Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition. Bone is one of the most common sites of metastases from multiple types of cancers and spinal metastases represent up to 80% of bone metastases ,2. They Over the years, incidence of spinal metastases have increased due to improved diagnostics and life expectancy of cancer patients ,6.In this regards, preservation of patient Quality of Life (QoL) is mandatory event in the latter stage cancer course. However, spinal metastases may determine spinal instability, with movement-related pain, symptomatic or progressive deformity, and/or neural impairments.Since the short life expectancy of affected patients, an early diagnosis should be achieved and a prompt treatment is advised in order to ensure a quick pain relief; nevertheless, suspecting early spinal metastases through radiography is difficult and diagnosis is often tardive .For this reason, spinal metastases are often addressed to palliation through several conservative and surgical treatments.In recent times, several advancements in oncological treatment have resulted in a longer survival of patients with spinal metastases. Therefore, palliative treatments even more aim to improve patient’s QoL since the longer life expectancy. Unfortunately, there is still no consensus on the most effective treatment to improve patient’s QoL and palliative treatments have to be tailored on patient’s status and life expectancy. They both are assessed through several prognostic scores specifically designed for spinal metastatic patients. Since the balancing between surgical risks and life expectancy, patients are often addressed to palliative care, which nowadays can rely on many different non-operative or minimally invasive treatments.After an extensive systematic review on literature, we therefore report an updated overview of the latest palliative treatments currently used in the management of symptomatic spinal metastases, in order to provide an insightful descriptive overview on the latest available treatments and to point out their efficacy in pain relief and the subsequent improvement of patient’s QoL.A systematic review of the literature was performed in order to assess the current treatments for the palliation of spinal metastases. A comprehensive search according to PRISMA guidelines was conducted on PubMed and MEDLINE in September 2021. Databases were queried for the following search strings: “spinal metastasis AND palliative care”, “spinal metastasis AND palliative treatment”, “vertebral metastasis AND palliative treatment”, “vertebral metastasis AND palliative care”. In addition, only articles published within the last 5 years were considered. Screening of titles and abstracts, as well as eligibility assessment of full-text articles, was conducted according to the topic of this review. Exclusion criteria were the following: non-English studies, publishing date before January 2017; studies discussing only vertebral fixation and posterior decompression; studies analyzing side effects of palliative approaches without investigating the outcome of each therapeutical approach; meta-analyses, reviews, surveys, preclinical studies, letters to the editor, commentaries, isolated case reports. Articles discussing the clinical outcome, survival, and quality of life of patients undergoing palliative treatment for spinal metastases were included.We obtained a review of the most updated evidence of the current palliative management of spinal metastases through a systematic and extensive literature search strategy according to PRISMA guidelines . The iniIn recent decades, important progress have been made in the medical treatment of oncological diseases resulting in considerable increase of survival time. Therefore, the management of cancer patients focuses nowadays on every potential way to improve their quality of life (QoL). The spine is a common metastatic location and this constitute a key element not just for the tumor evolution but also for the patient’s prognosis . VertebrSpontaneous pathological fractures due to unstable and weak vertebrae can occur, and most patients with vertebral metastases present intractable pain significantly affecting their QoL . PatientIn an era of improved oncological treatments, therapeutic decisions for patients with vertebral tumors have become more complex, as patients survive long enough to experience morbidity not just from tumor progression but also from oncological therapies . CurrentCancer-associated pain shares multifactorial and complex causes, and these are likely to vary with tumor-related and patient-related factors. Since this complex behavior, the treatment of pain related to spinal metastasis may require different and personalized techniques. In the whole scenario of palliative treatments, we resume the updated evidences on the most recent treatments for the palliative care of spinal metastases. Since the great variability in overall clinical presentation of patients with spinal metastases, reliable tools are required to precisely define the best palliative treatment for each patient. In order to reduce the subjectivity of clinical evaluation and to precisely estimate life expectancy, during the last decades several prognostic scoring systems have been proposed ,17.Tokuhashi score, Tomita score, Bauer Scoring System and Van der Linden scoring system are currently used to evaluate patient’s prognosis basing generally on systemic characteristics of primary tumor, spinal involvement and patient’s general performance status [Katagiri score takes into consideration a history of chemotherapy as key factor for prognostic evaluation [Oswestry Spinal Risk Index (OSRI) is aimed to simplify the evaluation of patient prognosis considering two factors: type of primary tumor and general condition [Among these, e status ,21,22,23aluation  and Osweondition . HoweverRades score is strictly aimed to the evaluation of radiotherapy as palliative treatment for patients with spinal metastasis at an advanced stage and impending paralysis [Spinal Instability Neoplastic Score (SINS) is aimed only to assess the degree of spinal instability order to address the most convenient surgical intervention [On the contrary, aralysis ; whereasrvention .SORG  nomogram and the New England Spinal Metastasis Score (NESMS) have been validated for the survival estimation of patients with spinal metastases. As regard the SORG nomogram, its clinical usefulness has been demonstrated since its capability of estimating 3 and 12 months individual survival probability of patients candidate to surgery through the evaluation of continuous variables such as hemoglobin levels, white blood cell count, age, previous systemic therapy, systemic metastases, multiple spinal metastases, primary tumor and performance status [More recently, the variety of prognostic scoring systems has widened by the introduction of other scores with higher sensitivity and specificity in predicting long-term post-operative survival than the previous ones. In detail, e status .On the other and, NESMS has been recently validated as clinical tool capable of predicting 1-year morbidity and mortality of patients undergone surgery for spinal metastasis through the evaluation of preoperative modified Bauer score, ambulatory function and serum albumin. In particular, the higher the NESMS pre-operative score is, the higher the odd of survival is 1 year after the treatment ,29.Radiotherapy is the most common palliative treatment for spinal metastases; its main purposes are palliation of pain, achievement of local tumor control, improvement of patient’s quality of life and prevention of adverse-related events, such as pathologic fractures and spinal cord compression. conventional external beam radiation therapy (cEBRT) as the primary treatment method for spinal metastases, both in oligometastatic and polymetastatic Spinal Tumors [Several studies consider l Tumors ,31,32.Generally, radiotherapy is effective for pain reduction and in maintaining skeletal integrity, while minimizing the occurrence of adverse related events such as pathological fractures. In facts, osteolytic metastases that have been successfully treated by RT subsequently appear normal or sclerotic on CT scan, due to re-ossification; thus, CT-follow up can be used to evaluate therapeutic outcomes after RT for bone metastases . As regards pain control, it has been demonstrated a significant decrease of pain after RT up to 93% . In caseHowever, RT treatment can be associated with various side effects depending on the affected column segment, its extent, delivered radiation dose and radiation delivery technique. The spectrum of symptoms ranges from pharyngitis/sore throat for metastases located in the cervical spine, esophagitis/dysphagia and limited lung fibrosis very rarely progressing to symptomatic pneumonitis in cases of the dorsal vertebrae involvement, gastrointestinal disorders like emesis, diarrhea and abdominal cramps because of the irradiation to the lumbar column, up to exceptional and unforeseeable bystander effects ,35. Low intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT) and stereotactic body radiotherapy (SBRT), have been developed over the years to improve the therapeutic index of RT in other challenging scenarios [More advanced precise RT techniques, such as, in order of complexity, cenarios ,40,41; fcenarios .intensity-modulated radiotherapy (IMRT) has been used to provide highly conformal target coverage while sparing organs at risk with