31 studies) building on previous reports by contributing updated data following widespread access to ART. Our meta-analysis combined larger, high quality studies, mostly from sub-Saharan Africa, reflective of the current population of HEU children. We found that HEU children have worse expressive language and gross motor development compared with HIV-unexposed children with small effect sizes, but with similar cognitive, receptive language, and fine motor skills. To our knowledge, this is the first systematic review to assess effects of different maternal ART regimens on the neurodevelopment of HEU children. We found that few studies explored the effects of ART, but the scarce evidence suggests that there is little, if any, effect of the specific ART regimens or drug classes assessed on neurodevelopmental outcomes, although concerns were raised for efavirenz and atazanavir.Implications of all the available evidenceHEU children are at risk for subtle impairments in expressive language and gross motor development in early life. Although effect sizes were relatively small, the large number of HEU children worldwide means that even these subtle deficits might have a substantial effect in high-HIV burden countries, particularly in environments with multiple overlapping risk factors. Supporting these children to thrive might require interventions that focus on expressive language and gross motor skills in early childhood. Future research with large, high-quality, longitudinal studies is needed to examine outcomes at older ages and to investigate underlying mechanisms, with consistent methodology and standardised tools across settings to inform prevention and intervention strategies.Access to triple-drug ART during pregnancy and breastfeeding has expanded, leading to improved maternal survival and higher breastfeeding rates, which might influence neurodevelopment.We searched MEDLINE, Pubmed, Embase, PsychINFO, Global Health, and Africa-Wide Information without language restrictions from database inception to May 27, 2020. We used search terms for “child”, “neurodevelopment”, and “HIV/ART”, which were adapted for each database. MeSH headings were also used in MEDLINE, and Emtree terms in Embase, combined with database-specific filters. The search strategy and search terms are in the We defined our inclusion and exclusion criteria in line with the Population, Exposure, Comparator, OutcomesEW and CJW independently screened all titles, abstracts, and full texts for eligibility. Differences were resolved by discussion with a third reviewer (KAD or AJP). Where relevant, authors were contacted to clarify study eligibility. Search results were de-duplicated in EndNote X8. Study quality and risk of bias of studies comparing neurodevelopment of HEU children and HU children were assessed independently by two authors (CB-C and CJW) using the validated National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.This systematic review and meta-analysis followed the PRISMA guidelines.Data extraction was done in duplicate , including study design and setting, population demographics, exposure (HIV testing and ART exposure), methodology, outcome measures, and results. Outcomes of HEU children were classified by comparison with HU children as better, worse, or no difference on the basis of the individual study significance testing (p<0·05) or absolute or relative differences with confidence intervals in cases where p values were not shown..Our first aim was to investigate the effect of intrauterine HIV exposure. We did a narrative synthesis of coprimary outcomes compared between HEU children and HU children. We assessed unadjusted results, since studies adjusted for different confounders, and noted any changes on adjusted analyses where reported. For each study, significant differences in neurodevelopmental scores or proportions of developmental delay between the two groups in each domain were recorded and presented using a similar approach to Prado and colleaguesI2 test, and Q-values were used to test for between-group differences. We planned to construct a funnel plot to examine publication biases where there were ten or more studies. Statistical significance was set at p<0·05.We did a meta-analysis of outcomes reported by six or more studies. As we anticipated substantial methodological heterogeneity and potential for confounding when assessing neurodevelopment, we limited this to high-quality studies and used a random-effects model. Due to the relatively wide age range in some studies, we used age-standardised values, where reported, and did sensitivity analyses using raw scores given the concern that the norms might overestimate development.For our second aim, we examined associations between maternal ART exposures, stratified by regimen, drug class and individual drugs (where available), and neurodevelopmental domains. We report a synthesis of results in a similar format to the primary aim. If ART studies were sufficiently similar, we planned a second meta-analysis. Finally, we reported a narrative synthesis of the effects of HIV and ART on head circumference and neuroimaging. We used Stata 16.1 for analyses and to derive forest plots.The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report.A