Resettled refugees from Muslim-majority countries are underrepresented in research and meeting their mental health needs remains a challenge for countries of resettlement. In this integrative review, we synthesize community-based mental health interventions using an ecological framework. Eleven relevant studies were identified using PubMed and PsychInfo database. Most interventions focus on micro-system level factors like promoting integration and social connections suggest improvement of outcomes including depression, anxiety, and psychological distress. Studies suggest how mental health programs addressing psychosocial wellbeing improves outcomes across ecological levels through: (1) early screening upon resettlement; (2) education and raising awareness of mental health; and (3) engagement of refugees in local community social support systems. Largely qualitative studies suggest benefits of engagement and education program for refugees, but there is a need for high quality, rigorous mental health intervention studies with resettled refugees with explicit attention to equitable and collaborative partnerships across multiple sectors in the community. There are an unprecedented 80 million people forcibly displaced globally. Refugees from Muslim-majority countries, including Afghanistan, Iraq, Somalia, and Syria, represent the largest refugee-producing countries in the world  and undergo a domestic medical exam. Screening for mental health and chronic health issues is not mandated the same way infectious diseases are for this population. The focus on refugees finding employment immediately upon resettlement may also compound existing stress related to acculturation or unaddressed mental health issues, especially if refugees do not speak English.Additionally, it is essential to highlight the social stigma surrounding accessing and using mental health services in the Muslim community. For many Muslims, help-seeking with family, friends, and faith leaders for mental health-related concerns occur before obtaining care from mental health specialists . In contrast, no studies identified in this review represent macro-level research. Mental health was generally operationalized as outcomes related to psychosocial stressors and wellbeing. For example, outcomes of interest included assessing social integration, social connectedness, and measures for depression and depressive symptoms, anxiety, and psychological distress.Only a few studies explicitly reported using the CBPR framework that guided the development of these interventions. The studies included in this review used non-randomized quantitative studies (n = 5), qualitative studies (n = 3), and mixed methods (n = 3) to evaluate pilot interventions. Analytic generalizations from these findings used mental health outcome measures and perceptions of refugees within their immediate environments. Largely qualitative studies suggest the benefits of engagement and education programs to improve mental health outcomes for refugees in the community setting. Most interventions (n = 7) targeted heterogeneous samples of resettled refugees from different countries of origin, including Somalia, Iraq, Iran, and Afghanistan. However, refugee participants within these study samples also included those from non-Muslim countries, including Burma, South Sudan, and others. While most studies had diverse samples of refugees, only a few (n = 4) focused on a single ethnic group   approach to developing their pilot study. In the Home Visiting Family Intervention Program, refugee community members were engaged across phases of the pilot and worked as interventionists, research assistants (RAs), and community advisory board (CAB) members  and focuses on the integration challenges experienced by newly resettled refugees. There is less attention to addressing mental health needs beyond the initial resettlement period and within the broader macro-level system. Muslim culture, religion, and mental health beliefs were generally discussed at the micro-level through education and de-stigmatization efforts. Although one intervention was implemented in a church setting, refugees’ religious affiliations were not reported. These findings suggest that developing culturally-tailored interventions targeting Muslim refugee groups within mosque settings is a critical gap in research—given that about half of the resettled refugees in the U.S. identify as Muslim.Mental health stigma remains a significant barrier to accessing mental health care among Muslim immigrants and is an essential aspect of developing culturally-tailored community mental health interventions Amri, . PromotiMoreover, previous research has long emphasized good communication and the need to address linguistic barriers as critical elements of interventions with resettled refugees  approaches have been identified as a methodology that has the potential to improve health and wellbeing in marginalized and under-resourced communities  times more likely to report a lifetime suicide attempt compared with Protestants (Awaad et al., Refugees from Muslim-majority countries represent an overlooked population in public mental health promotion, and we identify research gaps. There were limited randomized controlled trials that addressed the mental health needs of refugees from Muslim-majority countries. There is an urgent need to address the role of Islamophobia and perceived discrimination affecting this population. Muslim groups in the U.S. represent a religious minority vulnerable to discrimination that may exacerbate pre- and post-migration-related stressors (Alemi & Stempel, Although this study includes quantitative and qualitative research, combining the literature provides a more comprehensive understanding of the phenomenon and, thus, has the potential to inform future research and policy initiatives. A limitation in this study is in comparing studies because different measurements were used for the outcomes of interventions. It is also challenging to compare research findings on heterogeneous groups of refugees from other countries. For this reason, it may be beneficial to consider classifying refugees by region of origin rather than only country of origin.The ecological model is a useful framework for developing interventions for refugees because it highlights environmental levels of influence as targets for intervention development. Overall, these studies suggest that community-based mental health care using multi-sector collaborations effectively addresses psychosocial wellbeing among resettled refugees from Muslim-majority countries. Mental health may be improved by early screening of refugees upon arrival, providing culturally- and language-tailored education, raising awareness about mental health and services, and engaging refugees in intervention development. These elements promote engagement in developing more culturally tailored mental health programs. As resettled refugees in the U.S. become more diverse, there is a critical need for high-income countries to define, evaluate, and adopt culturally appropriate and effective interventions to address mental health in this population. Therefore, including refugee perspectives in research and partnership in intervention development and evaluation will be critical to promoting refugee mental health and wellbeing. This requires increased awareness, training, and funding, to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement.


Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Not only do the epidemiologic determinants and distributions of patients with ROP vary worldwide, but clinical differences have also been described. The Third Edition of the International Classification of ROP (ICROP3) acknowledges that aggressive ROP (AROP) can occur in larger preterm infants and involve areas of the more anterior retina, particularly in low-resource settings with unmonitored oxygen supplementation. As sub-specialty training programs are underway to address an epidemic of ROP in sub-Saharan Africa, recognizing characteristic retinal pathology in preterm infants exposed to unmonitored supplemental oxygen is important to proper diagnosis and treatment. This paper describes specific features associated with various ROP presentations: oxygen-induced retinopathy in animal models, traditional ROP seen in high-income countries with modern oxygen management, and ROP related to excessive oxygen supplementation in low- and middle-income countries: oxygen-associated ROP (OA-ROP). Retinopathy of prematurity (ROP) was first described in 1942 as an epidemic of blindness due to retrolental fibroplasia (RLF) among preterm infants, in which fibrous tissue formed behind the lens, the cause of which was originally unknown ,4,5, andFor the next two decades, RLF remained a rare event until a “second epidemic” of ROP occurred with improved survival of extremely preterm infants in the 1970s . In thesSince the quality of neonatal care has improved and neonatal mortality rates have decreased, ROP is a leading cause of preventable childhood blindness worldwide ,10. In LIt is now estimated that at least 15 million preterm infants are born per year, and 80% of these are born in low- and lower-middle-income countries (LMICs) such as India and sub-Saharan Africa (SSA) . With thIn a recent survey, SIBA found that the overwhelming majority of neonatal units in SSA cannot provide blended oxygen ,18. WithIn the “first epidemic” of ROP in high-income countries (HIC) with uncontrolled oxygen supplementation, RLF was largely eradicated prior to the development of indirect ophthalmoscopy or the first International Classification of ROP . Given sUnderstanding variations in animal models of ROP illuminates aspects of ROP pathophysiology that manifest differently worldwide. As animal models typically involve newborns rather than preterm animals, most animal models require simulation of a condition called oxygen-induced retinopathy (OIR) in term animals, many of whom have not completed retinal vascularization at birth but lack the typical comorbidities of human preterm infants .The current biphasic pathophysiology model of ROP was first postulated after studying kittens whose retinas are not fully vascularized until three weeks after birth. Exposing kittens to high oxygen, an initial hyperoxic phase of retinal vascular constriction and “obliteration” of growing retinal vessels was observed, which appeared directly related to the degree of immature vascularization and the magnitude of oxygen exposure. This “vaso-obliteration” from direct oxygen damage in “Phase 1” set the stage for “Phase 2,” when the avascular retina became relatively hypoxic due to poor retinal perfusion and increased oxygen demand in maturing avascular retinal tissue. The response to retinal hypoxia was abnormal re-vascularization, neovascularization into the vitreous, and subsequent retinal detachment .Although no animal model of OIR perfectly simulates human ROP, some species may be more closely aligned to certain features of ROP seen in humans. For example, in the mouse model, while retinal vascularization is already complete when pups are placed into a continuous high-oxygen environment, direct oxygen damage from hyperoxia causes vaso-obliteration, followed by intravitreal neovascularization, similar to what was seen in humans in the first and third epidemics of ROP . ObliterIn contrast, in the rat model, intermittent hyperoxia leads to delayed retinal vascularization, and vaso-attenuation is seen rather