results of bone density and pain control comparable to 3-dimensional conformal radiotherapy (3DCRT) [In patients with complex target volumes or challenging geometry,  (3DCRT) ,44. Alth (3DCRT) . This isVMAT, which is an evolved form of IMRT, allows an improved dose escalation and a reduction in radiation-induced toxicities and in overall planning time, when compared with the current conventional technique .stereotactic body radiation therapy (SBRT) has gradually emerged as a promising and well-tolerated treatment strategy for delivering high doses of radiation in a dose-escalated manner to the target vertebral region while minimizing radiation to nearby critical structures, such as the spinal cord, and to surrounding normal tissues [The  tissues . It impl tissues ,48,49. S tissues ,50,51,52 tissues  or with  tissues , with ol tissues  or with  tissues . The ind tissues  as well  tissues . Moreove tissues . However tissues .Lastly, new radiation delivery techniques like the Spatially Fractionated ones might be helpful when treating inoperable bulky tumors invading the spine by exploiting their immunogenic effect while not exceeding the spinal cord tolerance ,60.In the palliative treatment of spinal metastases overall treatment time of radiotherapy should be as short as possible ,61. MoreMany studies have shown that RT in lower doses is equivalent to higher radiation doses and that short course treatment should be preferred ,69,70,71The therapeutic approach for patients with spinal metastases should be decided on a case-to-case basis; for this reason, many patients receive radiotherapy alone, while others can benefit from the associations with other surgical and non-surgical treatments.In particular, in has been shown that the combination of RT and bisphosphonates in case of metastatic renal cell carcinoma may reduce the odds of pathological fractures and spinal cord compression and the combination of RT and PD-1 inhibitor may positively influence pain control and neurological improvement ,73.RT following surgery for spinal cord decompression and vertebral fixation or reconstruction has been proven as effective combined treatment for MESCC in case of patient with good prognosis and overall performance status and radiofrequency ablation (RFA) followed by RT may ensure a better local and pain control than RFA or RT alone [In those cases addressed to surgery, it has been proven that RT alone ,75.As regard physical therapies, the isometric paravertebral muscle training (IPMT) following RT has been proposed as a feasible treatment which may improve mobility, pain control and QoL in patients with unstable spinal metastases .tapentadol may improve pain and patient’s QoL thanks to the improvement in emotion functioning and fatigue due to tapentadol double action as opioid agonist and noradrenalin reuptake inhibitor [As regard pain therapy, RT combined with nhibitor .Radiofrequency ablation (RFA) is a minimally-invasive ablative technique which uses an alternating current through in order to ablate the tumor through the heating of an electrode; once the critical temperature is reached, local tissues and cells undergo thermal coagulation, causing necrosis of the tumor [he tumor . RFA washe tumor ,80.The clinical goal of RF ablation in vertebral metastases is primarily pain reduction, by the destruction of local sensory nerve fibers . Since tMoreover, RFA is thought to decrease the volume of the metastatic lesion and inhibit osteoclast activity .RFA is a mini-invasive treatment which presents several advantages, since it can be repeated several times with no risk of biological exposure than RT  and it pThe Metastatic Spine Disease Multidisciplinary Working Group stated that RFA may be ineffective in treating bone metastases in some situations: asymptomatic spinal metastases in patients with poor general condition, life expectancy of less than 6 months, pathological vertebral compression fracture and epidural spinal cord compression ,56.percutaneous vertebroplasty (PVP) or with balloon kyphoplasty (BKP) as safe and effective treatment for spinal metastases. RFA causes coagulation necrosis of tumor cells and the tumor cavitation prior to vertebral augmentation, thus reducing the complications of cement leakage and improving quality of life [Several studies have evaluated the combination of RFA with  of life ,81. On t of life . As suggmicrowave ablation (MWA). Compared with RFA, MWA is relatively insensitive to the high impedance of bone and desiccation, allowing deeper thermal penetration and more efficient heating; furthermore, MWA facilitates the use of higher temperature, a wider range, and a shorter time of ablation; however, in the treatment of spinal metastases, rapid heating and large ablation range may be disadvantageous, since overheating the tissue surrounding the tumor could result in serious neurologic complications [Another technique which employs thermal ablation for inducing coagulative necrosis of the tumor is ications .vertebral augmentation has been proven as safe and feasible treatment for painful bone metastases, relieving pain and increasing bone stability.The combination of MWA and Cryoablation (CA) may be a minimal invasive treatment for patients with spinal tumors not responding to RT [systemic or local therapies such as RT and vertebral augmentation. CA results in fast and long-lasting pain relief as well as acceptable rates of local tumor control. Main limitations of this technique are the limited experience and the risk of fracture [ng to RT . CA can fracture .However, ablative techniques such as RFA or CA, are contraindicated for tumor location within 1 cm of important structures such as the spinal cord, major nerves, and blood vessels .Surgery remains a fundamental option in the therapeutic armamentarium of treatments for spinal metastases.However, currently there is no consensus on the most effective treatment for the treatment of spinal metastases aimed to improve patient’s QoL nor on the indication for the type of surgical intervention; in fact, surgery if often urgently indicated for sudden neurological impairments and a pre-operative multidisciplinary evaluation based on objective score is not always possible ,87.open spinal surgery and percutaneous spinal surgery. As regard open surgery, metastasectomy may play an important role in effective local control of tumor in selected patients; however, it may delay further RT. In order to improve patients’ outcome, adjuvant therapy with both targeted therapy and cytokine therapy may positively affect patient’s survival [In case of pathological fracture secondary to spinal metastases, surgery may rely on two different treatments: survival .spinal fixation or vertebral augmentation) is associated with less morbidity than conventional open surgery for restoration of spinal stability. Preservation of the paraspinal musculature limits postoperative pain and hospital stay, and percutaneous spinal surgery does not involve delay in radiotherapy; moreover, percutaneous surgery may allow for rapid improvement in quality of life and walking ability for patients with spinal instability [Percutaneous spinal surgery (tability .vertebroplasty and kyphoplasty) is considered to be the preferred palliative surgical treatment for patients with spinal metastases [At present, vertebral augmentation (tastases . Besidestastases .Percutaneous vertebroplasty (PVP) was first introduced as a treatment option for aggressive hemangiomas of the lumbar spine [local bone destruction progression (LBDP) may occur early in case of reduced filling rate and cement volume; whereas filling rate > 0.646 was predictive of late LBDP [ar spine . Over thar spine . Howeverate LBDP ; whereasate LBDP .balloon kyphoplasty (BKP) for spinal metastasis. BKP is used to restore vertebral height through an inflatable balloon to reduce the pressure of cement injection and the risk of leakage. This technique seems to be associated with low postoperative complications as well as significant decrease in pain, use of opioids and length of hospital stay [Recent reports have shown promising results of tal stay . BKP maiBKP is performed through injection of polymethylmetacrylate (PMMA), even if some authors investigated the use of VK100, a mixture of Dimethyl Methylvinyl siloxane and Barium Sulphate, in order to reduce some disadvantages, such as exothermic reaction, rapid solidification and absence of osteoconduction .open kyphoplasty (OKP) is performed through decompressive hemilaminectomy associated with a contralateral percutaneous kyphoplasty, and in some cases to a posterior fixation, for symptomatic metastatic lesions in selected patients [Kyphoplasty may be performed also with open surgery. The patients .spinal cord stimulation (SCS) has been recently investigated in other chronic painful conditions than failed back surgery syndrome (FBSS) [Considering the more recent field of interest in alternative interventional free-of-side-effects treatment for cancer-related pain, the clinical effectiveness of e (FBSS) ,96. The e (FBSS) ,98,99. Se (FBSS) . The latThe spine is the most common site of metastatic bone tumors, which often require a prompt treatment in order to improve patient QoL. Since the short life expectancy in case of spinal metastases, patients are often addressed to palliation. In the wide scenario of palliative treatment, nowadays recent medical or surgical techniques represent valuable options for ameliorating pain and improving patients QoL in such condition.