total of 35 527 references were screened . We asseFor the first aim, comparing neurodevelopment of HEU children versus HU children, 19 (79%) of 24 articles were from Africa,Methodological quality varied, with eight reports judged good quality, 11 fair, and five poor . Sample Among the eight studiesI2=55·44%, p=0·028) and fine motor outcomes , high heterogeneity in cognitive outcomes  and receptive language outcomes , and no heterogeneity in gross motor outcomes . Sensitivity analyses excluding the one study from a high-income country,I2=72·23%, p=0·013, versus 24 month –0·19 [–0·27 to –0·11], p<0·0001; heterogeneity I2=0%, p=0·51), whereas gross motor outcomes showed similar findings at both ages.Overall, HEU children had worse expressive language outcomes  and gross motor outcomes  compared with HU children, but similar cognitive development , receptive language development , and fine motor development . There was moderate heterogeneity in expressive language outcomes Small studies comparing neurodevelopment of HEU children exposed to triple ART versus no ART in the first 24 months found similar outcomesAnalyses of individual drugs were predominantly reported from the SMARTT cohort; of the multiple drugs assessed, most had no evidence of significant associations with neurodevelopment. However, there was a signal for worse language outcomes in children exposed to atazanavir-containing versus non-atazanavir regimens at age 12 months,In the analysis of secondary outcomes , 11 repoWe systematically reviewed neurodevelopment in HEU children aged 0–5 years and identified 45 reports from 31 studies across four continents; most studies were from sub-Saharan Africa, where the majority of HEU children live. Although findings were heterogeneous, over half of all studies reported poorer neurodevelopment in HEU children than in HU children in at least one domain. Variability in study design, quality, population characteristics, and assessment tools might explain differences in results across studies. Among high-quality studies, in which 99% of HEU children were exposed to maternal ART, there was evidence that HEU children have poorer expressive language and gross motor function than HU children, although the deficits are subtle with relatively small effect sizes. Timing of assessment appears to affect findings, with language deficits becoming evident after age 12 months, highlighting the importance of long-term follow-up. We found no evidence of consistent associations between specific ART regimens and neurodevelopment, although generalisability of the evidence is limited.Our findings of impaired expressive language and gross motor development in HEU children are consistent with studies from before the introduction of ART.There was no evidence of cognitive impairment in the meta-analysis, consistent with studies reporting similar cognitive scores between HEU children and HU children at age 6–11 years.WHO guidelines changed in 2012 to recommend universal triple ART for pregnant and breastfeeding women (termed Option B+). To our knowledge, this is the first systematic review to assess the effect of specific ART exposure on the neurodevelopment of HEU children. Overall, our results are reassuring, showing no clear evidence of associations between different ART regimens and drug classes assessed  and neurodevelopment. However, interpretation of these results is limited by small study numbers and heterogeneous comparison groups. Data on individual drugs are dominated by publications from the observational SMARTT study, which includes children exposed to multiple different combinations. Overall, findings from SMARTT are encouraging,Secondary outcomes included head circumference, which is often used as a surrogate marker of brain growth and development and might serve as a useful biomarker in clinical practice. Our findings were mixed, and the prevalence of microcephaly varied across studies, suggesting that more robust evidence is needed with long-term follow-up. However, larger studies did suggest a small reduction in head circumference in HEU children compared with HU children. There was no evident association between head circumference and specific ART regimens or drug classes; however, potential associations with efavirenzPanelGiven the known effect of multiple factors on neurodevelopment, a more coherent approach is needed in which a unified set of covariates are measured and reported with adequate comparator groups to ensure consistency across studies and allow for generalisability.A standardised framework for assessments with validated cross-cultural measurements is required to improve comparability between different study settings with contextually appropriate norms. Reporting categorical delay scores is useful from a clinical perspective; however, the selection of the threshold is often arbitrary and might miss capturing the full relationship. Therefore, reporting both continuous and categorical measures in tandem might be the best approach.Individual neurodevelopmental domains should be examined separately. The use of multiple tools for assessing the different components of domains should be considered. This is particularly relevant given the language deficits identified in HEU children, since