than vaso-obliteration of existing vessels. This model of vaso-attenuation may more closely align with the typical ROP currently seen in HIC with improved oxygen management. Unlike ROP seen in humans, however, neither model typically progresses to retinal detachment .As described by McLeod et al., the canine model shares many features of human ROP . In thisAlthough vasoconstriction has been more commonly used to describe typical ROP findings seen in HIC since the “second epidemic“ , the conSimilar to the animal models of OIR, the pathophysiology of ROP in preterm human infants also appears biphasic. Even without supplemental oxygen, the retinal environment of the preterm human infant at birth is relatively hyperoxic compared to the intrauterine environment . SupplemDespite decades of clinical trials regarding neonatal oxygen support, no consensus on the optimal level of oxygen supplementation/saturation has been achieved to date to decrease the incidence of ROP while minimizing other adverse events . After tEven with ideal oxygen management, some extremely preterm infants will still develop severe ROP . In HIC For infants who developed severe ROP, treatment was first shown to prevent retinal detachment in the 1988 cryotherapy for ROP study , with suSince 2011, treatment of ROP using intravitreal injections of anti-VEGF agents have further improved structural outcomes for infants with posterior stage 3 ROP in the presence of plus disease  or aggreIn contrast to the extremely small preterm infants who develop severe ROP in HIC despite judicious oxygen use, relatively large infants can lose previously vascularized retinas when exposed to 100% oxygen . AlthougWhile the demographics of infants with ROP vary worldwide depending on prenatal care and oxygen management , distincIn addition to A-ROP, obliteration of vessels posteriorly, more anterior shunt vessels, capillary non-perfusion, and islands of avascular retina within vascularized retina have also been described . FollowiSimilarly, “ROP-like” findings have also been described in allegedly low-risk infants  exposed to 100% oxygen in Mexico. In 28 eyes of 15 infants who underwent fluorescein angiography, the authors described two groups demonstrating “ROP-like” retinal pathology. The first included nonproliferative retinopathy with capillary non-perfusion, arteriovenous shunting, plus-like disease, and absence of the foveal avascular zone (FAZ) without leakage of dye. The second was proliferative retinopathy with leakage of dye at the border between the vascular and avascular retina and/or at the optic disc. In the first group, the authors hypothesized that lack of dye leakage, which is common in typical ROP, suggests direct damage to more mature vessels rather than a primary defect of angiogenesis . SimilarFollowing excess unmonitored supplemental oxygen, unusual features of ROP have also been observed in larger preterm infants in SSA. After exposure to 100% oxygen, infants born at 32 weeks’ gestational age with birthweights ≥1500 g have developed distinctive retinal pathology not specifically described in ICROP. As shown in Across LMICs, including India, Mexico, and SSA, these characteristic features of ROP seen, including capillary non-perfusion, dilated vascular loops, and arteriovenous shunts, seem to indicate vascular damage rather than a primary defect of vasculogenesis . In partWhile primary prevention of preterm birth is the most important factor in reducing the prevalence of severe ROP, careful oxygen regulation is critical in minimizing the risk of blindness due to ROP among very preterm and extremely preterm infants . To thisMost major clinical trials for ROP treatment ,35,36 haIn contrast to HIC, where many patients remain in the neonatal unit at the time of ROP treatment, patients in LMICs are frequently discharged home prior to developing severe ROP, and practical considerations must be taken into consideration when determining the timing and modality of treatment. Laser, a more definitive treatment than anti-VEGF treatment, may be most appropriate in circumstances where follow-up is uncertain, although readmission to the neonatal unit for sedation and apnea monitoring poses financial and logistical challenges. On the other hand, OA-ROP patients with diffuse posterior capillary loss and severe ischemia may fare better with anti-VEGF than laser treatment . When paFinally, recent studies in HIC have shown the potential to reduce the progression of ROP with biphasic oxygen targeting, although evidence for these protocols is lacking in LMIC. During the first epidemic of ROP, Thaddeus Szewczyk observed that rapid withdrawal of oxygen was associated with retinal venous engorgement . In a suIn conclusion, over 80 years and three epidemics, with the third epidemic now expanding across SSA, the complex interaction between oxygen and the developing retina continues to present new challenges. When RLF was first described, the indirect ophthalmoscope was not yet available, and RLF was eradicated prior to the first International Classification of ROP. Modern ophthalmic equipment  now offers an unprecedented window into the retina, which was not previously available during the first epidemic of ROP, and allows us to better describe characteristic features of OA-ROP, which may have been present but undocumented in those early cases of RLF. As SIBA is working to halt another wave of blinding ROP across SSA, we should consider adapting our current strategies for ROP management and validating them in the setting of OA-ROP to facilitate the identification of infants with potentially blinding disease. In the future, a consensus report specific to OA-ROP may be helpful.


Novel avenues are emerging in the therapeutic panorama taking advantage of nanomedicine. In this review we will summarize nanoparticle-based approaches and the efficacy that NPs have intrinsically demonstrated and how they are also decorated by biomolecules. Furthermore, we propose novel cargoes together with recent advances in nanoparticle design/synthesis with the final aim to specifically target the insidious CSCs population in the tumor bulk.Primary malignant brain tumors are the most common solid neoplasm in childhood. Despite recent advances, many children affected by aggressive or metastatic brain tumors still present poor prognosis, therefore the development of more effective therapies is urgent. Cancer stem cells (CSCs) have been discovered and isolated in both pediatric and adult patients with brain tumors . CSCs are a small clonal population of cancer cells responsible for brain tumor initiation, maintenance and progression, displaying resistance to conventional anticancer therapies. CSCs are characterized by a specific repertoire of surface markers and intracellular specific pathways. These unique features of CSCs biology offer the opportunity to build therapeutic approaches to specifically target these cells in the complex tumor bulk. Treatment of pediatric brain tumors with classical chemotherapeutic regimen poses challenges both for tumor location and for the presence of the blood–brain barrier (BBB). Lastly, the application of chemotherapy to a developing brain is followed by long-term  Malignant brain tumors represent the leading cause of cancer-related deaths during childhood . AdvanceEpithelial–mesenchymal transition (EMT) is one of the hallmarks of cellular plasticity; different subsets of CSCs, depending on their spatial location in the TME, exhibit different EMT phenotypes . MoreoveIn the GBM context, CSCs perform a metabolic adaptation depending on available tumor microenvironment factors (oxygen and nutrient), supplied by surrounding non-neoplastic cells, to support tumor growth and stemness features  Figure . CSCs reIn the last years, an application of nanoparticles (NPs) in cancer therapy has emerged . The terNPs used in cancer therapy can be obtained from organic and inorganic materials or by a combination of them. Besides the “raw” material employed, NPs can differ in size, structure and shape. These features can be tuned and depend on the approach used in the synthesis method employed. NPs can be obtained by using the top-down or the bottom-up approach. The top-down method starts with bulk material to obtain smaller units by disruption or decomposition that are then converted into NPs. Conversely, the bottom-up approach involves atom materials that are progressively “clustered” and then converted into NPs .In both approaches, the synthesis is achieved using physical methods , laser method  or by using chemical techniques . ResearcA crucial aspect of NPs is their ability to specifically target cancer cells, which improves therapeutic effectiveness while avoiding damage to normal cells. Two are the main mechanisms used by NPs to reach target sites: passive targeting and active targeting.For the first time, in 1986, Hiroshi Maeda and colleagues described the pathophysiological phenomenon that occurs in solid tumor vasculature known as the “enhanced permeability and retention effect” (EPR effect) . This meThe concept of active targeting is based on the direct interaction between ligands and receptors. This interaction is exploited by the active targeting of NPs on cancer cells, with high affinity and precision, reducing, on one hand, the cytotoxic effects on non-target cells, and, on the other hand, favoring the endocytosis by tumor cells ,38. NPs EGFR is a tyrosine kinase receptor (RTK) that interacts with a variety of EGFR family ligands regulating various aspects of cell growth and development. In the context of human brain tumors, EGFR is overexpressed in a subset of GBM and MB, and EGFR targeting is a promising approach for the NPs’ delivery ,41.EGFR-decorated NPs (EGFR-NPs) can be used as carriers for chemotherapy agents that are not able to cross the BBB, in physiological conditions , and that are subsequently internalized by target cells via receptor-mediated endocytosis. Several studies reported examples of EGFR-NPs strategies in glioma tumors. Liu and colleagues developed drug-loaded NPs functionalized with dual-targeting of EGFR (expressed on tumor cells) and of low-density lipoprotein receptor-relative protein-1 (LRP1) . The dual targeting exhibited enhanced BBB penetrability and tumor targeting effects, in both in vitro and in vivo glioma models . AnotherBeyond the drug delivery, EGFR is an attractive biomarker also for brain tumor imaging, acting as both a diagnostic and therapeutic agent. This method could be used for the real-time tracking of NPs in crossing the BBB, in the accumulation of NPs within target tissues and in providing shape contour-defining imaging of the tumor. This strategy also aids in the detection of distant metastasis and residual disease following incomplete surgical resection. Additionally, the measurement of the dilution of NPs could be used as a marker of the cell proliferation rate in the different areas of the tumor. Among imaging agents, fluorescent molecules are gaining popularity in clinical diagnostics ,46. HadjThe Tf receptor (TfR) is a transmembrane glycoprotein with two subunits linked by a disulfide bridge, each of which can bind to a molecule of transferrin, and functions to transport iron into cells. TfRs are widely expressed in the body, including red blood cells, hepatocytes, monocytes, erythrocytes, intestinal cells and normal brain cells  but also in brain cancers, making TfR an excellent candidate for the design of targeted therapy in brain tumors ,49. One