Neuroendocrine tumor (NET) patients often suffer from metastases, thereby eliminating surgery as a curative treatment option. A possible treatment strategy for these patients is peptide receptor radionuclide therapy (PRRT). PRRT is composed of a radiolabeled peptide that can bind to the NET-cells via a specific receptor. After intravenous injection of the radiolabeled peptide and binding to the NET cells, the radionuclide induces DNA damage upon radioactive decay, leading to cell death. However, the majority of patients will not be cured with the current regimen. Therefore, there is an urgent need for therapy improvement. Previously, it was shown, in cell models, that the combination treatment of PRRT with a poly(ADP-ribose)-polymerase (PARP) inhibitor, which inhibits DNA damage repair, can be effective. As the next step towards patients, we have tested this combination treatment in animal models and showed that, in mice, the combination of PRRT with PARP inhibitors is more effective than PRRT alone, however not in all the tested models. This discrepancy is of importance for the translation of this type of therapy towards the clinic.177Lu]Lu [DOTA0-Tyr3]octreotate, is used to treat patients with metastasized neuroendocrine tumors (NETs). Even though PRRT is now the second line of treatment for patients with metastasized NETs, the majority of patients will not be cured by the treatment. PRRT functions by inducing DNA damage upon radioactive decay and inhibition of DNA damage repair proteins could therefore be used as a strategy to potentiate PRRT. Previous work has shown promising results on the combination of PRRT with the PARP inhibitor olaparib in cell lines and mice and we have been taken the next step for further in vivo validation using two different xenografted mouse models. We observed that this combination therapy resulted in increased therapeutic efficacy only in one model and not the other. Overall, our findings indicate a tumor-type dependent anti-tumor response to the combination of PRRT and olaparib. These data emphasize the unmet need for the molecular stratification of tumors to predetermine the potential clinical value of combining PARP inhibition with PRRT.Peptide receptor radionuclide therapy (PRRT), a form of internal targeted radiation treatment using [ PRRT consists of the somatostatin analogue octreotate, coupled to a DOTA-chelator, labeled with the radiometal lutetium-177. After injection in the circulation, NET lesions will be specifically targeted and DNA damage will be induced during radioactive decay leading to NET cell death [177Lu]Lu[DOTA0-Tyr3]octreotate (177Lu-DOTA-TATE) is EMA and FDA approved for treatment for metastatic gastroenteropancreatic NETs (GEP-NETs) and holds great promise in terms of the improvement of progression free survival and quality of life Ga-DOTA-TATE uptake, however with worse tumor control and all subjects reaching their humane endpoints [The possible synergistic effect of PRRT and PARP inhibition on tumor killing has been shown by us and others in different models, both in vitro and in vivo ,7,8, yetefficacy ,16. In andpoints ,18,19,20Second, the proliferation rate of different tumor cells could impact radiosensitization, especially in the context of drugs that affect DNA integrity. It has already been shown that a slow-cycling fraction of human colorectal carcinoma cells exhibit a multifold resistance to oxaliplatin and 5-fluoro-uracil compared to the faster cycling fractions in the same culture . This drNot only can cellular context, such as cycling rate or radioresistance, hamper the potentiation of PRRT using PARP inhibitors, but there are also direct mechanisms of PARP inhibitor resistance which can have the same effect. For example, upregulation or basal expression levels of P-glycoprotein (P-gp) efflux pumps on the cell membranes can cause multidrug resistance including resistance to olaparib, rucaparib and paclitaxel . In lineIn conclusion, the combination of DNA damage repair modulating drugs with PRRT is a promising therapeutic avenue. However, factors that can mitigate efficacy and potentially lead to resistance need to be taken into account when performing combination studies, both in vitro and in vivo. Such insights might improve potential clinical studies where PRRT is combined with drugs such as olaparib.We show the possibility of olaparib-PRRT combination treatment in the CA20948 xenografted mouse model, and show the lack thereof in the NCI-H69 xenografted mouse model. Further molecular stratification is warranted to anticipate therapeutic discrepancies in patients.


Solanum lycopersicum L.) genetic basis of traits conferring HMs tolerance and yield are assessed when irrigated with waste or canal water. The North Carolina Mating II analysis illustrate the amount of gene action, nature, and inheritance pattern. Genetic components depict the involvement of non-additive, additive, and maternal genetic effects in HMs tolerance inheritance and yield. A noticeable increase in cumulative additive variance for the number of flowers  and the number of fruits  is recorded for tomato plants irrigated with wastewater, illustrating additive gene action. However, female and male (MSf/MSm) square ratios also show an association with cytoplasmic inheritance. For HMs tolerance, both additive and dominant variances appeared to be significant; cumulative dominance variance  is higher compared to additive variance  for nickel (Ni), chromium (Cr), lead (Pb), manganese (Mn), and zinc (Zn), respectively, indicating dominance gene action. The genotype RIOGRANDI accumulated and translocated fewer HMs to the aerial part of the plant compared to CLN-2418A and PB-017906, thus presenting a tolerant tomato genotype according to the hydroponic experiment. This also exhibited a differential pattern of gene action for HMs tolerance, suggesting that genotypes possess significant differences for HMs tolerance.Wastewater irrigation is a substitute for surface water scarcity, but traces of heavy metals (HMs) result in deleterious implications for soil, crop productivity, and in humans. Crops presenting HMs tolerance in genetic behavior are important for producing tolerant genotypes cultivated under wastewater irrigation. In the first part of this experiment, the results obtained previously are re-assessed in a hydroponic system and similar patterns and concentrations of HMs are found in different tomato organs. Following this trial, the tomato’s ( Along with additive and non-additive gene effects, maternal effects were also involved in controlling the number of flowers, the number of fruits, and HMs tolerance, indicating the interference of the cytoplasm. HM Involvement of maternal effects for multiple HM tolerance through the MTP gene family has also previously been reported by El-Sappah et al. 1/2 showed over-dominance for the control of HMs tolerance, indicating that both additive and non-additive genetic effects control HMs tolerance.Heritability is considered an excellent index for transmitting characteristics to subsequent generations. To realize improvement in yield-contributing traits, a plant breeder must assess the percentage of inheritance in a population for any particular trait. It also enlightens the efficiency of subsequent generations regarding the selected traits in any breeding experiment. Genotypic, as well as environmental variance, can be assumed to approximate the chances of heritability and genetic advance, which depicts the probability of genetypic differences concerning environmental variables. Heritability and genetic advance were high with high additive gene effects for the number of flowers and fruits; therefore, direct selection without hybridization may help improve these characteristics . These rHeritability and genetic advance estimates also provide information about yield and HM tolerance inheritance patterns. Traits possessing higher genetic advances with high or low heritability estimates are desirable because of their higher additive genetic effects; therefore, selection may be effective based on genetic advances. Higher heritability estimates with lower genetic advances are undesirable because of non-additive genetic effects, which show that environmental effects regulate trait expression. Heritability and genetic advance were high to moderate for Pb, Cr, Mn, and Ni tolerance but not Zn. Therefore, direct selection without hybridization may be helpful for these characteristics . BecauseEstimates for different genetic components revealed that an additive genetic effect was responsible for the inheritance of yield-related traits such as the number of flowers and the number of fruits per plant. In contrast, a dominant genetic effect was responsible for the inheritance of different HMs tolerance. From the above results, it was observed that along with additive and non-additive genetic effects, maternal effects were involved in controlling different traits such as yield and HMs tolerance in tomatoes, showing the involvement of cytoplasm. An evaluation of the many hybrids/accessions is recommended to develop low metal-accumulator tomato genotypes with a higher yield. Because the above results are from a limited set of tomato germplasm, they cannot be generalized to all tomato genotypes . Multiple genes influenced genetic variation for metal tolerance with both additive and non-additive effects, but for HM tolerance, dominant genetic effects were observed most commonly , which a3 for 3 h under lab conditions. The samples were heated at 250 °C on a heating block until the appearance of tinted yellow color of the solution in digestion flask. The solution was diluted with distilled water up to 50 mL and filtered for the analysis of HMs with atomic absorption spectrophotometer. Two HM tolerant/low metal-accumulator genotypes (PB-017906 and CLN-2418A) and one susceptible/high metal accumulator genotype (RIOGRANDI) were selected out of 44 genotypes in a screening trial based on HM accumulation in a field experiment  and then results were re-assessed in the hydroponic experiment. A similar pattern of HM concentrations “as in sewage water”  was mainSeeds of the selected tomato genotypes were sown in sand-filled seedling trays, and moisture content was maintained. After 25 days of seedling establishment, in November 2018, seedlings were transplanted to the field soil in a replicated trial under two treatments, i.e., wastewater and canal water. At maturity, the crossing was performed according to North Carolina Design-II matting to develop genetic material for assessing genetic components of variability. Analysis of water and soil used in current experiment given in Floral buds of all genotypes in both water treatments were covered with a butter paper bag and emasculated with forceps two days before blooming. Any opened flowers present on the same inflorescence were removed to avoid mating. Desired male flowers of all the genotypes in both water treatments were stored in clean plastic bottles, and anthers were collected and sun-dried, so they opened to release pollens for crossing. Pollens were applied to exposed stigma with a dissecting needle; to ensure a good seed set, the style was repeatedly dipped in a pollen-containing petri dish.At maturity, fruits of F1 and selected parents were collected in bags, crushed, and fermented. Seeds were washed with fresh water to remove flesh and skin. Floating pieces were removed gently, and washing was repeated many times by adding fresh water to remove flesh and gel. Clean seeds were collected, dried, and stored. 1 hybrids seeds were sown in seedling trays and transplanted in field after 25 days of the seedling establishment during November 2019 in a triplicated trial in two sets, i.e., canal water and wastewater. Data regarding HM and yield-related traits were recorded at maturity by harvesting and analyzing ripened fruit. Accumulation of nickel (Ni), zinc (Zn), manganese (Mn), chromium (Cr), and lead (Pb) in tomato fruit were determined by performing acid digestion as described by [To assess inheritance patterns and genetic studies for HMs tolerance and yield-related traits, HMs tolerant (PB-017906 and CLN-2418A), susceptible parental genotypes (RIOGRANDI), and Fribed by . For yieBS) and genetic advance (GA) were calculated using formulas [Data were analyzed statistically using the analysis of variance technique  to find formulas ,59. Valuformulas . Data weformulas .Under such circumstances of surface water scarcity, wastewater is used for irrigation purposes, but one of its drawbacks is contamination with HMs. Due to the high cost, treatment is not possible in underdeveloped countries such as Pakistan. One of the solutions to this problem is to develop genetically tolerant genotypes that hold genetic capability physiologically and possess molecular mechanisms to block HMs from entering the food chain. Genotypic variation exhibited a differential pattern of gene action for HMs tolerance, suggesting that genotypes possess significant differences for HMs tolerance. Since roots are the first organ for the hyperaccumulation of different HMs ions as shown in different tomato genotypes, particularly RIOGRANDI, therefore, the pattern of enzyme activities and other metal accumulation in the root system needs to be determined, and intermittent use of clean water between wastewater irrigation will not only reduce the heavy metal load but could also enhance the soil fertility.