multiple indicators for speech and language might differentiate between vocabulary, grammar, and speech. As children grow older, differentiating between the various components of executive function also becomes increasingly important.The definitions of HEU and HIV-unexposed need to be carefully documented. We had to exclude many studies that combined HEU children and children with HIV infection together as HIV-exposed, or which combined children with and without HIV exposure together as HIV-uninfected. In the first instance, differences are likely to be overestimated due to the inclusion of children with HIV, and in the latter, differences might be underestimated due to the inclusion of children without HIV exposure.Studies should consider factors that are known to affect child neurodevelopment at the design stage (population criteria or covariates), such as low birthweight and preterm birth, small-for-gestational age, hearing impairment, genetic syndromes, and neurological disorders.Ongoing ART surveillance is needed and randomised controlled trials might help to identify the ART regimens that lead to optimal outcomes. This requires examination of duration of exposure  with adequate comparison groups of specific regimens.Given the dynamic nature of neurodevelopment, the developmental trajectory of HEU children compared with their unexposed peers should form the basis for future work. More large-scale longitudinal studies are needed given the potential subtle deficits early in life, and follow-up is required to determine longer-term effects.ART=antiretroviral therapy. HEU=HIV-exposed uninfected.Our study had several strengths. We reviewed multiple neurodevelopmental outcomes among HEU children up to age 5 years, from diverse contexts across several continents. The meta-analysis addressed sample size and methodological weaknesses of individual studies. We used effect sizes to combine measurement tools, allowing us to identify vulnerability in specific domains and to estimate a measure of effect that could be applied to different tools and ages in the future. Health-care workers can be guided by the effect sizes and examine for small delays in development in this group of children. Our study builds on previous reviewsIn conclusion, early-life neurodevelopment of HEU children is modestly impaired, specifically in expressive language and gross motor domains. Although effect sizes were small, our findings suggest a subtle yet clear demarcation of differences in abilities between HEU children and HU children at young ages. Given the growth in the global population of HEU children, with the largest increase in Africa, this difference in neurodevelopmental function might have a substantial effect together with other risks faced by this population. There were no consistent signals that specific ART regimens or drug classes affect neurodevelopment; however, evidence is scarce and well designed randomised trials are required. Understanding the potential toxicities or relative neuroprotection of antiretrovirals would allow modification of maternal ART regimens to optimise infant neurodevelopment. There was a scarcity of neuroimaging studies, and our review raises some important methodological considerations for future studies examining neurodevelopment in HEU children . Greaterhttps://osf.io/yeqj3/ and in the The study protocol and materials are available at AJP declares paid participation on the Botnar Research Centre for Child Health independent external review board and is a member of several data and safety monitoring boards with no payment, none of which relate to the current research. DJS has received research grants or consultancy honoraria from Discovery, Johnson & Johnson, Lundbeck, Sanofi, Servier, Takeda, and Vistagen. All other authors declare no competing interests.


In regenerative medicine, the aim is to develop and employ methods to regenerate, restore or replace damaged/diseased tissues or organs. Regenerative medicine investigates using tools such as novel technologies or techniques, extracellular vesicles, cell-based therapies, and tissue-engineered constructs to design effective patient-specific treatments. This review illustrates current advancements in regenerative medicine that may pertain to transplant medicine. We highlight progress made and various tools designed and employed specifically for each tissue or organ, such as the kidney, heart, liver, lung, vasculature, gastrointestinal tract, and pancreas. By combing both fields of transplant and regenerative medicine, we can harbor a successful collaboration that would be beneficial and efficacious for the repair and design of  What has stemmed so far from this collaboration is a new webinar series featuring speakers from both worlds and whose sessions are available on YouTube (the link https://www.youtube.com/watch?v=Qz21se2VSbs&t=212s relates to the very first edition of the webinar series). On the editorial front, transplant journals are publishing more and more regenerative medicine manuscripts. Transplant societies are establishing committees focusing on regenerative medicine-related topics like cell therapy or organ bioengineering. Some examples: In 2014, AST launched the Transplant Regenerative Medicine