Insulin was the first molecular “Trojan horse” described able to cross BBB and to deliver somatostatin . Subsequently, Shilo and colleagues developed insulin-targeted NPs and demonstrated, in in vivo models , the ability to cross the BBB five times more than controls . FurtherThe low-density lipoprotein (LDL) receptor (LDLR) is over-expressed in tumors (cells and blood vessels) and in the BBB, which allows the use of LDL-NPs for brain-targeted therapy. Various in vivo and in vitro studies reported an increased diffusion of LDLR ligands-functionalized NPs: LDL or Apolipoprotein E and B (ApoE and ApoB) ,66. A stMB is the most common malignant pediatric brain tumor arising in the cerebellum ,73. CurrThe main approach used to target the CSCs is the use of NPs-encapsulated drugs functionalized with antibodies/ligands targeting simultaneously two or more CSCs markers. Kim et al. developed high-density lipoprotein-mimetic nanoparticles (eHNPs) incorporated with apolipoprotein A1 (to enhance the BBB crossing) and anti-CD15 (a murine SHH MB cancer stem-like cell target) to achieve dual targeting and a SHH inhibitor (Sonidegib (LDE225)) to affect CSCs. eHNPs effectively crossed the BBB, delivered drugs and had powerful anti-neoplastic activity on the CSC population, demonstrated in different SHH MB models: cells in vitro, ex vivo in organotypic tumor slice culture and in vivo (model of a SmoA1 MB tumor-bearing mouse) . Also, BAmong gliomas, pediatric-type diffuse high-grade gliomas (pHGG) are malignant tumors which arise from different brain locations, such as the cerebral hemispheres, thalamus, brain stem or spinal cord . The exiNPs have many applications in medicine, but the main role in cancer treatment is certainly complex molecule delivery. We listed the principal cargoes, with different molecular and physico-chemical properties, in the brain CSCs cancer stem cells target strategy see also .Nano-delivery protects drugs from rapid degradation, reducing the effective therapeutic dose by minimizing the side effects of its intrinsic cytotoxicity. On the other hand, it carries the drug into the TME tumor microenvironment and promotes cellular uptake. The most common NPs-transported drugs in brain tumors are presented below. According to Infante et al., in the context of SHH-MB CSCs, NPs can be used to overcome the drugs’ poor water solubility. Glabrescione B (Gla B), an SHH inhibitor, was delivered in a self-assembling amphiphilic polymer micelle. This strategy demonstrated high drug loading and stability, low cytotoxicity, and tumor growth inhibition in allograft and orthotopic models of Hh-dependent MB . Kim J eTwo different methods of NP encapsulation were used based on the drugs’ properties: hydrophobic Cur was loaded in the cationic core, whereas hydrophilic DOX was in the outer shell polymer of NPs through electrostatic interactions. DOX and CUR were effectively delivered in vivo in a rat model of glioma and decreased the percentage of CSCs from 4.16% to 0.9%. This type of NP may be a promising strategy for delivering drugs with different physicochemical properties . In anotAs mentioned above, receptors overexpressed via cancer cells can be loaded on NPs for targeted therapy. CSCs possess receptors on their surface that have been used as markers to isolate and identify this rare population. The unique immunophenotype of CSCs permits their discrimination among the other cells. A typical marker of brain tumor stem cells is CD133, a glycoprotein promoting tumorigenesis, with spheroid formation ability. Several strategies to specifically target CD133 have been explored, including the use of antibodies, aptamers and immunotherapy . AptamerNPs loaded with drugs represent the main types of NPs currently tested in clinical trials for pediatric brain tumors. Indeed, the clinical translation of nanomedicines in this field is full of challenges and obstacles due to : (i) theSmall interfering RNA (siRNA)-based strategy silencing technology is an interesting tool to target proteins that are crucial in cancer diseases. Ideal target gene candidates in cancer therapy comprise oncogenes, proliferation, angiogenesis and cell cycle .Delivery of siRNA to the brain is challenging due to the low stability of the molecule and the accessibility of brain parenchyma . The nakThe use of NPs loaded with siRNA is reported in pediatric ependymoma and MB in an in vitro study. PEGylated chitosan-modified gold NPs were employed to deliver siRNA against Ape1 enzyme, which repairs DNA damage and sustains cancer cells upon damage induced via gamma irradiation . Cohen eNon-coding RNAs are emerging as critical regulators of biological processes in brain cancers .Among non-coding RNAs, microRNAs (miRNAs) have been identified as differentially expressed in pediatric brain tumors compared to normal/healthy brains, influencing survival and response to therapy. MiRNA signatures in pediatric brain tumors reveal how miRNA are differentially expressed in tumor with respect to normal tissue , in respMiRNAs associated with CSCs, differentially expressed in six pediatric solid tumor cell lines have been identified as potential targets . For insRestoration or inhibition of the above-mentioned miRNAs to the physiological levels could be a therapeutic strategy used to quell survival strategies adopted specifically by CSCs inside the tumor bulk. However, miRNAs administration requires a delivery system that ensures the molecules’ stability. Lopez- Bertoni et al. took a multiplexed approach by designing a polymeric nanoparticle loaded with two miRNAs, miR148a and miR-296-5p, that could regulate tumor growth in GBM . Poly-β The complex interplay between cancer and immune cells regulates tumor development: indeed, immune system activity has a key role in controlling disease initiation and progression and at the same time the immune microenvironment is highly influenced by tumor signaling. For these reasons, immunotherapy represents a powerful therapeutic approach for many types of cancer but has shown less benefit against pediatric brain tumors. The presence of the BBB as well as the high tumor heterogeneity and a suppressive immune microenvironment have limited the development of effective immunotherapeutic approaches. To this purpose, combining immunotherapy with nanotechnology could provide novel opportunities to improve pediatric brain cancer therapy. Different types of nano-immunoconjugates have been developed to reduce immunosuppression or improve immune activation in brain tumor sites ,109. CheThe BBB represents one of the main challenges in brain cancer therapy due to its low permeability to the majority of drugs. As a result, pre-clinical studies are mainly based on the identification of strategies to enhance BBB-crossing and brain tumor accumulation of drugs. 2D cell cultures have been widely used to study drug responses in vitro, but they are not able to fully recapitulate the tumor features and microenvironment and to properly evaluate the therapeutic potential of anti-cancer compounds. For this reason, recent pre-clinical studies have been focused on the development of 3D culture models to better mimic the tumor’s complexity as well as BBB–brain tumor interactions and to properly predict the in vivo treatment responses. Perini G et al.  used a 32O2, particularly enriched in the TME. Shen Z et al. [3O4/Gd2O3 hybrid NPs. The authors have demonstrated, in vitro and in vivo, that these NPs are able to cross the BBB and are internalized into cancer cells. In tumor cells they release Fe2+, Fe3+ and CDDP, that cooperate to give rise to the Fenton reaction, producing ROS and inducing cancer cell death. In the U87 MG orthotopic mouse model, a higher uptake of these NPs has been observed in the tumor site compared to the liver as well as an inhibition of tumor growth and extended survival time, demonstrating the efficacy of the ferroptosis therapy. In the last years, with the aim of improving the delivery of chemotherapy agents in brain cancers, NPs are widely used to build nanocomposite platforms and hydrogel that can be directly brain implanted. Scott et al. [Although drugs are the main tested and used cargoes in brain tumor nanotherapy, innovative approaches must be developed to increase drug delivery as well as to reduce toxicity; in this context, protein and ferroptosis therapies can be promising strategies. Protein therapy is a therapeutic approach that, due to the limited cellular uptake of the protein toxins, has the advantage to avoid the off-target cytotoxicity of chemotherapy agents. Jiang et al.  have genZ et al.  have synt et al.  have devt et al.  have loat et al. ,127. Indeed, the brain CSCs’ fate is also determined by an intricate multicellular network , extracellular matrix components and secreted factors. The crosstalk with TME components contributes to the maintenance of CSCs and the stimulation of tumor progression. Furthermore, the increase in energy demand of tumor bulk led to aberrant angiogenesis. Based on the technical advancements, the TME has been intensively analyzed because of transcriptomic, proteomic, metabolomic and spatial information. These innovative studies are giving new insights into how TME contributes to prognosis and therapy response ,129. ThuThe complete therapeutic success against pediatric brain tumors is strongly hindered by the potential damage that therapies may induce on a developing brain. Prospective preclinical and clinical research must consider this aspect and therapy design should be intended to ensure efficacy and reduce side effects. The use of NPs as a delivery method of drugs and other bioactive molecules offers clear advantages in accessing the anatomic location of these aggressive cancers. As extensively described and reported, NPs can indeed overcome the BBB obstacle when decorated with receptors that are overexpressed both by BBB-building cells and cancer cells. This strategy allows discriminating cancer cells from surrounding healthy ones, thus directing the therapeutic agents towards malignant cells. However, tumor bulk is heterogeneity in cellular composition and the presence of CSCs, a less differentiated cellular population, cause augmented resistance to surgery and radio/chemotherapy. Thus, the specific eradication of the CSC compartment requires understanding and operating on the increasing amount of biological information on CSCs and their unique properties should be considered for the specific eradication of the CSC compartment. Different brain cancer pre-clinical models are used to evaluate the efficacy of designed NPs, however, preclinical studies have been conducted mostly on adult cancers, such as GBM. Further investigations on pre-clinical models designed specifically for pediatric brain tumors need to be developed. The improvement of NPs’ features and the delivery of chemotherapy drugs and other molecules have a huge potential for future investigations in the eradication of the CSC compartment. The crosstalk between TME and CSCs should be deeply studied. Achieving these objectives may have the potential to develop nanomedicine-based personalized therapy to treat pediatric brain cancer. .The following key actors should be considered in a nano strategy to target brain CSCs such as: (i) NPs; (ii) the BBB; (iii) cancer stem cells; and (iv) pre-clinical models.It is fundamental to consider all these complex actors to make possible the development of nanomedicine-based personalized therapy to treat pediatric brain cancer stem cells.