We then use connectopic mapping to map inter-individual variation in fine-grained topographical organization of functional connectivity in the striatum—a central hub in motor, cognitive, affective and reward-related brain circuits—and use multivariate machine learning  to show that these individualized topographic representations predict transdiagnostic functional domains out of sample . We propose that investigating psychiatric symptoms across disorders is a promising path to linking them to underlying biology, and can help bridge the gap between neuroscience and clinical psychiatry.Transdiagnostic approaches to psychiatry have significant potential in overcoming the limitations of conventional diagnostic paradigms. However, while frameworks such as the Research Domain Criteria have garnered significant enthusiasm among researchers and clinicians from a theoretical angle, examples of how such an approach might translate in practice to understand the biological mechanisms underlying complex patterns of behaviors in realistic and heterogeneous populations have been sparse. In a richly phenotyped clinical sample ( Psychiatric disorders are behaviorally and biologically complex, as is evidenced by our syndrome-level understanding of their clinical phenomenology. While a common framework is critical for providing patient care and evaluating the efficacy of therapeutic options, classification systems that are commonly used to define psychiatric disorders also constrain the way in which we are able to connect these disorders to underlying biology . MoreoveWithin such frameworks, neuroimaging studies have made significant progress in linking specific domains of functioning to brain networks and regions across disorders , 8, 9. TThe striatum is extensively connected with almost the entire cortex and is involved in multiple behaviorally relevant circuits which can be probed, for example, through functional connectivity. However, connectivity in the striatum is topographically organized, such that nearby regions in the striatum are connected with nearby regions in cortex and therefore conventional functional connectivity approaches are unable to capture the complexity of functional connections within this complex system, nor reflect the topographic characteristics of striatal organization at the single-subject level. Through recent advancements, we can now investigate the topographic organization of striatal circuits through connectopic maps . These mIn this study, we apply connectopic mapping to a richly phenotyped, transdiagnostic and highly comorbid cohort—the ‘Measuring Integrated Novel Dimensions in neurodevelopmental and stress-related mental disorders’ (MIND-Set) study—aiming to (i) dissect psychiatric symptom profiles within a heterogeneous and clinically representative sample, providing subjective quantitative measures across different domains of functioning (“behavior”) that cut across diagnoses and measurement instruments and (ii) show that these domains of functioning are linked to the topographic functional organization of the striatum at the level of the individual patient. To achieve these goals, we apply an innovative multivariate analytical strategy that combines penalized canonical correlation analysis with stability selection that provides the ability to learn brain-behavior associations whilst providing unbiased estimates of generalizability and strong statistical guarantees over false detection of associations.A detailed description of analytical procedures is provided in the supplement. In brief, data were collected as part of the MIND-Set study, an observational, cross-sectional study that includes adult patients with stress-related and/or neurodevelopmental disorders that were assessed at the outpatient unit of the department of psychiatry at the Radboud university medical center (Radboudumc) in Nijmegen, the Netherlands. For a more detailed description of the study design and set-up we refer to previous work . ImportaDiscovery/neuroimaging sample: participants from the MIND-Set cohort were included who met criteria for at least one of the following psychiatric disorders: major depressive disorder, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), and had completed behavioral and neuroimaging assessments . Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV-TR (SCID-I/P) [Replication sample: The replication sample was used to replicate the exploratory factor analysis (EFA) structure in an independent sample, n = 188 . This replication sample followed the same inclusion process and deep phenotyping as the main sample, with the exception of an MRI session.CID-I/P) , the DiaCID-I/P)  and/or tCID-I/P) . ReplicaWe used an extensive panel of questionnaires covering multiple symptom and functional domains  for each subject [n = 17) if a clear gradient could not be estimated, due to imaging artefacts or spatial correlation of individual gradients to the group maps was low, following the protocol by Isakoglou et al. [Imaging data was processed using standard pipelines with FSL 5.0.11  and careful attention was given to addressing known confounds in resting FMRI, such as head motion (see supplementary data) , 29. We  subject . This meu et al. . For eacu et al. , 21. Theu et al. . The CCAu et al.  and out-u et al. , and is A total of 186 subjects were included in the final analysis . As per the study design, the sample contained high levels of comorbidity across symptoms and diagnoses: 102 subjects had a single diagnosis, 69 had two diagnoses, 13 had 3 diagnoses and 2 subjects had all included disorders .Exploratory factor analysis on 31 scales and subscales across psychiatric symptomatology decomposed behavioral data into four factors . This interaction explained variance ((R2), out-of-sample) across three of the four behavioral domains , comparable in size to previous CCA-derived brain-behavioral associations [Functional domain scores and trend surface coefficients were entered into a penalized canonical correlation analysis. Stability selection revealed the first and third-order trend surface coefficients in the ciations . While tAdditional tests were performed to determine whether our results could be explained by other effects see . FirstlyIn this work, we showed how complex behavioral data in a sample with high psychiatric comorbidity can be represented in stable and reproducible domains of functioning. These functional domains are cross-diagnostic in that each of these domains incorporate parts from different questionnaires, and reproducible in that we were able to derive effectively identical latent structure across two independent samples. These domains of functioning are also similar to broad research areas in cognitive neuroscience in both healthy and clinical populations . We founWe established that these functional domains are reflected in underlying brain function, as represented by the functional organization of the striatum across disorders. While the strength of the observed relation is in line with other studies using similar (CCA-)analysis methods, our findings in light of the broad scope of behavioral information and highly comorbid sample used in this work highlight the value of transdiagnostic frameworks in understanding the biological underpinnings of psychiatric disorders and symptomatology. In addition to the earlier-mentioned relevance of the striatum in stress- and neurodevelopmental disorders, there is a large body of literature that supports our findings in linking striatum function and connectivity to the functional domains we observed. The ventral striatum is the key node within reward-circuitry, and crucial in the context of arousal and (dis)inhibition . Within Taken together, known associations between striatal function and several functional domains in both clinical and healthy populations corroborate our findings. Furthermore, several studies have found striatal structure and/or function to be a marker for general symptoms, regardless of diagnosis . The venSeveral limitations to the current work need to be addressed. Firstly, the MIND-Set sample is highly comorbid by design, so replication and generalization studies in less complex or healthy samples are warranted to demonstrate transferability of the functional domains. Secondly, while substantial for a highly heterogeneous cohort, our sample size is moderate. Although balanced by careful assessment procedures including rigorous out-of-sample validation and stability selection , repeatiIn conclusion, we showed how psychiatric symptomatology can be deconstructed into functional domains that are reflected in underlying neurobiology. We believe that this transdiagnostic approach, which enables investigating domains of functioning that still carry the signature of the classified disorder while also incorporating individual variation that transcends the label, has great potential in overcoming current limitations in clinical and computational psychiatry. With a stronger biological footing and individualized nature, the functional domains could prove valuable in predicting clinical outcome. Through transdiagnostic research and understanding how disruptions in neural circuitry give rise to non-specific psychiatric symptoms or shared symptoms across different disorders, we will be able to pave the way for personalized treatment targeting circuits, regardless of which classified disorder is present.Supplementary information