Community of Practice. The Cell Transplantation Society rebranded its name as the Cell Transplant and Regenerative Medicine Society. At the same time, while the European Society of Organ Transplantation (ESOT) established the European Cell Therapy and Organ Regeneration Section (ECTORS) in 2019.In 2011, Transplant International published the first manuscript illustrating how regenerative medicine technologies will impact transplant medicine . In the This manuscript aims at updating the transplant audience on the recent advances in regenerative medicine that may be pertinent to transplant medicine. These advances will be presented separately by organs.Mesenchymal stromal cells (MSC) have long been of interest to the kidney transplantation world mainly for their immunomodulatory properties . Howeverex vivo model of DCD renal allograft preservation. In this study, five pairs of discarded DCD kidneys were treated with 108 MSC or placebo, perfused ex vivo for 24 h in a proprietary machine perfusion system, and eventually evaluated for DNA synthesis, cytokine/chemokine synthesis, cytoskeletal regeneration, and mitosis. The authors observed that the study group showed increased synthesis of adenosine triphosphate, a reduced inflammatory response, increased synthesis of growth factors, normalization of the cytoskeleton, and mitosis. More recently, a similar study conducted ex vivo reported comparable results using 50 million multipotent adult progenitor cells (MAPC) that are inherently similar to MSC  during ex vivo normothermic machine perfusion  and advances in three-dimensional bioprinting techniques that use a combination of cells, artificial and natural biomaterial, and biologically active molecules to reconstruct or regenerate damaged tissues or whole organs provide a potential solution to the shortage of transplantable kidneys. However, unlike two-dimensional planar tissue, the complex kidney structure is composed of various cell types in specialized locations on the specific composition of extracellular matrix protein for proper kidney function. Thus, making bioengineering of the kidney for transplantation still challenging. Although challenges still exist in whole organ engineering, the development of wearable hemodialysis devices may serve as a viable novel alternative dialysis technology that can enhance a patient’s freedom and quality of life . MultiplIn kidney transplant medicine, novel techniques, and technologies such as three-dimensional (3D) cell cultures that incorporate key kidney features can lead to the design of more patient-specific targeted therapies . Kidney Cardiac cell therapy is considered the only cure for cardiovascular disease; current sophisticated long-term treatments  are only palliative. However, in the continued absence of standardized criteria, the injection of cells from different sources and stages of differentiation , bone marrow‐derived mononuclear cells (BMMNCs), mesenchymal stem cells, hematopoietic stem cells, endothelial progenitor cells), have not produced consistent results . All expCurrent protocols are focused on cell differentiation in the ischemic region but neglect the need to restore the original myocardial bioarchitecture. The unique spiral-like arrangement of the contractile cells in the myocardium represents the anatomical foundation of the heart’s functional prowess. Instead, after injection into the injured myocardium, stem cells grow and differentiate without a specific polarization; hence, they contribute to the heart contracting in an uncoordinated and inefficient fashion. The issue of the post-injection cell orientation has been addressed by growing cells on polymeric biocompatible structures (scaffolds). These are made of natural, artificial, and composite materials, characterized by a variegated design providing cells with mechanical support to favor a three-dimensional orientation . Recent Further knowledge must be developed on the ECM structure and the complex array of biological and physical signals interlacing scaffolds and cells. In this context, an auspicious research direction is represented by the emulation of the ECM structure (microfibers embedded in a matrix). Experimental scaffolds made of a woodpile structure embedded in hydrogel are already under investigation, and have shown promising preliminary results . HoweverAnother factor for successful cell therapy is the modulation of the turmoil microenvironment in damaged tissue. This can hamper its response to humoral/immunostimulant factors or alien cell integration. Deprivation of blood supply modifies tissue pH, while cell debris, tissue edema, and cell misalignment disrupt the signals related to the stiffness of the recipient myocardial tissue. Furthermore, ECM breakdown products, and mitochondrial DNA activate a robust inflammatory reaction, while the invasion of non-myocardial cells creates an ecosystem unfavorable for living cells. In this context, chemokines mobilize monocytes that transdifferentiate into macrophages releasing pro‐inflammatory cytokines  detrimental to surviving cardiomyocytes. These inflammatory factors stimulate fibroblast proliferation, enhancing scar tissue formation to substitute dead cardiomyocytes and prevent ventricular wall rupture. At