Progress in engineering research has shifted the interest from traditional monolithic materials to modern materials such as fibre reinforced composites (FRC). This paradigm shift can be attributed to the unique mechanical characteristics of FRCs such as high strength to weight ratio, good flexural strength, and fracture toughness. At present, synthetic composites dominate the automotive, aerospace, sporting, and construction industries despite serious drawbacks such as costly raw materials, high manufacturing costs, non-recyclability, toxicity, and non-biodegradability. To address these issues, naturally occurring plant fibres  are being increasingly researched as potential reinforcements for biodegradable or non-biodegradable polymer matrices to produce environmentally friendly composites. In this study, sisal fibres were selected owing to their low production costs, sustainability, recyclability, and biodegradability. The hydrothermal ageing and mechanical characteristics of sisal fibre-reinforced epoxy (SFRE) composites were determined and compared with glass fibre-reinforced epoxy (GFRE) synthetic composites. Moreover, a first-of-its-kind numerical model have been developed to study the hydrothermal ageing and mechanical characteristics of SFRE, along with GFRE, using ANSYS software. Moreover, microstructural analysis of flexural tested GFRE and SFRE samples were carried out to identify the microstructural properties of the composites. Both experimental and numerical results exhibited an influence of short- or long-term hydrothermal treatment on the flexural properties of glass and sisal fibre-based composites. In the case of GFRE, the moisture uptake and fibre-matrix de-bonding existed, but it is less severe as compared to the SFRE composites. It was found that the dosage of sisal fibres largely determines the ultimate mechanical performance of the composite. Nonetheless, the experimental and numerical flexural strengths of SFRE were comparable to GFRE composites. This exhibited that the SFRE composites possess the potentiality as a sustainable material for advanced applications. Research and engineering advancements have redirected emphasis away from traditional monolithic materials and focuses towards novel materials such as fibre reinforced composites (FRC). The distinctive mechanical properties of FRC, including high tensile strength, strong flexural modulus, and impact resistance, have caused this massive change. A low-strength polymer matrix is reinforced with greater strength fibres ranging from glass to carbon. Although completely synthetic composites dominate the automobiles, aircraft, sporting goods, and infrastructure sectors , they haOn the other hand, polymer matrices are widely used due to their useful characteristics which include: lightweight, attractive optical properties, ease of shaping, high material stability and good thermal and electrical insulation. However, they also have limitations such as low modulus and low service temperatures. When fabricating an FRC, the polymer matrix must be carefully selected for its intended application since the matrix binds the individual fibres together into an integral unit, enhancing the load-carrying capability of the composite, and protecting the fibres from mechanical abrasion and environmental degradation. These polymers are amorphous or semi-crystalline in nature and consist of linear or branched chains bonded by strong intramolecular but weak inter-molecular forces; this means they can be moulded and remoulded easily by varying the heat and pressure. However, their applications in FRCs are limited due to their low service temperatures ,5. OtherSynthetic fibres can be made from inorganic and organic raw materials. Glass fibres, carbon fibres, aramid fibres, and boron fibres are the types of synthetic fibres that are widely used as reinforcing material . InorganNatural fibres, also known as lignocellulosic materials, have long been used as reinforcing materials due to their numerous benefits, including high strength, low density, biodegradability ease of handling, renewable resource, electric, thermal, and acoustic insulation, aesthetic aspects, and non-toxicity. In recent years, there has been an increasing interest in using natural fibres as a reinforcing agent in composites to build low-cost construction materials . Their rEach sisal plant leaf contains 1000 to 1200 bundles of fibres. These bundles consist of 4% fibres, 8% dry matter, 0.75% cuticle, and around 88% of water. The fibres are extracted by retting and scraping or by mechanical extraction. Once the fibres are extracted, they are washed with clean water to remove the leaf juices, adhesive solids, chlorophyll, and so on ,35. SisaThis phenomenon is quite prevalent for composites reinforced with natural fibres, in fact, according to Hu, Sun , the mecGlass fibres and natural fibres were used as a reinforcement material for epoxy resin as shown in In this study, low-cost epoxy resin  and hardener  were used. The resin has a low viscosity resin and is free of any residual solvent. Epoxy resin possesses aromatic groups, which makes it three times more powerful than polyvinyl resin. Moreover, it tends to withstand much greater impacts than either polyvinyl or polyester resin due to its high thermal stability. Hence, the epoxy resin had better mechanical properties than polyester or polyvinyl resins. Both fibres and the epoxy resin possessed effective adherence to each other, so it is proposed that the resultant composite will possess better mechanical characteristics than conventional glass fibre. The epoxy resin also exhibits better fiber-matrix interaction upon alkali treatment of reinforcing fibres. The hardener was used as a curing agent for curing epoxy at relatively low temperatures (room temperature). The widely used catalysts or hardeners are aromatic amines, aliphatic amines, and carboxylic anhydride. Both chemicals were provided by ATL composites Private Limited. As per the specifications, its pot life is nearly 2 h at room temperature and the demoulding time of almost 28 h. These properties make it very suitable to be used on a lab-scale and a commercial scale .Glass fibres were obtained as chopped sheet matting and they were used as received, without any chemical treatment. The fibres were sorted and cut into appropriate lengths for reinforcement, as shown in The different steps involved in the preparation of sisal fibres are shown in The final stage in preparing the sisal fibres was the alkali treatment using a 6% NaOH in a process referred to as mercerisation. Mercerisation enhances the surface roughness and increases the spread of reaction sites on the fibre as the cellulose in the fibre becomes exposed . Raw sis® software. Dimensional consistency is important for comparing the performance characteristics of different composites. The material used for the mould was ultrahigh molecular weight polyethene (UHMWPE) since it does not adhere to the epoxy and thus, fabricated composites can be separated easily from the mould. Moreover, this mould can be shaped using a machine with a high-speed water jet. The design information was sent to the QUT workshop, and the respective mould was received after fabrication. The principal mould for composite fabrication was designed using SolidWorksThe composite was fabricated using a UHMWPE mould having dimensions 80 mm × 10 mm (H × W) and a height of 4 mm as shown in The hydrothermal testing of GFRE and SFRE samples was carried out by following the ASTM D5229 standard . The comThe different stages of hydrothermal treatment are shown in ® 5MP USB Microscope Camera, Sydney, Australia, as shown in The microstructures of the GFRE and SFRE composite samples was analyzed using a DigitechThree-point bending tests were carried out according to ASTM D790-07  to invesThe machine applies the force onto the center of the specimen as shown in f = Flexural stress (MPa)σf = Flexural strain (mm/mm)εf = flextural modulus of elasticityEP = maximum load at a given point (N)L = distance b/w supports (mm)b = width of tested beam (mm)d = thickness of tested beam (mm)D = measured deflection (mm)m = slope (N/mm)Multiple flexural tests were carried out using GFRE samples, as shown in The results obtained by hydrothermal ageing of fibre composites were compared with the numerical studies conducted in modern finite element ANSYS software , as showA water absorption test was carried out on the GFRE and SFRE. The samples were kept in water for 24 h at room temperature. The results revealed that SFRE absorbed more moisture than GFRE. The moisture absorbed was as high as 4%, as shown in The flexural behaviour of GFRE samples under hydrothermal conditions is presented as a stress vs. deflection curve in The stress vs. deflection curve shown in The flexural strength of the GFRE samples treated under four different hydrothermal conditions is compared in It should be noted that, unlike the GFRE, hydrothermal ageing had no real effect on the SFRE samples up to C3, and the flexural strength only decreased by 7%. However, there was a large change under C4 and a sharp decline of 37% in flexural strength; the SFRE samples can perform well for 40 days under 100% humidity at a temperature of 60 °C. The variations in flexural strength can be explained based on the moisture uptake exhibited by natural fibres. Upon exposure to moisture, water penetrates by the capillary mechanism and forms hydrogen bonding with the hydrophilic groups of natural fibres. The mechanism of water uptake by sisal fibres in the epoxy composite presented elsewhere . This prThe flexural strengths of GFRE and SFRE under various hydrothermal conditions were modelled numerically using ANSYS software as mentioned before. The analysed models in the software are shown in A comparison of the experimental and numerical flexural strengths of the SFRE obtained in this study is also shown in ® 5MP USB Microscope Camera, Australia are shown in The microstructural images of the GFRE and SFRE composite samples obtained using the DigitechBoth experimental and numerical results revealed that the flexural properties of both types of GFRE and SFRE composites are affected quite significantly by short- or long-term hydrothermal treatment.GFRE experienced moisture uptake and fibre-matrix de-bonding, but not as much as SFRE composites. This means the amount of fibre is important since it determines the final mechanical characteristics of the composite.SFRE samples did not experience very much hydrothermal ageing up to C3 at a temperature of 60 °C and humidity of 100% during 1000 h; their experimental and numerical flexural strengths were comparable to GFRE composites.This study showed that SFRE exhibited moisture uptake and fibre-matrix de-bonding, as do GFRE, but with less severity, as their flexural properties are affected by short or long-term hydrothermal treatment. In addition, applications involving flexural loads in natural environments were found to be more reliable and durable with glass fibre-based composites.Microstructure analysis revealed the formation of bubbles and fibre pull-out mechanism in both GFRE and SFRE composites, especially with the SFRE, which were mainly responsible for the moisture absorption and de-bonding under flexural loading characteristics of GFRE and SFRE composites.This study presents a comprehensive study on the hydrothermal ageing and mechanical characteristics of SFRE composites and then compared them with the hydrothermal ageing and mechanical characteristics of GFRE composites. In addition, a first-of-its-kind numerical model has been developed to study the hydrothermal ageing and mechanical characteristics of SFRE, along with GFRE, through modelling and simulating with ANSYS software. Moreover, the microstructural properties of the composites were identified by microstructural analysis of flexural tested GFRE and SFRE composites. Based on the results of this study, the following conclusions can be drawn:


Structural and functional variability of human leukocyte antigen (HLA) is the foundation for competent adaptive immune responses against pathogen and tumor antigens as it assures the breadth of the presented immune-peptidome, theoretically sustaining an efficient and diverse T cell response. This variability is presumably the result of the continuous selection by pathogens, which over the course of evolution shaped the adaptive immune system favoring the assortment of a hyper-polymorphic HLA system able to elaborate efficient immune responses. Any genetic alteration affecting this diversity may lead to pathological processes, perturbing antigen presentation capabilities, T-cell reactivity and, to some extent, natural killer cell functionality. A highly variable germline HLA genotype can convey immunogenetic protection against infections, be associated with tumor surveillance or influence response to anti-neoplastic treatments. In contrast, somatic aberrations of HLA loci, rearranging the original germline configuration, theoretically decreasing its variability, can facilitate mechanisms of immune escape that promote tumor growth and immune resistance.The purpose of the present review is to provide a unified and up-to-date overview of the pathophysiological consequences related to the perturbations of the genomic heterogeneity of HLA complexes and their impact on human diseases, with a special focus on cancer. Three dThe study of patterns of inter-species conservation of these genomic regions uncovers interesting aspects associated with the evolution of the adaptive immune system. Some non-mammalian vertebrates, such as chickens, carry only a rudimental adaptive immune system in which only one MHC of each class is dominantly expressed, genes encoding proteins for antigen processing machinery (TAP and TAPBP) are very polymorphic and located next to class I MHC loci. This logistic genomic relationship suggests that the coevolution of these two clusters is of crucial importance for their function, likely defining their specificities for immune responses and resistance to pathogens , 23. ConThe evolutionary step allowing for the introduction of an antigen-based immune specificity is assumed to be the integration of RAG transposable elements in the jawed vertebrates’ genome, ancestral transposons at the basis of RAG1 and RAG2 recombinase activity governing the processes of V(D)J recombination, responsible for the diversity of antibody and T cell receptor repertoires (TCR) . This evIntroducing this evolutionary perspective on antigen-specific immunity is of crucial importance for understanding the immunogenetic risk for certain infectious and immune-related diseases and may help in tracking patterns of MHC dysfunction at the basis of cancer evolution or susceptibility to complex diseases.via a process of balancing selection, favoring alleles or allelic combinations able to sustain the burden of diverse pathogens to which human populations have been exposed to throughout their history  , 37, is ce versa Figure 3per extenso, by an individual with a given HLA genotype.This quantitative parameter has rapidly found applicability in many contexts due to its ability to capture the breadth of the immune peptidome presented by two different HLA alleles and, + T-cells compared to fully heterozygous individuals, defining an immunogenetic configuration that may reduce the chances to respond to checkpoint inhibitors   . Allelics (KIRs) . NK cells (KIRs) , 62, 63.s (KIRs) –68.Non-classical class I HLA molecules  have shown an important role in both immune surveillance and tolerance, essentially displaying regulatory functions towards NK and T cell activation. Although similar in structure to classical class I molecules, non-classical HLA class I alleles are oligomorphic and often exhibit a limited tissue distribution, modulated in inflammatory conditions. The decreased variability accounts for a limited immune peptidome repertoire and specific immunoregulatory functions. In physiological conditions, HLA-E binds self-peptides generated from the peptide leader sequence of class I molecules , participating in immune tolerance , 70. OthDownregulation of the antigen presentation machinery represents a paradigm of evasion from anti-tumor immune surveillance.Large genomic aberrations, fine somatic mutations, epigenetic silencing and transcriptional modifications involving directly the HLA region or genes encompassing antigen degradation, transportation and processing have been invoked across large cohorts of solid tumors and hematological disorders, all as a result of a common lynchpin: the selective pressure induced by the antigen-specific adaptive immune system.immunoediting deriving from the study of immune responses in tumor physiopathology. Cancer immunoediting is a complex network of events that characterizes the double capability of tumor immune surveillance to both coerce and endorse tumor growth, by inducing evolutionary pressures culminating in specific patterns of clonal selection . Such a process may last for a long time (equilibrium phase) during which tumor surveillance opposes cancer progression. However, the constant pressure operated by the immune surveillance on the instable cancer genome may culminate in genomic or transcriptional aberrations in HLA, antigen presenting and processing machinery- or checkpoint- related genes , allowing tumor cells to evade immune surveillance  of chromosome 6p21 –85 RecenSeveral other mechanisms underlying down-regulation or loss of HLA class I in human tumors have been described, resulting in many different phenotypes . Total lvia abolition of the presentation of immunogenic peptides is the CN-LOH of the non-matched HLA allele in allogeneic HCT. Such a complex genomic phenomenon, which occurs in the setting of mismatched HCT transplants, underlies the duplication of the matched allele replacing the mismatched gene in recipient-derived hematopoiesis, as mechanism of leukemic relapse (graft versus leukemia effect) is circumvented, allowing disease relapse.A paradigmatic example of how somatic aberrations in the HLA region can lead to immune escape  relapse , 91. In As mentioned above, the HLA-restricted antigen-specific immune response exerts a mechanistic pressure against unknown and non-self-peptides and, by this virtue, cancer cells harboring mutated, strong immunogenic proteins are eliminated. This process underscores an important pathophysiological aspect. Tumors with higher levels of immune infiltration may have  a lower mutational burden, in line with the observed better outcomes of patients whose cancers are characterized by stronger immune signatures –94. The In tumor biology, the down-modulation of HLA-restricted immunity becomes an example of evolutionary adaptation established by mutated cells undergoing immune selection. In this context, one of the multiple outstanding issues is how to treat cancer patients who present with “the stigma” of immune escape, i.e. whose tumor has developed one or more immune evasion phenotypes. For instance, in case of disease recurrence after allo-HCT, a lower response rate to donor lymphocyte infusion and other immunomodulatory strategies has been shown in case of loss of the mismatched haplotype, with a slight improvement in survival when patients receive a second transplant from a different donor, thereby re-establishing the HLA heterogeneity balance , 97. AlsAll these observations are in line with the inconsistent immunotherapy efficacy across cancer cohorts and with the unmet clinical need for providing non-HLA restricted immunomodulatory strategies overcoming the above-mentioned issues. An important example of non-HLA restricted immunotherapy is represented by genetically engineered T cells (TCRs and chimeric antigen receptor -CAR- T cells), or bispecific T cell engager therapies (BiTE) whose specificity is designed to be directed against precise tumor neoantigens bypassing MHC restricted epitope presentation by means of modified T cell surface molecules able to target specific overexpressed cancer antigens (i.e. CD19 in lymphoproliferative disorders) , 99. NonAs said, NK cells exert their anti-tumor activity in a way mostly independent of the presentation of specific neoantigens, being still able to discriminate between healthy and transformed cells. Due to this ability, there is a rapidly emergent interest in developing engineered CAR-NK cells as a strategy of cancer cellular-therapy. The short life, the safety profile particularly with regards to the absence of major cytokine release, and the innate cytolytic activity against a great variety of cancers render CAR-NK-based platforms particularly attractive for implementation in different clinical settings of onco-hematology –103.via HLA-restricted pathways, as a mechanism of “adaptive” rescue. Such clonal selection obviously requires some level of cell division, and can thus only operate in tissues with regenerative activity, but it might be worthwhile to explore this in appropriate autoimmune settings beyond IAA.Clonal evolution can theoretically occur in all types of cancer where the immune system exerts an initial control on the neoplastic cells. One could speculate that similar mechanisms of immune escape may be present at a certain level also in some autoimmune disorders. A prototypic example in this direction is represented by idiopathic aplastic anemia (IAA), an immune mediated bone marrow failure disease characterized by T cell mediated destruction of hematopoietic stem cells, translating in failure of hematopoiesis , 105. HeMolecular dysfunction of individual HLA heterogeneity constitutes a common mechanism at the basis of a number of pathological processes encompassing infectious, neoplastic and possibly autoimmune pathophysiology. On one hand, the assessment of germline HLA genomic and structural diversity may have important prognostic implications as in the case of risk profiles associated with response to immunotherapy, or the propensity to develop certain autoimmune disorders. On the other hand, somatic loss of heterozygosity or reduced presentation of immunogenic peptides may configure patterns of immune escape in a variety of disorders of both neoplastic and non-malignant nature. Given the importance in human diseases, the analysis of HLA genotypic configurations and the relative somatic dysfunction should be integrated in clinical practice, especially in the immunology and onco-hematology fields, where their assessment may help in refining patients’ prognosis and the suitability for immunomodulatory agents’ interventions.SP reviewed available literature and wrote the manuscript. CG, MR, VV and TL provided critical discussion and revised and edit the manuscript draft. All the authors conceptualized the study and agreed to the published version of the manuscript.We acknowledge the following sources of funding: AA & MDSIF, VeloSano Pilot Award, and Vera and Joseph Dresner Foundation–MDS (to VV), Italian Society of Hematology, Italian Society of Experimental Hematology, Fondation ARC pour la recherche sur le cancer (to SP), American-Italian cancer foundation (to CG), Deutsche Forschungsgemeinschaft  – 437857095 (to TL).We thank all the reviewers who contributed with constructive comments to improve this work.TL is co-inventor on a patent application for using HED as a prognostic marker for immunotherapy success.