The development of rootstocks with a high-quality dwarf-type root system is a popular research topic in the apple industry. However, the precise breeding of rootstocks is still challenging, mainly because the root system is buried deep underground, roots have a complex life cycle, and research on root architecture has progressed slowly. This paper describes ideas for the precise breeding and domestication of wild apple resources and the application of key genes. The primary goal of this research is to combine the existing rootstock resources with molecular breeding and summarize the methods of precision breeding. Here, we reviewed the existing rootstock germplasm, high-quality genome, and genetic resources available to explain how wild resources might be used in modern breeding. In particular, we proposed the ‘from genotype to phenotype’ theory and summarized the difficulties in future breeding processes. Lastly, the genetics governing root diversity and associated regulatory mechanisms were elaborated on to optimize the precise breeding of rootstocks. Malus domestica Borkh.) fruits are widely enjoyed and have become popular among consumers. Grafting is used in apple production to ensure the desired characteristics of fruit trees in orchards, shorten the lengthy juvenile period, and ensure high fruit quality and high yields , cytokinin (CK), and N-terminal signal peptides.Malus sieversii Roem) GRETCHEN HAGEN 3 (GH3) gene, MsGH3.5, encodes an IAA-amido synthetase that affects apple growth and development by modulating auxin levels and signaling pathways -Aux/IAA interactions. ARFs are TFs that regulate auxin responses in plants. In apple, 31 putative ARF genes have been identified and divided into the following three subfamilies: I, II, and III . Furtherpathways . These fIPT5b), a gene involved in CTK biosynthesis and catabolism, works to maintain a high CTK content in apple rootstock roots. Under salt stress, apple roots maintain high CTK levels, as IPT5b expression is not inhibited by proline due to the deletion of the proline response element (ProRE), leading to improved root cell division activity ) and degradation [via cytokinin dehydrogenase (CKX)] genes in plants  Figure . Isopentactivity   exerts an inhibitory effect on the root growth of apple seedlings, indicating that MdCEP1 negatively regulates root development . The CLEnditions   using a wide range of wild resources to conduct a wider range of trait statistical analyses; (2) exploiting computer learning to screen excellent apple chassis materials (which might be the best solution available); and (3) using models such as genotype-to-phenotype prediction or whole-genome selection prediction to select accessions based on genotypes. In future breeding processes, the material composition, line selection, assembly, testing, promotion, and many other components might be determined using a series of models designed for breeding decision making to assist or even replace manual decision making, ultimately achieving data-driven intelligent design-based breeding. Gene-editing technologies using new methods, such as clustered, regularly interspaced and short palindromic repeats (CRISPR)/CRISPR-associated 9 (Cas9), have accelerated the innovation of new crop plant breeding materials and the cultivation of new varieties ,166. To In this review, we discussed the genetic diversity of apple rootstocks among varieties, information on genome sequencing and provided a functional annotation of different varieties of apple, and information on the development of molecular markers and functional genes. According to the current literature, future genome studies should increase the density of genetic maps and improve molecular markers, which is more important for researching the genetic breeding of apple combined with the phenotype. Conventional breeding and phenotypic breeding are now being gradually replaced by molecular breeding, which will be replaced by intelligent breeding in the future. In this sense, methods to design intelligent farming systems for apple warrant further investigation; apple germplasm resources constitute the genetic material basis for cultivating new varieties or types of apples and provide usable rootstocks for production. Therefore, they are very important for the development of apple production. We propose that an apple germplasm bank and genome should therefore be improved and established. The use of genomic information and key genes for classical breeding combined with germplasm resources for germplasm innovation is helpful. Promoting the industrialization of classical breeding with a scientific and rigorous attitude is also important. At present, most global agricultural development must focus on quantitative needs, strengthening crop genetic breeding efforts, and promoting the development of the modern agricultural industry, which is an important research direction to ensure the security of global agriculture.


The pathomechanics of many musculoskeletal spinal disorders are still poorly understood, which makes it challenging to develop and apply effective preventive strategies, treatment modalities and rehabilitation plans . MoreoveMotion Analysis and Musculoskeletal Modeling in Treatment of Spinal Disorders.To provide a complementary forum for discussion among interested researchers, we organized a virtual symposium and invited interested authors to participate. The symposium was held on 12 May 2021, with a total of 13 presentations on studies in this area from authors of nine different countries and a total of 130 participants from over 20 different countries. The abstracts and videos from this symposium may be found online here: The Research Topic has a total of 13 papers, including methodological developments in spine motion analysis and modeling, studies of how spinal disorders affect spine biomechanics, and studies of treatments and interventions. Measurement of spinal motion was a component of eight studies presented here, including six using optoelectronic motion capture, one using inertial measurement units (IMUs), and one using quantitative video fluoroscopy. Three studies used biplanar radiography (the EOS imaging system) to evaluate 3D spinal posture or curvature. Four studies used musculoskeletal models to evaluate spinal loading, and one study used finite element models to evaluate spinal strain. Seven studies examined specific spinal disorders with measurements in patients, including chronic low back pain, lumbar spinal stenosis, adolescent idiopathic scoliosis, and adult spinal deformity. Four studies focused on the effects of treatments, and two on the use of biomechanical loading outcomes to inform prediction or prevention of spine conditions.Severijns et al. quantified palpation error on the positioning of spinal markers, and how it would affect estimates of spinal postures. Mediolateral palpation error was larger in adult spinal deformity (ASD) patients than healthy controls, but other errors were similar, and correcting palpation errors improved marker-based estimates of spine curvature. Overbergh et al. examined the test-retest reliability of spinal kinematics evaluated during seated forward bends in ASD patients based on subject-specific kinematic models. Excellent reliability was reported for some range of motion (ROM) outcomes , but poor for others , and test-retest variability was greater than operator-induced uncertainty. Fasser et al. presented a procedure for generating subject-specific musculoskeletal models based on bi-planar radiography data (EOS imaging system), using these to set skeletal geometry as well as mass distributions. Breen et al. reported on lumbar intervertebral motions in healthy subjects during flexion and return motions, using quantitative video fluoroscopy. This provides an important reference standard for spinal motion, which is needed for validating other approaches for spinal motion analysis and for future comparison in patients with spinal disorders.Advances in the state of the art for motion capture and musculoskeletal modeling have enabled new studies focused on spinal disorders in recent years, as evidenced by many of the studies in this Research Topic. However, efforts continue to develop and improve these methods. Saad et al. showed that patients with ASD, particularly those with sagittal or hyperkyphotic deformities, adopt different movement strategies than healthy controls during sit-to-stand motions, including maintaining a flexed trunk and more sagittal trunk ROM. Similarly, Christe et al. examined various functional spinal movements in patients with chronic low back pain and found that sagittal movement patterns can distinguish patients from healthy controls, particularly angular velocities which are lower in patients. Finally, Mousavi et al. examined walking in patients with lumbar spinal stenosis. The presence of neurogenic claudication symptoms minimally affected spine motion and posture, but increased estimated lumbar spine loading by 7%.Several studies reported significant effects of spine disorders on spinal motion or loading. Kinel et al. assessed the ability of patients to perceive and self-correct their posture and 3D spine shape. Most patients were unable to improve their spine shape instinctively, pointing to the need for careful training in appropriate exercises to develop this capacity. Bassani et al. examined the use of biomechanical parameters, including muscle and intervertebral forces, to predict scoliotic curve progression of adolescent idiopathic scoliosis. However, accounting for these measures did not improve the prediction. Huang et al. used motion analysis to quantify the motion during two different cervical manipulations . Two studies included simulations of spinal fusions: Loenen et al. examined the effect of a titanium interbody cage for spinal fusions on strain patterns in patient-specific finite element models, while Rasmussen et al. performed a simulation study of how lumbar fusions affected spinal loading using musculoskeletal models. The latter suggests that lateral or asymmetric lifts are a particular concern, with post-operative increases in loading regardless of surgical approach. Finally, and relevant to prevention of spinal disorders, von Arx et al. used motion capture-driven musculoskeletal full-body models to investigate spinal loads under three types of lifting techniques. Stoop lifting thereby resulted in lower compressive loading compared to squat and freestyle lifting. And even though stoop lifting resulted in higher anterior-posterior shear forces in the mid to upper parts of the lumbar spine, they were the lowest in the L5/S1 segment, which is most frequently affected by degenerative spinal disorders.Two studies examined spine biomechanics in patients with adolescent idiopathic scoliosis, but with different goals. Collectively, the studies presented in this Research Topic used motion analysis and musculoskeletal modeling to gain new insights into spinal disorders and highlight the potential of these methods for clinical applications. The methodological development studies provide important information on the current state-of-the-art in motion analysis and modeling of the spine and help address limitations that must be overcome for widespread clinical translation of these techniques. The studies of spinal conditions demonstrate that the biomechanical effects of various spinal conditions are detectable using current biomechanical analysis methods, supporting future efforts to elucidate these effects and translate these methods to clinical applications. Finally, several studies here provide important examples of how biomechanical analyses may be helpful in planning, developing, or optimizing treatments, as well as preventive strategies. As editors of, and contributors to, this topic, we sincerely hope this collection of studies can serve as a roadmap to accelerate translation of motion analysis and modeling to clinical management of spinal disorders and can ultimately lead to design and development of new and more effective interventions for spinal disorders. We look forward to continued efforts over the next few years to leverage the methodological developments and examples found here toward clinical applications in this exciting and emerging field.


