Vaccination is still the most cost-effective way to combat infectious illnesses. Conventional vaccinations may have low immunogenicity and, in most situations, only provide partial protection. A new class of nanoparticle-based vaccinations has shown considerable promise in addressing the majority of the shortcomings of traditional and subunit vaccines. This is due to recent breakthroughs in chemical and biological engineering, which allow for the exact regulation of nanoparticle size, shape, functionality, and surface characteristics, resulting in improved antigen presentation and robust immunogenicity. A blend of physicochemical, immunological, and toxicological experiments can be used to accurately characterize nanovaccines. This narrative review will provide an overview of the current scenario of the nanovaccine. Vaccination is the practice of delivering an antigenic substance into a person’s body to activate their immune system and generate adaptive immunity against a pathogen . It has A nanoparticle is defined as a particle with at least one dimension of <100 nm. It is considered to be the building block for nanotechnology. The ability to synthesize and manipulate such materials has led to a recent resurgence in the use of particles in these size ranges by several industries and humans . The use2) NPs, carbon black NPs, and titanium dioxide (TiO2) NPs, for example, have been shown to stimulate the nucleotide-binding domain-like receptor protein 3 (NLRP3)-associated inflammasome ) were used as expression hosts [® by Pasteur- Mérieux Aventis and Sci-B-Vac™ by SciGenin Israel are examples of recombinant HBsAg based on VLP [A number of vaccines that use VLPs have also been approved for use against the hepatitis B virus (HBV) and HPV. The recombinant HBV vaccine is a huge achievement since it is the first commercially available vaccine based on VLPs. The vaccine contains a recombinant hepatitis B virus core antigen (HBsAg), and for the production of immunogenic VLPs, yeast  are other vaccine delivery vehicles that have been shown to have strong adjuvant properties in clinical trials. These micelles (40 nm in size) contain colloidal saponin  , cholestCibulski et al. evaluated the immunological activities of ISCOMs formulated using cholesterol, phospholipids, and OVA as a model antigen derived from Quillaja brasiliensis (QB-90). When IQB-90 was subcutaneously administered, specific IgG1 and IgG2 antibodies were produced, as well as T-cell proliferation and increased Th1 cytokine production. An advantage over traditional ISCOMs based on Quil A is that intranasal delivery stimulates serum IgG, IgG1, and mucosal IgA responses at distal systemic sites .Polymeric NPs are remarkably fascinating for the administration of vaccines due to their biodegradability, stability, safety, ease, surface modification, biocompatibility and predictability ,113,114.Mtb hypoxic lysate. Adsorption of Rv1733c DNA on PLGA-PEI nanoparticles and application to the lungs increased T-cell proliferation and IFN-γ production more than intramuscular vaccinations. Pulmonary priming with np-adsorbed Rv1733 cDNA followed by Rv1733c protein boosted the greatest immunogenicity. According to these findings, PLGA–PEI np can be used to deliver DNA vaccines through pulmonary delivery to enhance T-cell responses in a DNA prime/protein boost vaccine regimen [Another important polymer in polymeric NPs is polyethyleneimine (PEI), which is known to be a cationic polymer and is extensively used in DNA delivery and gene therapy applications. Apart from poly-L-lysine (PLL), PEI is an acceptable nonviral nucleic acid transfer agent . A PEI-b regimen .Studies have been conducted on inorganic nanoparticles for their potential use in vaccines. Inorganic NPs have benefits for vaccine distribution due to their hard structure and predictable fabrication; however, they are predominantly nonbiodegradable. To enhance the immune response, inorganic NPs have been used as adjuvants and delivery vehicles. The main inorganic NPs are carbon, silica, calcium phosphate, aluminum-based, gold and magnetic nanoparticles. Several studies have been performed on how the size and shape of an inorganic nanoparticle can affect vaccine delivery . Tsai etGold nanoparticles (AuNPs) are easily fabricated into a variety of shapes . These types of nanoparticles can induce humoral and cellular responses . By conjBased on a study by Xu et al., gold nanorods were modified with poly or polyethyleneimine, which significantly enhanced cellular and humoral immunity, as well as T-cell proliferation, by activating antigen-presenting cells, compared with naked HIV envelope plasmid DNA treatment in vivo . Wang anFor decades, emulsions have been extensively used in the formulation of vaccines, and currently, they are being researched for use in vaccine delivery systems. Since emulsions are thermodynamically unstable, they can separate into two different phases, i.e., oil and water ,153,154.Furthermore, microemulsions (MEs) are newly developed vaccine delivery systems that possess higher target specificity and more therapeutic effectiveness than nanoemulsions in terms of spontaneous production and thermodynamic stability ,157,158.v/v) and two surfactants, polysorbate 80  and sorbitan trioleate , which are emulsified in citrate buffer to produce droplets of ~160 nanometers in size. BALB/c mice were immunized intratracheally along with two booster doses, resulting in antigen-specific antibodies, lower bacterial loads in the blood and lung tissues, and a reduction in inflammatory cytokines [To protect against Acinetobacter baumannii infections, Yang et al. designed a vaccine combining the OmpK/Omp22 fusion protein with MF59, which is an oil-in-water (o/w) emulsion containing squalene  can be accurately characterized through physicochemical, immunological, and toxicological tests. In NVs, the main objective is to facilitate an efficient immune response to the cargo while reducing nanocarrier (NC) reactions. Each critical parameter must be evaluated according to its mechanism of action and the impact it has on the performance of every component in the formulation. Additionally, mRNA- and protein-based NVs will require different characterization techniques. Moreover, the immunogenicity and safety of the formulation are influenced by its