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The dynamics of rural human-environment systems in developing countries have increasingly been attracting attention. Agent-based modeling (ABM) is a valuable simulation tool for detecting complex feedback loops in rural human-environment systems with a ‘bottom-up’ approach. However, such models require the prerequisite analysis of household typology to simulate households’ decision-making process, where a gap exists between having accurate classification criteria and a simplified modeling framework. This study aimed to develop a household typology for two selected counties in southwest China based on multivariate analysis techniques and the classification tree method. Four categories of socioeconomic variables, including labor conditions, resource endowments, economic status, and social connections, were screened as possible factors impacting agriculture practice decisions. The results showed that household diversification in the study area was mainly determined by diversified livelihood strategies of off-farm work, livestock breeding, subsidy dependence, and traditional planting. Five distinct household types were identified: non-farm households, part-time households, livestock breed households, subsidized households, and traditional planting households. The household types were associated with specific cropland use behaviors, and their decision-making behaviors were verified with bounded rationality theory . The quantitative classification criteria obtained in this study were clear and could be easily identified and used by ABMs. Our study provides a basis for further simulation of the complicated rural human-environment systems in southwest China. Currently, China is putting significant efforts into solving its environmental problems while reducing poverty in especially rural areas ,2. It isAgent-based modeling (ABM) with its ‘bottom-up’ approach is increasingly used as a powerful tool for modeling complex changes in rural human-environment systems ,10. The Several studies have used various criteria and methods to describe diversity in rural households or farmers, which varies greatly depending on the purpose of the classification. Some authors qualitatively defined household types based on a single criterion or several criteria. For example, the proportion of non-farm income was used in China to study household livelihoods status and its influence on regional land use change . Baccar Most ABM studies classified household types using empirical methods for the purpose of model simplification, but few of them tried to differentiate households quantitatively. For example, farmers in the American Corn Belt were classified into four types based on factors influencing their conservation practice decision-making using a simple mutually exclusive method . HousehoOur literature review found that for the purpose of ensuring that each type of household agent has significant differences in their decision-making, and obtain relatively simple classification criteria as required by the ABM simulation, combined qualitative and quantitative typology analysis is needed based on the characteristics of or the factors impacting household agricultural production decisions. Thus, the objectives of this study were (a) to present an application of multivariate analysis techniques and the classification tree method for household typology identification, (b) to evaluate the reliability of the method by conducting statistical tests on their actual cropland management behaviors within-group variance, and (c) to discuss strengths and weaknesses of the method used for rural studies, especially ABM studies. The dataset used in this study was derived from a baseline survey in two Southwestern China counties of Baoxing and Puge, designed to characterize the plot-scale differences of cropland disturbance intensity and its environmental consequences ,7.2, had an estimated population of 59,000 inhabitants and 21,500 households at the end of 2014, and the population density was approximately 19 per square kilometer [2, had an estimated population of 199,000 inhabitants and 56,000 households in 2014, and the population density was approximately 104 per square kilometer [Baoxing county is located at 102°28′–103°02′ E and 30°09′–30°56′ N, has an area of 3144 kmilometer . Baoxingilometer . Puge isilometer   reviewed the complex causality between household’s demographic characteristics and their environmental behaviors . Zhang eAgricultural system diversity is also deeply affected by household resources endowments , which iEconomic conditions and income strategies reflect differences in farmers’ purchasing power for agricultural materials, which directly affect agricultural production decisions ,31. IndiSeveral multivariate techniques are frequently applied for classification, including Factor Analysis (FA), Multidimensional Scaling (MDS), Principal Component Analysis (PCA), and Cluster Analysis (CA). PCA and CA methods are commonly combined to carry out quantitative classification research in rural areas ,32,33. HCATPCA for dimensionality reductionBecause the CATPCA method can handle nominal, ordinal, or numerical variables simultaneously, and can also apply to non-continuous variables , it was Two-Step clustering method for household classificationThe basic assumptions for the two-step clustering method are that continuous variables must be normally distributed and categorical must be multi-nominally distributed; and variables must be independent . FortunaClassification tree for obtaining classification criteriaA ‘classification tree’ was chosen as the most appropriate method to construct the typology in this study. Based on Boolean statements, indicators with the most obvious differences between clusters were used as classification criteria in the classification tree method to construct typologies. The quantitative classification criteria were based on the results of CATPCA, two-step cluster analysis, and existing qualitative classification criteria ,41. NameIn order to verify the effectiveness of our household typology, differences in households’ actual cropland management behaviors were analyzed. Cropland use behaviors were separated into physical and chemical disturbance behaviors  Table 2Table 2, The variables related to factors influencing household decision-making were distributed into two components by CATPCA . The TotThe Two-Step cluster algorithm also suggested a five-cluster solution . The quaThe classification tree method was used to obtain quantitative classification criteria based on Boolean statements defined by the top three variables: NIR greater than 50% and 90%, LIR greater than 50 %, and SIR greater than 50%. The quantitative classification criteria were supported by the results from the CATPCA, two-step cluster analysis , and exiOur results showed that household types in the Baoxing County were mainly part-time and non-farm households, accounting for 32.3% and 25.7%, respectively. In Puge County, on the other hand, traditional planting household dominated, accounting for 53.8% .Specific profiles of each household type were described with the eight most influential variables and are presented in Non-farm households (type 1). These households had the highest level of cash income, with the highest NIR and the lowest LIR and SIR. The labor force in these households had much higher education than in other households and were usually more inclined to take part in the Grain for Green Project, as confirmed by their high level of SLR.Part-time households (type 2). These households had the second highest CI levels in the study area, and NIR was second only to the non-farm households. In most cases, the young and middle-aged labor force engaged in non-farm work, whereas the old labor force engaged in planting at home. Resource endowments in these households were the lowest, with the lowest levels of CLA and FLA, and they were more inclined to take part in the Grain for Green Project, with the highest level of SLR.Livestock breed households (type 3). These households had the second lowest CI levels in the study area. Livestock breeding was the basic livelihood strategy, and they generally did not consider non-farm work, as verified by their low level of NIR.Subsidized households (type 4). These households had the lowest CI levels in the study area, with the highest proportion of subsidy income. Labor conditions in these households were the poorest, with the smallest labor force and the lowest education level. Traditional planting and breeding were also their important sources of livelihoods beside subsidies. Due to the limited labor force, their willingness to participate in the Grain for Green Project was also very strong, as indicated by the second highest level of SLR.Traditional planting households (type 5). These households had the highest resource endowments in the study area, as reflected by the highest levels of FLA and CLA. Coupled with their low level of SLR, this reflected that their livelihoods were more dependent on traditional planting. Because cash crop planting was their main livelihood strategy, their cash income levels were not as low as expected.The identified household types were associated with specific cropland physical disturbance behaviors, and generally showed the same trends between planting food crops (corn) and cash crops (tobacco). The statistically significant descriptors are shown in The identified household types identified were associated with specific cropland chemical disturbance behaviors and showed different trends between food and cash crops. The statistically significant descriptors are shown in Many household-level socioeconomic factors have been found to be related to household decision-making behaviors. However, for simulating the complex changes to rural human-environment systems using ABM, indicators used for the classification of households should be as simple as possible . In thisCluster analysis is an effective method for typology studies ,23,33,42As opposed to the current methods, however, we obtained classification criteria based on the classification tree method with reference to the top three indicators identified by two-step clustering analysis . The appBased on the current knowledge, we screened 21 social-economic indicators that potentially influenced households’ cropland use behaviors . HoweverOther research shows that cropland use behaviors in For cash crops planting, the opposite trend was observed within the identified five household types. Traditional planting households had higher yield-increasing inputs; part-time households had higher labor-saving inputs; and subsidized households had the lowest labor-saving and yield-increasing inputs . BecauseFor further ABMs studies, the household types obtained here can be used as a state variable of household agents, which on the one hand determines how household agents differentially allocate their labor force to each livelihood strategy, on the other hand reflects their disparate willingness to abandon or use cropland. Because labor force allocation may be different each year due to market fluctuations and policy changes , regionaThe typology methods used in this study enabled the identification of household groups, and the Kruskal–Wallis test showed that most variables representing household cropland use behaviors differed significantly among the identified groups. These indicated that the identified household types were distinct and had different agricultural production decisions. Because it was based on a reduced set of variables and a concise classification criterion, it was also easily used through the rapid household questionnaire survey with a limited set of questions. Thus, our typology can be used not only in future ABM studies, but in further studies exploring the diversity of rural household livelihoods and the dynamic changes in households’ environmental behaviors. It should be noted that the identified household types may differ greatly because of the varied purpose of classification. In addition, the actual household types in different regions may vary greatly due to different rural development backgrounds. In this regard, this study can also be viewed as an exploratory methodology that could be improved upon in additional studies.This study generated a household typology in typical counties of Southwest China to simulate the complex processes of agent decisions in ABM, using the combined methods of multivariate analysis and classification trees. Household agents in the study area were classified into five different groups based on the top three household socioeconomic variable indicators. The classification criteria were clear and could be easily identified and used by the ABM. The identified household types were associated with specific cropland use behaviors, and their decision-making behaviors were verified following the bounded rationality theory with profit maximization as the primary goal. Our study thus provides a basis for the further simulation of the complicated rural human-environment systems using ABM methods and offers a framework for the further study of rural livelihoods and environmental protection. However, the actual household types in different regions may vary greatly due to different rural development backgrounds; thus, this study should be regarded as a methodology analysis that could be used in other regions rather than using the quantitative classification criteria directly.