Social determinants of health (SDH) are non-medical social needs key to reducing health disparities and improving health outcomes. Adequately identifying patients’ unmet SDH needs in primary care (PC) is a critical first step in addressing them, yet many questions remain regarding feasibility and implementation of screenings and how to effectively meet patients’ needs and improve their outcomes. With formative and process evaluation analyses, we report on the development and implementation of a community-based pilot study to proactively target high-risk, low-income, older patients with SDH needs. Over a six-month planning period, leadership from a PC clinic and a community based aging services organization (CBO) collaboratively created a shared infrastructure for in-office SDH screening by clinicians with direct referral to CBO for SDH support. The research team addressed challenges of workflow and barriers to sharing/accessing electronic health records. The pilot program will cover a 2-year period  in which patients are screened at annual visits and followed-up in the community. In the first 6 months, 286 patients were screened, from which 34 (12%) CBO referrals were made, and nine patients were receptive to receiving more information, suggesting a need to explore patient barriers and receptiveness to services/supports. We report on lessons learned, adaptations to the pilot, efforts to increase identification of eligible patients, and strategies to enhance uptake of services beyond the traditional health care setting. Investment in health and aging services partnerships is a viable pathway to reducing health care use and spending, especially for older adult populations


Conventional imaging methods, such as ultrasonography, computed tomography, and magnetic resonance imaging may be inadequate to accurately diagnose lesions of the head and neck because they vary widely. Recently, the arterial spin labeling technique, especially pseudocontinuous arterial spin labeling (pCASL) with the three-dimensional (3D) readout method, has been dramatically developed to improve diagnostic performance for lesion differentiation, which can show prominent blood flow characteristics. Here, we demonstrate the clinical usefulness of 3D pCASL for diagnosing various entities, including inflammatory lesions, hypervascular lesions, and neoplasms in the head and neck, for evaluating squamous cell carcinoma (SCC) treatment responses, and for predicting SCC prognosis.As functional magnetic resonance imaging, arterial spin labeling (ASL) techniques have been developed to provide quantitative tissue blood flow measurements, which can improve the performance of lesion diagnosis. ASL does not require contrast agents, thus, it can be applied to a variety of patients regardless of renal impairments and contrast agent allergic reactions. The clinical implementation of head and neck lesions is limited, although, in recent years, ASL has been increasingly utilized in brain lesions. Here, we review the development of the ASL techniques, including pseudocontinuous ASL (pCASL). We compare readout methods between three-dimensional (3D) turbo spin-echo and 2D echo planar pCASL for the clinical applications of pCASL to head and neck lesions. We demonstrate the clinical usefulness of 3D pCASL for diagnosing various entities, including inflammatory lesions, hypervascular lesions, and neoplasms; for evaluating squamous cell carcinoma (SCC) treatment responses, and for predicting SCC prognosis. Understanding the blood flow characteristics of lesions in the head and neck, as well as morphological features, is vital for accurate pretreatment diagnosis or post-treatment follow-up because blood flow is variable according to the entities of lesions and is changeable depending on the treatment response.Among all imaging modalities that are currently feasible in clinical fields, color Doppler ultrasonography (US) is a possible option for evaluating blood flow in lesions and has been used for assessing perfusion properties of superficial organs, such as the salivary glands. However, it may be an inappropriate tool to evaluate lesions that are located in the deep structure of the head and neck . As alteRecently, arterial spin labeling (ASL) techniques have been clinically applied to provide noninvasive quantitative tissue perfusion assessments without contrast administration . AdditioASL utilizes arterial blood water as an endogenous diffusible tracer by inverting blood magnetization using radio frequency (RF) pulses in the carotid and vertebral arteries . LabeledASL was initially introduced, in the 1990s, to the brain field to calculate cerebral blood flow after rat experiments ,40, and PASL was proposed in 1994 ,45 and eThe pCASL technique is considered to be a combination of both CASL and PASL advantages, which employs 1000 or more shaped RF pulses at a rate of approximately 1 per ms. Thus, the temporal duration of the labeled bolus is longer in pCASL than in PASL because the blood in pCASL is continuously inverted as it flows through a labeling plane, which implies superior labeling efficiency to CASL, and causes better SNR than PASL and CASL ,47,48. TThe application of ASL techniques in the head and neck region was delayed although its utility was initially developed in the cerebral perfusion quantification, mainly because of less perfusion and more complex vessel anatomy in the head and neck than those in the brain, which cause lower primary signal due to low proton density and susceptibility effects . Here, wTo the best of our knowledge, the thyroid was the first organ in the head and neck that was documented in the clinical usefulness of ASL images . In 2009In 2015, Fujima et al. reported that TBF measurement by pCASL with multi-shot spin-echo (SE)-EPI was feasible in patients with head and neck SCC . They deIn 2016, Fujima et al. successfully reported the usefulness of pCASL with multi-shot SE-EPI and the same matrix size and acceleration factor as those in the report in 2015 for assessing the treatment response in nonsurgical treatment . Their sSeveral studies, from 2015 to 2018, have reported on ASL techniques for evaluating parotid gland lesions. Kami et al. reported on the parotid blood flow of Sjögren’s syndrome glands, which were significantly higher than those of healthy glands using 3D turbo spin-echo (TSE) pCASL . Kato etASL signals obtained using the labeling methods can be imaged by various types of readout sequences. Readout methods for pCASL should be optimized to improve the SNR of pCASL to evaluate head and neck lesions. EPI provides high sensitivity, rapid volumetric data acquisition , and robk-space [k-space is very low, which can be problematic [k-space, as well as its center using an optimized-variable flip-angle scheme [Meanwhile, 3D readout methods provide higher SNR due to off-resonance artifact insensitivity  and supek-space . Howeverblematic . Wherease scheme . Severale scheme ,55.We previously evaluated the difference between the image quality of pCASL with 2D EP and 3D TSE using Cartesian acquisition . All imacontrol and SIlabel are the time-averaged signal intensities in the control and label images, respectively. T1,blood is the longitudinal relaxation time of blood (1650 ms), α is the labeling efficiency (0.85), SIPD is the signal intensity of a proton density-weighted image, and τ is the label duration (1650 ms). The value of λ was 1.0 mL/g. We used the same model and conditions as those used for calculating blood flow in the brain to calculate TBF. We show that 3D TSE pCASL has a better head and neck blood flow delineation than 2D EP pCASL with higher SNR and less image distortion -related disease is a systemic fibro-inflammatory disease, which can affect the salivary glands in more than 30–40% of patients, submandibular glands more often than parotid glands, and bilateral salivary glands more often than unilateral salivary gland . Other tVascular lesions are rare entities in the head and neck but can be clearly depicted by a pCASL image if the lesions have the hypervascularity feature. These lesions can affect the pediatric population; thus, noninvasive methods for diagnosis should be prioritized before endovascular treatment or surgery. Regarding brain lesions, Kishi et al. reported a case of hemangioblastoma in the cerebellopontine angle showing extremely high tumor blood flow on the pCASL image, which provided additional useful information for the differential diagnosis of schwannoma and meningioma . LikewisCarotid body paraganglioma , arterioAs an advanced ASL technique, contrast inherent inflow-enhanced multiphase angiography (CINEMA), introduced by Nakamura et al., provides the information on hemodynamics and structure of vessels in the target tissue without contrast agents ,67. The Differentiating MTs from benign tumors, which comprise 45% of PAs, followed by WTs, is essential among various types of salivary gland tumors. Kato et al. successfully showed that the ASL method was useful in differentiating WTs from PAs and MTs using tumor-to-parotid gland signal intensity ratios (SIRs) to facilitate salivary tumor diagnosis . Howeverall, which represented all parameters of ADC in combination, showed the best diagnostic performance [all, which represented all parameters of TBF combined, and ADCall as compared with the AUC value for TBFall or ADCall alone for differentiating MTs from PAs and WTs [Our previous study utilized