the same time, the anti‐inflammatory M2 macrophages secrete factors that may recruit and activate exogenous or resident progenitor cells. It is crucial to modulate the post-ischemic microenvironment to favor the implant of new healthy cells. An environment in favor of new healthy cells can be achieved by improving the pharmacological treatments currently in use and injecting cell populations able to interact with immune and non-immune cells. MSCs release soluble factors that impair T‐cell proliferation and differentiation, cytokine secretion, and cytotoxic potential. They suppress the formation of TH1 and TH17 while enhancing the formation of TH2 lymphocytes, which produce anti‐inflammatory cytokines, such as IL‐4 and IL‐10 . In addiMitochondria transfer is one of the biological processes triggered by stress signals, during which mitochondria are transported from healthy donor cells and incorporated into the endogenous mitochondrial network of the damaged recipient cell, in order to repair damage and restore its bio-energetic profile and health . As mitoDifferent cell therapies and bio artificial livers have been attempted and used not only for advanced cirrhosis but also for: Acute and acute-on-chronic liver failure, inborn errors of metabolism, chronic cholestatic, autoimmune diseases, and non-alcoholic fatty liver disease  . HepatocMSCs derived stem cells, including bone marrow hematopoietic stem cells (HSCs) (CD34 and CD133) and MSCs , are autologous, easily sourced, and readily cryopreserved, allowing for transplantation procedures with minimal, if any, complications . HoweverN = 25) at the 6-month follow-up   and the ollow-up . In Westollow-up . Prelimiollow-up . RemarkaEmbryonic stem cells evoke ethical concerns. Significant advancements have been made in defining protocols for the differentiation of human-induced pluripotent stem cells (iPSCs) into functional mature hepatocytes, e.g., induced multipotent progenitor cell-derived hepatocytes , the dirIn 2009–2010, the first experiments involving whole-liver decellularization in rodents were conducted by Chronic respiratory diseases are among the leading causes of death after cardiovascular diseases and cancer, accounting for about 5.7% of total deaths in 2017 . The golin vitro  in small and large animal models  and heterotopic transplantation models are being developed to bridge to orthotopic lung transplantation. EVLP is a clinically used procedure for normothermic support of donor’s lungs prior to transplantation. Conceived and developed at the Toronto Lung Transplant Program led by pioneering surgeon Shaf Keshavjee  . Choosinfunction . Isolatefunction .in vivo to provide the cells with the appropriate mechanical cues and allow for vascular, lymphatic, and neural ingrowth. Synthetic materials such as polyglycolic/poly lactic-co-glycolic acid (PGA/PLGA) or polyglycolic/poly-L-lactic acid (PGA/PLLA) have readily tunable mechanical properties that have been used to generate scaffolds for GI applications  ications . Naturalications  and acelications  provide ications . While aications . They haications .in vitro cell culture, such as the development of organoid systems and the generation of scaffolds that recapitulate in vivo organ mechanical and biochemical properties, are promising for the generation of tissue-engineered GI organs.The lack of transplant options and dismal intestinal transplant survival rates present a significant clinical need for tissue-engineered GI organs; however, GI tissue complexity presents a major challenge to achieving this goal. Recent advances in β cell replacement through either whole pancreas or islet transplantation represents the gold standard for the treatment of longstanding morbid diabetes mellitus . HoweverExtensive efforts have been focused on developing effective islet encapsulation approaches to eliminate the need for chronic immunosuppression to prevent allograft rejection and recurrence of autoimmunity, for example by designing novel encapsulation materials, and engineering the site of transplantation to improve graft vascularization and provide local immune modulation, in order to overcome some of the aforementioned challenges. Several strategies, including microencapsulation of islets in hydrogel microcapsules  as well in vitro and stimulate accelerated inosculation with the host vasculature in vivo. Such an architecture will ensure efficient nutrient and oxygen diffusion , cell lines, and primary cells with or without bioreactor or biomaterials/scaffolds such as PLGA or Matrigel are used to generate complex 3D organoids structures that mimic their in vivo counterparts. Large and small intestinal, esophagus and stomach organoids have been generated from donor tissue or PSCs (in vitro. Organoids can be designed in an organ region-specific manner, such as that of the different brain compartments (in vitro organoids are the inability to generate mature and diverse cellular structures, their inconsistent reproducibility, and the deficiency of surrounding vascular, nervous, and immune systems necessary to recapitulate the in vivo tissue interaction. Limitations also exist in generating vascularized and architecturally organized organoids to mimic their in vivo organ counterparts precisely and efficiently. 