Brain tumors represent the leading cause of disease-related mortality and morbidity in children, with effective treatments urgently required. One factor limiting the effectiveness of systemic therapy is the blood-brain-barrier (BBB), which limits the brain penetration of many anticancer drugs. BBB integrity is often compromised in tumors, referred to as the blood-brain-tumor-barrier (BBTB), and the impact of a compromised BBTB on the therapeutic sensitivity of brain tumors has been clearly shown for a few selected agents. However, the heterogeneity of barrier alteration observed within a single tumor and across distinct pediatric tumor types represents an additional challenge. Herein, we discuss what is known regarding the heterogeneity of tumor-associated vasculature in pediatric brain tumors. We discuss innovative and complementary preclinical model systems that will facilitate real-time functional analyses of BBTB for all pediatric brain tumor types. We believe a broader use of these preclinical models will enable us to develop a greater understanding of the processes underlying tumor-associated vasculature formation and ultimately more efficacious treatment options. The BBB is established through physical and functional interactions of different cell types, referred to as the neurovascular unit (NVU) –3, incluMedulloblastoma (MB) is the most common type of malignant pediatric embryonal tumor that forms in the cerebellum . Large sin vivo. Together these studies point to the influence of tumor genotype on the development of an intact BBTB and reinforce that in vivo preclinical models of MB faithfully recapitulate the intratumoral and intertumoral heterogeneity of the BBTB phenotype of primary MB.Elegant preclinical studies are consistent with clinical observations, with heterogeneous BBTB permeability observed in various widely used preclinical MB mouse models. High-resolution dynamic CE-MRI analyses was recently used to evaluate the integrity and permeability of BBTB in a murine genetically engineered mouse model (GEMM) of SHH MB and patient-derived orthotopic xenograft (PDOX) models from SHH and Gp3 MB . BBTB inVarious alterations in a number of components of the NVU is likely contributing to BBTB dysfunction in MB. The degree of BBTB permeability observed by MRI was shown to be correlated to differences in the structural and subcellular features of tumor-associated vasculature . Intact VEGF), a principal angiogenic factor, in cell line xenograft Gp3 models and Gp3 MB patients  mouse models, all revealed a minimal change in vascular phenotype within tumors compared to normal brain (Diffuse Intrinsic Pontine Glioma (DIPG), more recently termed Diffuse Midline Glioma (DMG) , is a hial brain . The ECsal brain , 65. Moral brain .The studies described here have begun to unravel the complexity of BBTB in MB and DMG and the relevance of modifying BBTB function for more effective, targeted treatment. However, before we can do this, a better understanding of the processes underlying tumor vascularization and the tumor-specific changes in NVU composition and BBTB function are urgently required. Next, we describe a range of innovative preclinical models that can be utilized to accelerate this understudied aspect of pediatric brain tumor biology.Preclinical mouse PDOX and GEMM models of MB and DMG are widely used as the gold standard for preclinical testing of novel therapeutics –69. StudIn murine models, non-invasive techniques such as positron emission tomography (PET), computed tomography (CT), and more commonly MRI, have uncovered changes in the BBTB . Howeverex utero, allowing live visualization of organs and cells during zebrafish development. Although structural similarities of zebrafish and human proteins remain to be determined, whole genome sequencing has identified that approximately 80% of disease associated genes in humans are conserved in zebrafish . When placed on a p53 null background, these rb1 knockout fish developed malformations of the skull and lesions on the eye. Histological analysis of the lesions revealed that the majority resembled CNS-PNET tumors and others were glial-like (sox10 expressing cells (In the context of brain cancer, zebrafish provide a powerful model to monitor dynamic interactions between tumor cells and NVU cell types, therefore determining what pathological changes might be contributing to BBTB malfunction. To date a small set of genetic zebrafish models have been established to study pediatric brain tumors –102. Oneng cells . This reng cells . Human dng cells . One chang cells –106. Wheng cells , 108.Nevertheless, we propose that with well-established methods in place to visualize NVU cell types in the zebrafish brain –99 and din vitro cell culture methods have been used in basic research for many years to study mechanisms of cancer cell growth and evaluate drug efficacy. Various pediatric brain cancer cell lines are currently commercially available, with the most widely published MB models such as D283MED, D341MED, D425MED, UW228-2 and DAOY propagated in vitro for decades. As seen with other widely utilised brain cancer cell lines (Traditional ll lines , it is ill lines , limitin3D spheroid models are being increasingly developed for a variety of pediatric brain cancers , 112 repin vitro platforms in conjunction with animal models will be highly important to better understand the molecular mechanism of such ailments and providing novel therapeutics that have been thoroughly tested to target tumors in the presence of a heterogeneous BBTB.Although 3D BBB-tumor co-culture models have not yet been implemented to study tumor spheroids derived from pediatric brain cancer, data from adult brain tumors supports the feasibility of this approach , 127. FoIneffective drug delivery is thought to be a contributing factor underlying the failure of novel therapeutic strategies in early phase clinical studies after demonstrating significant preclinical anti-tumor efficacy. Understanding the plasticity of the BBTB by utilizing complementary pre-clinical models will help to overcome one of the biggest barriers to effective intratumoral drug penetration. This review has summarized recent discoveries that emphasize the relevance of BBTB heterogeneity in pediatric brain tumors. We propose that, in order to better understand how BBTB differences arise and what the functional consequences are for treatment, multi-disciplinary approaches that utilize innovative pre-clinical models hold great potential.EM, SD-M, SS, LG and AL conceptualized the idea of this review and co-wrote the manuscript. All authors contributed to the article and approved the submitted version.


Charge, size, nature of neurotherapeutics, and formulation excipients influence the effective and targeted drug delivery using nanocarriers via the nasal route. This article elaborates on the recent advances in nanocarrier-based nasal drug delivery systems for the direct and effective brain delivery of the neurotherapeutic molecules. Additionally, we have attempted to highlight various experimental strategies, underlying mechanisms in the pathogenesis and therapy of central nervous system diseases, computational approaches, and clinical investigations pursued so far to attain and enhance the direct delivery of therapeutic agents to the brain via the nose-to-brain route, using nanocarriers.Alzheimer’s disease (AD) is one of the neurological ailments which continue to represent a major public health challenge, owing to increased life expectancy and aging population. Progressive memory loss and decrease in cognitive behavior, owing to irreversible destruction of neurons along with expensive therapeutic interventions, call for an effective, alternate, yet affordable treatment for Alzheimer’s disease. Safe and effective delivery of neurotherapeutics in Alzheimer’s like central nervous system (CNS) disorders still remains elusive despite the major advances in both neuroscience and drug delivery research. The blood–brain barrier (BBB) with its tight endothelial cell layer surrounded by astrocyte foot processes poses as a major barrier for the entry of drugs into the brain. Nasal drug delivery has emerged as a reliable method to bypass this blood–brain barrier and deliver a wide range of neurotherapeutic agents to the brain effectively. This nasal route comprises the olfactory or trigeminal nerves originating from the brain and terminating into the nasal cavity at the respiratory epithelium or olfactory neuroepithelium. They represent the most direct method of noninvasive entry into the brain, opening the most suitable therapeutic avenue for treatment of neurological diseases. Also, drugs loaded into nanocarriers can have better interaction with the mucosa that assists in the direct brain delivery of active molecules bypassing the BBB and achieving rapid cerebrospinal fluid levels. Lipid particulate systems, emulsion-based systems, vesicular drug delivery systems, and other nanocarriers have evolved as promising drug delivery approaches for the effective brain delivery of anti-Alzheimer’s drugs with improved permeability and bioavailability  Alzheimer’s disease (AD) is considered a fatal irreversible neurodegenerative disorder mainly affecting the brain . AD showAcross the globe, 50 million people (approximate) more than 60 years of age are suffering from dementia and 50–70% of population from AD . The numDiverse drug molecules are developed for treatment of various CNS ailments like the following: treatment of epilepsy: amiloride and oxcarbazepine.Treatment of schizophrenia: olanzapine, risperidone, and quetiapines.Treatment of Alzheimer’s disease: rivastigmine and memantine.Treatment of Parkinson’s disease: resveratrol and selegiline.Treatment of bacterial meningitis: chloramphenicol.These currently available/approved drugs have restricted access to the brain due to the presence of blood–brain barrier (BBB), thus creating a significant challenge in attaining therapeutic effectiveness. In addition, availability of minute pores and drug efflux transporter (P-glycoproteins) systems in the BBB leads to a decrease in the therapeutic concentration of compounds in the central nervous system (CNS) . The satThe most important causative parameter and efficient strategy in AD management is still not known, although there is sufficient literature works on the basic biological and clinical neuropathology of AD . The chaIn the last five decades, numerous novel compounds and treatment methods are clinically studied in the management of CNS ailments with a huge investment by pharmaceutical industries. However, merely 8% of these antipsychiatric products reached the market . Most of1) Genomics: genomics opens the doors for efficient delivery of neurotherapeutics, but it requires significant individualization depending on the condition. The formulation of molecules targeting individualized therapy is time-consuming and costly. Each molecule needs to meet regulatory guidelines involving studies in large population .2) Specificity: the major challenges associated with neurotherapeutics start with complex, anatomically specific, and temporally intense behavior of the target organ, that is, brain functioning. .3) Animal models: the selection of the animal model for CNS disease is critical as it is very essential to understand their validities such as pace, and predictive and constructive validities along with abnormalities in selected animal models .4) Trial conduct: conducting the clinical trials of neurotherapeutic formulations in resemblance to other trails is challenging. Clinical trials are very common to the project management tasks, but neurotherapeutics trials consist of unusually intense challenges .Currently, six drugs including the recently investigated monoclonal antibody Aduhelm™ (Aducanumab) used in the management of AD are approved by the US Food and Drug administration (FDA) . These cHence, there is a necessity to explore nanoplatforms to tackle these problems.The various drug delivery mechanisms utilized to disrupt or overcome the BBB and increase drug molecule transport across this barrier to the CNS have been investigated in the management of AD. These approaches are classified into invasive, noninvasive, and current BBB disruption therapies . InvasivThe intranasal pathway for brain targeting is useful in the management of different neurodegenerative diseases like Alzheimer’s, schizophrenia, Parkinson’s, epilepsy, meningitis, and brain tumor. The common intranasal transport pathway for brain targeting includes passive partitioning, carrier-mediated transport, and paracellular pathway . It also• With significant advantage in crossing the lipophilic BBB, particle manufacturing procedures for lipid nanoparticles are easy to scale up. Lipidic nanoparticles easily penetrate the BBB.• Pharmaceuticals are preserved from chemical and enzymatic breakdown by lipidic nanoparticles. They can also help nullify the negative effects of some pharmaceuticals.• Diverse active molecules have been successfully targeted to brain tissue using nanoparticles .