histogram analysis for evaluating the difference of TBF measured by 3D TSE pCASL among PAs, WTs, and MTs. Histogram analyses are considered to be strong and reliable quantitative surrogate markers of tumor heterogeneity . As a reformance . Reporteformance . We obta and WTs . We conc and WTs .pCASL has been also reported to be useful in differentiating other head and neck tumors. SCC is the most common malignant tumor, and inverted papilloma is the most common benign tumor in the nasal or sinonasal cavity . Fujima Ahn et al. evaluated the histogram TBF parameters derived from pCASL between human papillomavirus (HPV)-positive and -negative in oropharyngeal SCC . OropharFujima et al. revealed that a decreased TBF in patients with head and neck SCC reflected a treatment effect, such as a decreased intratumoral arteriovenous shunt or a reduced vascular bed volume after chemoradiotherapy or endothelial cell damage of blood vessels by radiation therapy . These tFujima et al. applied 2D EP pCASL to measure the TBF of SCC as a prognostic indicator and reported that lower pretreatment TBF likely indicated a poor prognosis in patients with SCC in the head and neck regions, such as nasal or sinonasal cavity and oropharynx, who were treated with superselective arterial infusions of cisplatin with concomitant radiation therapy . AdditioFujima et al. also showed that an increased TBF in patients with a good prognosis could be observed just after the second arterial cisplatin infusion of superselective arterial infusions of cisplatin with concomitant radiation therapy, which was consistent with the previous study with CT perfusion ,81. TheyMore recently, machine learning (ML)-based analyses have been increasingly applied for evaluating various types of lesions. Fujima et al. revealed an ML algorithm combining MRI data including pCASL, DWI, and conventional MRI, such as T1WI and T2WI could highly predict the treatment outcome in patients with sinonasal SCCs . In theiFinally, ASL is an emerging technique that provides perfusion information of lesions. We successfully obtained images with excellent SNR by using pCASL with the 3D TSE readout method, although the application of this technique to the head and neck region was initially difficult as compared with the brain. Thus, we demonstrated that this method might enhance the diagnostic performance of critical lesions, such as inflammation, vascular lesions, salivary gland tumors, and head and neck SCCs. ASL can provide useful blood flow-related information in a lesion with high sensitivity, but the drawback includes intrinsically inadequate anatomical and morphological data. Thus, a machine learning-based analysis should be applied to diverse head and neck lesions in the future to obtain quantitative data from both morphological and functional MRI sources, including ASL images, which may further improve diagnostic accuracy.


Janus particles have emerged as a novel and smart material that could improve pharmaceutical formulation, drug delivery, and theranostics. Janus particles have two distinct compartments that differ in functionality, physicochemical properties, and morphological characteristics, among other conventional particles. Recently, Janus particles have attracted considerable attention as effective particulate drug delivery systems as they can accommodate two opposing pharmaceutical agents that can be engineered at the molecular level to achieve better target affinity, lower drug dosage to achieve a therapeutic effect, and controlled drug release with improved pharmacokinetics and pharmacodynamics. This article discusses the development of Janus particles for tailored and improved delivery of pharmaceutical agents for diabetes treatment and antimicrobial applications. It provides an account of advances in the synthesis of Janus particles from various materials using different approaches. It appraises Janus particles as a promising particulate system with the potential to improve conventional delivery systems, providing a better loading capacity and targeting specificity whilst promoting multi-drugs loading and single-dose-drug administration. Janus particles are a special type of nanoparticles or microparticles with surfaces having two or more different physical properties . The terJanus particles react similarly to amphiphilic molecules with a spatial separation of two physiochemically as well as functionally distinct parts on their surfaces and also within the particles . Thus, aIn general, Janus particles are classified into polymer-polymer, polymer-inorganic, lipid, metallic, organic-inorganic, organic-organic, and inorganic-inorganic particles based on the materials used for their synthesis . MoreoveThis article discusses novel concepts in the synthesis of various Janus particles from different materials (in both micro and nano sizes), focusing on their varying structural and functional characteristics for tailored and improved pharmaceutical applications. The potential of Janus particles for diabetes treatment and antimicrobial applications is also discussed.Janus particles were discovered and developed in the search for a novel drug vehicle that can accommodate multiple drugs via double emulsion systems. This class of particles refers to colloidal particles with anisotropic properties and an asymmetric geometry due to chemical and/or polarity variations ,16. FiguIn general, Janus particles are divided into two main groups, such as compartmentalized and patchy forms, based on their morphology. Compartmentalized Janus is a complex particle consisting of various phase-divided domains within a core, whereas patchy Janus particles have precisely controlled patches with different surface structures . The advJanus particles are structurally distinguished by the presence of two distinct hemispheres with unique properties, such as morphologies, physiochemical characteristics, and functionalities in a single entity . Numerouco-glycol)-(PLGA)/polycaprolactone (PCL) Janus particles for the successful delivery of both hydrophilic and hydrophobic drug molecules. They applied a novel double emulsion technique to encapsulate two drugs with different water solubility into biocompatible Janus particles and deliver them together. They demonstrated staggered release of the drug molecules with independent release kinetics. The staggered release of drugs is particularly advantageous in treatments that require the administration of multiple drugs sequentially at specific rates over a limited period. This allows pre-programmed release characteristics of Janus particles to meet different therapeutic requirements. Results showed excellent encapsulation efficiency (85–94% for hydrophobic and 68% for hydrophilic agents), successful compartmentalization of agents within the carrier to avoid interference, and controlled release of two agents over time [It is worth noting that different structures of Janus particles can lead to unique physicochemical and functional properties . For exaver time  as shownIn another study, advances in dual-reacting Janus particles for biomedical applications have been demonstrated by the carriage and release of payloads with stimuli-only behavior. This release pattern cannot be achieved with core-shell or monomorphic nanoparticles. A thermo-reactive polymer named poly(2-hydroxyethyl methacrylate) (PHEMA) and a pH-sensitive polyelectrolyte called poly(2-dimethylaminoethyl methacrylate) (PDAMEMA) were used as carriers for doxorubicin and ibuprofen, respectively. The resultant Janus particles have two different morphologies (snowman-like and dumbbell-like shapes), with different loading capacities for both drugs. The study showed that doxorubicin was rapidly released under low pH conditions due to its high solubility, while the release of ibuprofen was higher under neutral pH conditions (~7.4) . This tuOther studies have also shown the promising potential of Janus particles. Studies show gold-nickel Janus nanorods for non-viral delivery of vaccines and genes with higher transfection efficiency ; polymerMasking, self-assembly, microfluidic approach, and phase separation are the common methods for the fabrication of Janus particles, as summarized in Masking is a manufacturing technique based on the chemical alteration of one side or compartment of particles to create asymmetric Janus particles. It is a simple method that allows the coupling of different functional groups to generate Janus particles. In this method, Janus particles are formed when the uncovered hemisphere is masked by chemical reagents, which later trigger their unique properties, or when the particles are confined at the interface of two immiscible mixtures . The masThe self-assembly approach is widely used for the competitive surface assimilation of incompatible ligands, such as hydrophobic and hydrophilic ligands, on particle surfaces and for block copolymer formation, including di- and tri-block copolymers as summarized in Microfluidics is a method that requires an organic solvent (dispersed phase) to dissolve both hydrophilic and hydrophobic compounds. Later, the dispersed phase is injected into an aqueous phase to create amphiphilic droplets by controlling the flow rate of both the dispersed and aqueous phases. This technique allows equal quantities of different polymers to be encapsulated in the resultant droplet as the dispersing phase exerts the same shear force, resulting in the formation