3D bioprinting has been proposed to address and resolve some of these issues and accelerate the generation of complex organoids (in vivo counterparts both structurally and functionally.Organoids are miniature self-organized 3D structures composed of one or more cell types that partially recapitulate the structure and function of tissues and organs. Organoid technology has emerged as a powerful tool for studying organ development, disease progression, and drug screening . Organoi or PSCs  (Spence  or PSCs . Organoi or PSCs . This abartments . Multipaartments  and cultartments . Additiorganoids . Thus, iIn the past few decades, regenerative medicine has provided evidence that technologies like decellularization, 3D bioprinting, cell and organ engineering, and blastocyst complementation may offer platforms for the bioengineering, repair, and regeneration of transplantable organs. Although emerging data is promising, the complexity of solid organs poses a significant challenge, and further research and substantial investments are needed, as well as a synergic collaboration among all stakeholders, namely scientists, academia, industry, funding agencies, and governmental institutions. Advancements in basic research knowledge of stem cells, biomaterial, and developmental biology in combination with various biotechnologies and bioreactors are crucial for fast growth. Development and incorporation of chip technologies, organoids, and 3D bioprinters are opening new avenues and directions for the future. As it is clear to us that “no field in health sciences has more interest than organ transplantation in fostering progress in regenerative medicine because the future of no other field more than the future of organ transplantation will be forged by progress occurring in regenerative medicine” , we ther


Nanotechnology, and specifically the use of nanoparticles (NPs), has been intensively explored during the recent decades in order to solve unmet clinical needs and face different biotechnological challenges. However, their success has been rather modest due to several limitations associated with the use of current nanomaterials. In this sense, one of the aspects in which current NPs have failed is in the development of complex formulations, including biological cues in/onto their surface in a cost-effective manner. Moreover, the potential toxicity of the chemicals used for NP synthesis is still an important safety and environmental concern that prevents the implementation of many of such formulations. In this scenario, naturally occurring NPs offer a unique opportunity to overcome these biocompatibility, efficacy and cost-effectiveness issues.Production of naturally occurring NPs, synthesized either directly within living cells or biofabricated through the application of biological catalyzers, have become an appealing source of NPs with value in the biomedical and biotechnological fields. Such technologies provide unique insights, enabling the preparation of complex nano-sized systems, e.g., Inclusion bodies (IBs) or extracellular vesicles (EVs), formed by a milieu of active biomolecules, in relatively simple ways while rendering highly biocompatible interfaces, optimal for their use in biomedicine. In addition, the diversity in composition and structure of naturally originated NPs empower a significant number of distinct applications also in the biotechnological field, such as their use as immobilized biocatalysts or as biosensors for a spectrum of analytes. This diversity is further fueled by the capacity of tailoring natural NPs structure and functionality in a bottom-up approach via the genetic modification of the biological factories. Among the most common naturally occurring NPs we can find protein-only NPs, IBs, virus-like particles (VLPs), vaults, EVs, magnetosomes or polymeric particles (PP). Besides, a variety of metallic NPs can also benefit from the use of bio-catalyzers during their fabrication. In this regard, the implementation of greener synthesis processes is of paramount importance in the actual context of global environmental crisis.Barguilla et al. validated IBs as sub-micron protein particles displaying no cytotoxicity, genotoxicity or oxidative stress over Caco-2 cells, irrespective of the prokaryotic cell factory employed for their biofabrication. Such reports are very helpful in order to elaborate future product safety profiles and gain insight on the NP/cell interplay. In the same line, but approaching the potential toxicity of NPs from a structural perspective, Gil-Garcia and Ventura reviewed an intriguing strategy to drive IB formation while avoiding the use of potentially toxic amyloid-like domains to pull down proteins into valuable NPs. Thus, standard recombinant manipulation would allow to replace the amyloid (highly beta) conformation of natural IBs by a coiled-coil fold, composed of two or more α-helices. This last protein motif is widely used by nature to create supramolecular assemblies and could reduce potential undesired side effects derived from the amyloid nature of IBs. Nevertheless, numerous studies reported no evident toxicity caused by IBs after challenging cell or animal models . Serum is a biological fluid extremely rich in EVs and