• Without surface modification or functionalization, lipidic nanoparticle medicines can be transported directly to the CNS (which may affect the efficacy). This technique can be employed in a variety of ways, including intradermal, oral, nasal, and parenteral delivery.• Nanoparticles, having compact morphology, easily penetrate through capillaries and are taken up by biomolecular cells, allowing for an effective medicine at the targeted areas in the body.• Biodegradable polymers used in the formulation of nanoparticles provide prolonged medication release at the targeted location for days or even weeks, following injection .The existence of the BBB limits therapeutic development in AD. More than 95% of small biomolecular medicines and all of the large molecular pharmaceuticals fail to pass across the BBB. The difficulty of transporting medications over the BBB is one of the most significant concerns and obstacles in the development of novel therapies and therapeutic measures for AD . The negvia absorptive mediated transport. Nasal epithelium possesses negative charge, and hence, cationic lipid nanocarriers can demonstrate better interaction and bioadhesion during intranasal delivery. Few reports have shown an effective nose-to-brain delivery by neutral- and anionic-charged lipid nanocarriers via endocytic or transcellular mechanisms , poloxamers, cholesterol, polyethylene glycol (PEG), capmul MCM, precirol, lecithin, and compritol 888 ATO along with the size and charge on lipid excipients have a profound impact on the nose-to-brain delivery of neurotherapeutic drugs . Positivchanisms .SLNs are thought to be desirable colloidal drug delivery methods for brain targeting. The ability of these formulations to cross the BBB, which enables the medicine to enter into the CNS in useful quantities, is one of the most intriguing problems they face. High drug concentrations are required for neuroprotection, a situation that is challenging to attain due to efflux processes that move treatments from the brain to circulation and, most importantly, because medications are unable to penetrate the BBB. SLNs have emerged as a promising candidate in terms of safety, stability, low toxicity, large scale production, and drug loading. Many researchers attempted to address this problem in recent years using medicinal chemistry-based strategies and modern drug delivery systems .In vitro and in vivo testing revealed that SLNs of piperine coated with polysorbate-80 reduced superoxide dismutase levels, reduced cholinergic degradation, caused minimum immobilization in the animal, and reduced the presence of amyloid plaques  attractive platforms for successful transport of bioactive molecules across the BBB. NE as a viable medication delivery strategy for the therapy of neuronic illnesses is enabled by innovative surfactants and cosurfactants. Their tiny particle size (50–500 nm) allows for homogeneous dispersion of medicines and a larger payload for site-specific delivery . Intranavia circulation and cellular absorption in the brain cells. The vesicular morphology of liposomes helps in delivery of both hydrophilic and hydrophobic neuroactives. The liposome research has shown that they have a wide range of pharmacological activities like anti-ischemic, neuroprotective, antiepileptic, and antibacterial properties. These formulations have been investigated as cargos for therapeutic import across the BBB by active targeting . After a 2-day nasal permeation, the niosomes’ efficacy and biocompatibility were established. delivery .Geophila repens is a climbing plant found to have anticholinesterase qualities and hence is used for improving memory performance. The antioxidant capabilities of Geophila repens leaves were examined and found to be significant, presumably attributed to the prevalence of triterpenoids, phenolic chemicals, and flavonoids. Systemic absorption of phytochemical compounds via the BBB is challenging for developing phytoformulations for AD therapy. To overcome these concerns, the Geophila repens phytosome-loaded intranasal gel was prepared with better nasal–brain penetration capabilities. In this experiment, transcutol was used as a permeation enhancer, while hydroxypropyl methyl cellulose (HPMC) was used as a gelling agent. During ex vivo studies, this gel exhibited significant penetration across the nasal mucosa without any irritation. Furthermore, it had a similar proportion of acetyl cholinesterase inhibition to donepezil (97%) but was higher than 20% from normal Geophila repens leaves’ gel and accelerated angiogenesis, indicating that it has the potential to change the cognitive behavior of Alzheimer’s condition in patients , owing to the diffusion mechanism  are inorganic materials made of graphite sheet tubes of nanosized dimensions. CNTs can be either single-walled or multi-walled, with open ends or may be closed with fullerene caps. Recently, multi-walled carbon nanotubes (MWCNTs) have been found to exert neuroprotective effects by the modulation of vital neurotrophic factors when delivered al route . Electroal route . Thus, Mal route . CNTs aral route . In caseal route .via olfactory and trigeminal systems, bypassing the BBB (Nanomicelles are nanosized carriers (particle diameter 10–100 nm) molded by self-association of amphiphilic surfactants or copolymers in aqueous solutions . It comp the BBB . PEGylat the BBB . Thus, n®  device uses hydrofluoroalkane as a gas propellant to deliver liquids and powders to the olfactory epithelium to ensure consistent dosing with better brain bioavailability. Electronic atomizers generate vortex of nebulized particles to enhance the uptake in the upper nasal cavity with minimum pharyngeal deposition. One such developed device is ViaNase™  for precise dosing and better nose-to-brain delivery of insulin. This device enhances cortical blood flow, vasoreactivity, and cognition.Powder dosage forms and specially designed devices are currently explored for better nasal delivery of vital actives as these approaches can overcome the primary barriers in the olfactory epithelium, namely, the nasal valve and the nasal vestibule. The particle size in the range of 1–10 μm is reported to be suitable for better olfactory deposition . Some ofvia the intranasal route was assessed and found to illustrate persistent memory recovery, with significant decrease of plaques encircled by β-amyloid oligomers. Likewise, researchers are now exploring the nose-to-brain delivery approach for improving feasibility, success rate, and clinical success of simulated nasal casts, gene delivery, and vaccine approaches in the neurotherapies of AD, dementia, or Parkinson’s disease. Clinical studies about intranasal delivery of biomolecules, stem cells, and vaccines are summarized in ClinicalTrials.gov database . More than 130 trials are in phase 1/2/3. However, there has to be more evidence for the ease of clinical translation and market launch of intranasal neurotherapeutic formulations which could be feasible by the use of nanoformulation and comprehension of mechanistic and immunological aspects.With more biotechnological and pharmaceutical advances, the avenues in AD therapies are expanding. Mesenchymal stem cells (MSCs) are reported to be valuable in curing the intractable neurodegenerative disorders, owing to their neuroprotective effects exerted by the release of neurotrophic factors . The intvia the olfactory nerve pathway and trigeminal nerve pathway of the nasal cavity, therein bypassing the brain barriers and improving the diffusion of drug molecules. However, this promising combination of nanocarriers and intranasal delivery needs to elucidate better clinical profiles, pharmacodynamics, and pharmacokinetics for sustainable recovery from neurodegenerative diseases and complications.Neurodegenerative disorders such as Alzheimer’s disease (AD), migraine, schizophrenia, Parkinson’s disease, and brain injury lead to memory impairments. Physiological barriers like blood–brain barrier (BBB), blood–cerebrospinal fluid barrier along with efflux transporters like P-glycoprotein (P-gp) prevents effective therapy using neurotherapeutics. Conventional oral routes offer mere superficial therapy, while invasive delivery mechanism leads to adverse cardiac and extrapyramidal side effects. The intranasal route of administration has, thus, surfaced as a valuable alternative with noninvasive, effective, safe, and targeted delivery of neurotherapeutics. Additionally, nanocarriers help achieve better brain targeting


Thrombotic microangiopathy (TMA) consists of a group of occlusive microvascular disorders, which include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TMA can be classified as primary or secondary based on the etiology. Gemcitabine-induced TMA is a rare side effect of the drug with varying clinical presentations. We present a case involving the classic triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and renal failure associated with gemcitabine. Gemcitabine was immediately stopped, and our patient's condition improved with conservative management. Thrombotic microangiopathy (TMA) comprises clinical disorders of thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TMA is characterized by systemic or intra-renal platelet aggregation with thrombocytopenia, microangiopathic hemolytic anemia (MAHA), and end-organ damage . TMA canA 66-year-old female with a past medical history of stage IV breast cancer presented to the emergency department (ER) for the evaluation of acute-onset shortness of breath. The patient had been on gemcitabine therapy for the past four months, with the last dose received on the day of the presentation. The patient had initially presented to the chemotherapy infusion center for her routine session of gemcitabine chemotherapy. After receiving chemotherapy, she started having shortness of breath, gradually worsening with associated orthopnea. On arrival at ER, the patient was in acute respiratory distress with a respiratory rate of 29 breaths per minute, blood pressure of 181/106 mmHg, and heart rate of 96 beats per minute. Physical examination showed bilateral rhonchi on chest examination and lower extremity pitting edema. No jugular venous distention was appreciated. Chest imaging showed evidence of pulmonary edema and bilateral pleural effusions. The patient was placed on noninvasive ventilation with improvement in respiratory status over the next couple of days. Blood workup showed anemia, thrombocytopenia, elevated creatinine, and evidence of hemolysis with elevated serum lactate dehydrogenase (LDH) and low haptoglobin  after ADAMTS13 showed a value >50%, which excluded the diagnosis of TTP. Due to a persistent rise in creatinine and blood urea nitrogen (BUN) with oliguria, the patient was started on hemodialysis with nephrology recommendations. Renal ultrasound was unremarkable with normal renal cortical echogenicity. Complement levels were normal. ANA and hepatitis B and C were negative. Transthoracic echocardiogram showed an ejection fraction of 45% with grade-I diastolic dysfunction. The patient received packed red cells and platelet transfusions to improve the hemoglobin and platelet count. A left renal biopsy was carried out, which showed thrombotic microangiopathy, mild tubular injury superimposed on diffuse mild to moderate tubular atrophy, and interstitial fibrosis Figure .The patient’s clinical condition continued to improve during hospitalization. She was on room air at discharge but still dependent on hemodialysis. Gemcitabine was stopped on discharge. Six months after discharge, the patient was off hemodialysis, and her thrombocytopenia had improved.TMA is classified as primary when the etiology is idiopathic and secondary when the constellation of symptoms occurs secondary to an infection, autoimmune disorders, pregnancy, malignancy, drugs, bone marrow transplantation, or cytotoxic chemotherapy. TMA can be secondary to cancer itself, but that is more likely to present as TTP, while TMA secondary to chemotherapy manifests as symptoms of HUS . HUS is The clinical manifestations of gemcitabine-induced TMA can include dyspnea related to pulmonary edema, peripheral edema, hematuria, neurological abnormalities with laboratory evidence of worsening anemia, and thrombocytopenia with elevated markers of hemolysis . AccordiThe mainstay of treatment includes cessation of gemcitabine and supportive management, which includes blood and platelet transfusions, dialysis, and control of respiratory symptoms . While tTMA and its subtypes can be potentially fatal. Gemcitabine has been identified as one of the potential causes of secondary TMA presenting as HUS. It is important to be vigilant for signs and symptoms of TMA in patients on gemcitabine therapy and to stop it immediately if symptoms of this disorder develop. The prognosis of HUS related to chemotherapy and malignancy is poor, with high mortality rates. The mainstay of treatment is the cessation of gemcitabine and supportive management, while various novel treatment options have been reported in the literature.