of Janus beads. Subsequently, polymerization is initiated by thermal initiation or UV irradiation . A modifThe concept of the phase separation technique is based on an oil-in-water emulsion, where the oil phase consists of two incompatible polymers, that are homogeneously mixed with the help of a co-solvent and dispersed dropwise in a water phase, followed by precipitation of Janus particles after evaporation of the solvent as summarized in Several factors must be considered while synthesizing Janus particles with symmetrical compartments, which include the degree of incompatibility and the molecular weights of the two compounds, as well as the interfacial tension at the water-solvent interface. It has been reported that compounds with a high degree of incompatibility and a high molecular weight in addition to a low interfacial tension can produce more symmetric Janus particles ,72. ThusRecently, several effective drugs have become available on the pharmaceutical market. However, their efficacy in the treatment of common diseases, such as cancer, diabetes, and neurodegenerative diseases is still hampered by factors, including low targeting, systemic cytotoxicity to other normal cells, poor solubility and hydrophobicity, excessive and frequent dosing, and rapid renal filtration ,78,79. TDiabetes is a major health problem, and according to the World Health Organization (WHO), more than 366 million cases of diabetes complications are expected worldwide by 2030 . Generalco-glycolic acid) (PLGA) and polycaprolactone (PCL) by a one-step emulsion-solvent evaporation technique [Among the various applications of Janus particles for drug delivery, it has been utilized for the treatment of diabetes . In thisechnique ,99. In aechnique . In thisAnother Janus particle, composed of the biopolymer ethylene vinyl acetate (EVA)/poly(L-lactide) (PLLA), was used to encapsulate superparamagnetic iron oxide nanoparticles (SPIONs) in addition to rapamycin and glibenclamide. The use of SPIONs to release drugs selectively represents a novel and potentially effective method for diabetes treatment. The encapsulated SPIONs triggered the release of glibenclamide from Janus particles via the application of radiofrequency, especially during meal ingestion, and suppressed insulin secretion, when it is not required ,101. Thi2O3/SiO2 nanoparticles (JFSNs) as a biosensor for the detection of glucose and hydrogen peroxidase was demonstrated by colorimetric measurement over a wider range of pH and temperature with great stability. The study demonstrated that JFSNs with asymmetric properties can be immobilized with glucose oxidase to provide highly selective and reproducible colorimetric detection of glucose, exhibiting the catalytic effect of both glucose oxidase and peroxidase. Consequently, Janus particles can be used to integrate two different detection systems as a multifunctional glucose biosensor to diagnose glucose content in samples such as blood serum [Janus particles have been extensively studied to improve the targeted diagnosis of diabetes, as indicated in od serum . In addiod serum . The fluThere are a variety of antidiabetic drugs that have been developed to treat diabetes through different mechanisms, either to increase insulin levels in the body or to achieve successful islet transplantation. Rapamycin is a hydrophobic immunosuppressant that is widely used in chemotherapeutic treatments and the suppression of post-transplant rejection. Rapamycin acts by moderating the body’s immune system to suppress immune rejection of the graft for post-transplant diabetes treatment ,106. Dex+ and Ca2+ channels, ATP-sensitive K+ channels, and non-selective cation channels. It also regulates exocytosis and intracellular energy homeostasis and stimulates islet cell growth, insulin gene transcription, and neogenesis [Further, Janus particles can facilitate the long-term release of immunosuppressants such as rapamycin and dexamethasone when co-administered with islet transplantation. They allow sustained release of immunosuppressants for up to 30 days, which is twice the duration of natural islet cell rejection. This is achieved by controlling the mixing ratio of the particles, the interfacial tension, and the spreading coefficient. Janus particles represent a smart engineering approach to increase the solubility limit, slow the degradation of immunosuppressants, and maintain the minimum therapeutic dose via the right biopolymers with high loading capacity and slow degradation rate. For example, the half-life of rapamycin in the blood is 15 h. It is possible to release the drug continuously in the blood for three weeks with biopolymers, such as PLGA ,109,110.ogenesis . It has ogenesis .In a recent study by Fan et al. (2019) , novel rInnovative Janus particles with distinct and independent compartments are an intelligent delivery system that can release both γ-aminobutyric acid (GABA) and glucagon-like peptide 1 (GLP-1) either simultaneously or sequentially at desired time intervals, allowing spatially controlled encapsulation of different functionalities. This can be achieved by the proper selection of polymers to form asymmetric structures that can control the loading capacity and release pattern of different bioactive ingredients with incompatible properties in a single particle . RecentlE. coli in 24 h, along with UV protection properties (ultraviolet protection factor (UPF)—733) and high hydrophobicity with a contact angle of 152°, which can be attributed to the shape of Janus particles [Staphylococcus aureus after being introduced into a cotton fabric [Staphylococcus aureus and Gram-negative Pseudomonas aeruginosa due to their Janus structure. In addition, the Janus structure altered the dissolution rate of iron in a sodium-phosphate buffer solution, with a higher dissolution rate for iron-copper samples than for iron-silver nanoparticle samples [Recently, several Janus particles were identified to have antimicrobial activity and were either incorporated into textiles or used as microbial inhibitors. Hou et al. (2021)  synthesiarticles . In addiarticles  preparedn fabric . Moreoven fabric  demonstr samples .Botrytis cinerea fungi. In addition, these materials also showed antibacterial activity against Bacillus subtilis, E. coli, Staphylococcus aureus, and Salmonella choleraesuis [S. aureus and E. coli due to the release of silver ions and the phenolic hydroxyl groups of cardanol. Moreover, these structures were found to have little or no cytotoxicity [Jia et al. (2015)  synthesieraesuis . Additioeraesuis  used redtoxicity . All theE. coli pathogens by rotational diffusometry through the amplification of specific genes. The detection was found to be specific for E. coli DNA at 50 pg/µL. This technique was shown to be superior to a conventional polymerase chain reaction (PCR) with an improved detection time of less than 60 min [E. coli isolates of initial 50 cells per drop of concentration within 20 min [Salmonella typhimurium as shown in S. typhimurium with a limit of detection (LOD) of 102 colony-forming unit (CFU) [Apart from antimicrobial efficacy, Janus particles possess enhanced biosensing ability. Recently, Das et al. (2021) used Janus particles prepared from fluorescent polystyrene particles (1 micron) for the detection of n 60 min . Furthern 20 min . Furtherit (CFU) . Thus, JAlthough Janus particles have gained attention only in recent times, they have been used for pharmaceutical applications and have been under extensive research. For example, certain commercially available bilayer drug tablets are manufactured in the Janus dosage form to encapsulate and deliver two different or incompatible active pharmaceutical ingredients (APIs) for different therapeutic effects ,130. JanMoreover, Janus particles offer tremendous superiority in terms of size, surface properties, and shape, and provide the desired biodistribution, pharmacodynamics, and pharmacokinetics . Their lJanus particles represent a unique innovation in the field of biomedical materials and enable the application of biodegradable Janus particles for in vivo bioimaging and therapeutic delivery, as they can be engineered to have minimal/no toxicity . For exaChallenges still associated with Janus particles include nanoscale size control, development of Janus particles with uniform shape, scalability of production at high yield, low production cost, and regulatory hurdles . It is sJanus particles are a promising platform for the development of tuneable and robust multimeric formulations with different payload capacities and targeting capabilities for different disease conditions. They offer the possibility of combining different pharmaceutical agents in a multimodal treatment to improve therapeutic efficacy. This article focuses on the unique properties and importance of Janus particles as advanced formulations for pharmaceutical applications. The use of Janus particles promises to overcome the drawbacks of conventional delivery systems, such as high therapeutic doses, frequent drug administration, low specificity to target cells, and single drug loading applications. In addition, Janus particles possess several advantages to improve drug efficacy in terms of better solubilization, bioavailability, and pharmacokinetics. Nevertheless, further research efforts are essential to overcome the limitations of Janus particles and enhance their potential for broad theranostic application.