therefore a very interesting source for isolating these NPs in enough amounts. Thus, FBS-derived EVs were functionalized with Icariin as an alternative way to promote osteoblast proliferation and bone regeneration in vitro, significantly increasing the observed activity compared to Icariin alone.Of note, the notorious biocompatibility exhibited by IBs is shared by other types of naturally occurring NPs such as EVs. In this regard, EVs are cell membrane bound vesicles secreted by virtually any cell type that can be exploited as efficient delivery systems as exemplified by Shahzadi etal. presented a representative work where spherical silver nanoparticles (AgNPs), with different antioxidant, cytotoxic and antimicrobial activities, were efficiently generated in a cost-effective and environmentally friendly process using plant biotechnology. This is an example of how biological systems can be efficiently used as catalyzers for the biosynthesis of inorganic NPs from externally sourced metal ions, avoiding the use of hazardous chemicals generally employed in the production of such materials. Moreover, AgNPs, biofabricated in this fashion, can additionally incorporate plant-derived phytochemicals, conferring novel antioxidant properties and expanding thus, the spectrum of biological applications of generated nanomaterials.With respect to the use of natural NPs in green biotechnology, the present issue also includes diverse and interesting contributions. McNulty et al. as reagents for therapeutic protein purification. In this work, virus-based immunosorbent nanoparticles, generated using plant-based manufacturing and virus-functionalized magnetic particles were shown as a potential alternative to the traditional chemical methods used in the biopharmaceutical industry. Of note, such assemblies showed an extraordinary binding affinity capacity for therapeutic proteins.Another example of green biotechnology is collected here by the virus-based nanomaterials generated by Hrabarova etal. This work is yet another example of the enormous potential exhibited by cell protein waste NPs to be re-formulated in order to achieve new objectives. In this regard, the authors successfully engineered a highly soluble green fluorescent protein to produce bioactive IBs with an increased sensitivity to metals and di-/tri-inorganic phosphates. Their approach was based on the addition of small aggregation-prone peptide tags that also show modified sensitivity for poly-phosphates and metals ions. Thus, the same type of biosensors could be used to detect the presence of metal ions such as Cu2+, Zn2+ or Hg2+ in environmental samples or to monitor pyrophosphates levels in plasma, which possess value as a biomarker for various diseases.Finally, a novel usage for bacterial IBs as potential biosensors has been described by All in all, the present research topic reflects the growing interest of natural NPs for different biomedical and biotechnological purposes, where novel applications are steadily appearing and main limitations, e.g., toxicity studies, are being tackled. However, some issues such as: standardization of natural NPs characterization, cumbersome scaling up processes or further understanding of body responses to long term exposure should still be addressed in order to fully fulfill the promise of such NPs.


There is an increased interest in utilizing real-world data (RWD) for pharmaceutical research and regulatory decision-making. The development and use of pediatric medicines could benefit greatly from real-world data studies given nearly half of drugs prescribed to children are “off-label”, meaning there is a lack of pediatric-specific evidence from controlled trials, while there is an abundance of data from routine clinical practice. Currently, the use of real-world data, such as data from electronic health records, is lacking in pediatric research, especially within infectious diseases. Here, we discuss opportunities and challenges for real-world data to generate evidence on the optimal treatment and management of infectious diseases in children. Children have been historically regarded as therapeutic orphans in drug development, resulting in few drugs with pediatric indications and a lack of evidence in drug labels approved by the United States Food and Drug Administration (FDA) . While tOne consequence of delayed, limited, or lacking pediatric evidence is the prescription of drugs for “off-label” use. Off-label use constitutes the prescription of a drug outside the prescribing information authorized in the drug label or package insert, including indication, age, dose, formulation, or administration route . StudiesTo date, legislative and regulatory actions aimed to improve pediatric drug labelling have focused on incentivizing and improving clinical trials . In thisRWD broadly describes any data generated from routine delivery of healthcare and/or relating to a patient’s health status . RWD canEHRs contain extensive data assets that can be leveraged in infectious diseases research . ExposurClinical ‘cure’ from infectious disease is challenging to ascertain with certainty in routine practice; thus, it is not a reasonable effectiveness outcome in EHR-based infectious disease research. One RWD study of six medical centers evaluated the outcome of clinical failure, defined as composite 30-day mortality, 30-day microbiological failure (infection reoccurrence with the same organism), and failure to resolve symptoms during therapy . HoweverQuantitative drug measurements in plasma are an essential component of dose determination in pediatric drug development because absorption, distribution, metabolism, and elimination change as a child grows and develops . These momparative safety and effectiveness- CAnalyses with RWD have the potential to generate meaningful real-world evidence that can support regulatory decision-making and guide clinical practice. This impact was certainly demonstrated during the COVID-19 pandemic when RWD was utilized by research groups worldwide to generate evidence on disease progression, outcomes, and vaccine effectiveness and safety . CompareStudying antimicrobial treatment duration- Current infectious diseases research supports shorter antibiotic treatment courses for acute infections than the historical standard . These cPharmacology studies of dose-(concentration)-response- Head-to-head comparison of pharmaceuticals in randomized controlled trials is rare beyond the investigational drug and an active control. Observational studies utilizing RWD such as EHRs have the potential to contribute evidence on comparative safety and effectiveness of drugs on the market typically used to treat a disease. Such evidence can be useful in informing treatment selection to optimize effectiveness and safety or identify patient subgroups that may benefit from one pharmaceutical intervention over another . The stuPredicting antimicrobial resistance and Clinical Decision Support systems for antimicrobial prescribing- The relationship between dose, concentration, and response are critical for informing optimal treatment of infectious diseases. Such analyses require a range of tested doses and/or concentrations for characterization. Quantitative drug measurements from e.g., therapeutic drug monitoring (TDM) would provide concentrations for population pharmacokinetic modelling or concentration-response analysis. Dose-response can also be evaluated with sufficient dose heterogeneity in the pediatric population. However, EHR data may contain homogenous dosing in the pediatric population . In this case, drug concentrations  can be used to inform dose-(concentration)-response along with other factors known to influence drug exposure such as age, body weight, or renal function. These analyses could identify pediatric subgroups at risk of suboptimal dosing.Descriptive studies for hypothesis generation- Application of machine learning to EHR data has allowed the prediction of bacterial resistance with good accuracy . These aEHR data can be used for discovery or descriptive studies. For example, data from EHRs can be analyzed to understand the antimicrobial prescribing patterns in the pediatric population  or adverse drug outcomes with a particular high-risk drug or combination of drugs. These findings can be used learn where gaps exist in knowledge and to generate hypotheses that can be evaluated in future prospective studies.vice versa, resulting in a potentially incomplete patient profile. Since effective treatment of infectious diseases depends on host (immune), pharmacological, and pathogen factors, incomplete or inaccurate data on these factors could impact study findings. There is inherent uncertainty in the amount of drug a patient took in the outpatient setting. Infectious disease diagnosis may be based on clinical assessment alone; therefore, the pathogen, susceptibilities, and site of infection may be unknown. Furthermore, RWD pharmacology studies utilizing quantitative drug concentrations will likely be limited to drugs with an existing TDM program and in patients for which clinical need is present  since TDM is not widely utilized in the management of infectious diseases except for vancomycin and aminoglycosides . With growing commitment from these agencies, enhanced RWD utilization in pediatric infectious diseases research will follow.To better enable use of RWD in future pediatric infectious diseases research, enhanced data sharing along with adoption of common data structures is needed. This will enable larger, more diverse populations from multiple institutions to be studied more easily. Additionally, further development and reporting on data quality and standards of RWD assets and biostatistical methodology to handle incomplete or missing data will enhance the quality of evidence generated from the research. Investment from national and global research and regulatory agencies like the National Institutes of Health (NIH), World Health Organization (WHO), United States Food and Drug Administration (FDA), and European Medicines Agency (EMA) is needed to drive this field forward. An example of such investment is the newly established NIH Maternal and Pediatric Precision Therapeutics Hub (MPRINT), which “serves as a national resource for expertise in maternal and pediatric therapeutics to conduct and foster therapeutics-focused research in obstetrics, lactation, and pediatrics while enhancing inclusion of people with disabilities” and contains a real-world evidence core (