physicochemical properties ,199. To Extracellular vesicles (EVs) are a class of bi-layered membrane vesicles with a diameter of less than one nanometer that are created by practically all cells. Body fluids such as blood, saliva and breast milk naturally contain EVs. Traditionally, EVs are categorized according to their size, chemical content, and biogenesis route. According to their biosynthesis, exosomes and microvesicles are the two primary categories of EVs that may be widely defined. Multivesicular bodies (MVBs) produce extracellular vesicles (EVs) such as exosomes, which are 30–150 nm in diameter before being expelled upon MVB integration with the plasma membrane. The outward budding of the plasma membrane, which is controlled by the movement of phospholipids, results in the formation of microvesicles . ExosomeIt is possible that exosome-based vaccines will be widely used therapies in the future because of their involvement in disease development, their function in preventing viral infections, and their ability to induce a host immune response. Exosomes and viruses are comparable in terms of size, molecular make-up, biomolecule transfer methods, ability to enter host cells, biosynthesis and growth of viruses in host cells. One well-known example is human immunodeficiency virus (HIV-1), which accelerates its spread throughout the host’s body by manipulating EV biogenesis via the ESCRT pathway. As a result of changes in EV cargo during viral infection, including the transfer of viral particles into uninfected cells and modulation of immune response, researchers have also characterized EVs, investigated their therapeutic potential (as a drug delivery system) or used them to present antigens for safe vaccine design . AdditioExosomes may carry and distribute substances to target cells in infectious diseases, making them a double-edged sword . ExosomeAdditionally showing promising results was a vaccination formulation that used unaltered exosomes as adjuvants for the recombinant HBV antigen, with exosomes inducing a Th1 immune response and raising mouse IFN-g levels as a result. More study is needed to identify potential therapeutic targets for HBV vaccine candidates that use exosomes as adjuvants or delivery mechanisms. Despite the wide variety of vaccine types available for influenza infection, studies have shown that exosomes can be used as a unique platform for developing influenza vaccines, with benefits above those from conventional vaccinations. For instance, exosomes released from the airways during influenza infection may contain host proteins that have anti-influenza characteristics and may stimulate immunological responses . ExosomeS. aureus-induced fatal sepsis. Additionally, when Streptococcus pneumoniae-derived EVs were cultured with murine DCs, they internalized quickly and increased the production of the inflammatory mediator tumor necrosis factor (TNF)-a [Schistosoma mansoni is the primary parasite that causes the widespread disease schistosomiasis, which kills more than 280,000 people each year worldwide. There is currently no vaccine against schistosomiasis, which emphasizes the importance of developing such a vaccine. Exosome immunization against S. mansoni infection has only been proposed by a small number of writers [S. mansoni worms contain miRNAs and proteins crucial in host-parasite interactions, including nutrition acquisition, invasion and immunomodulation [S. mansoni featured multiple candidates for vaccines, comprising proteins involved in several life cycle phases, suggesting their potential significance at different phases of the parasite’s life cycle [Bacterial exosomes and outer membrane vesicles (OMVs) have been found to be powerful immune modulators instead of pathogenesis-inducing agents. As a potential venue for multiple contagious disease vaccines, it has become increasingly popular to synthesize EVs from gram-positive bacteria. Staphylococcus aureus-derived EVs have been modified to be nontoxic and serve as potential vaccine candidates. Genetically modified EVs have been shown to display immunogenic effects and protect mice against  (TNF)-a . Schisto writers ,247. Exofe cycle .Exosome-based clinical studies can be categorized into three groups, each with a different methodology. Exosomes can first be utilized to transport medications to specified sites. Exosomes are also made from mesenchymal stem cells. Additionally, patient reactions are triggered by exosomes that contain particular mRNAs and miRNAs . In 2005One of the typical gastrointestinal conditions seen in clinical practice is colorectal cancer (CRC). Malignant ascites can develop when CRC cells enlarge and seed the peritoneal cavity. In clinical practice, patients with malignant ascites always have a poor prognosis. However, therapeutic treatment of CRC patients with ascites may benefit from the extraction of exosomes found in effusions and the activation of immune responses against cancer by exosomes produced in ascites (Aex). Aex is a safe, nontoxic, and tolerable cancer vaccine. According to Shengming Dai et al., Aex from CRC patients can be used to induce anticancer immunity, and adjuvant GM-CSF can significantly boost Aex’s effectiveness. In vivo DTH testing demonstrated that Aex alone is sufficient to induce systemic anti-Aex immunity, indicating that Aex is immunogenic on its own. Aex can activate CD8+ CTLs and may induce antitumor immunity specific to tumor antigens such as carcinoembryonic antigen (CEA). In vivo and in vitro, exosomes generated by heat-stressed CEA-positive tumor cells can both initiate and increase an HLA-A*0201-restricted and CEA-specific CTL response due to their ability to collect HSPs and MHC-I molecules . An exosDue to the coronavirus outbreak, the priority of exosome-based therapeutic clinical studies has recently switched from addressing cancer to combating COVID-19 in an attempt to design novel vaccines ,255. An Exosome therapies are being used in 12 ongoing clinical trials at ClinicalTrials.gov. Exosomes overexpressing CD24 at two dosages with a patient follow-up of 23 days are being tested in phase I (NCT04747574) and phase II (NCT04902183) independent clinical trials on patients with mild or severe COVID-19 infection. Currently, two phase I and II clinical trials (NCT04602442 and NCT04276987) are being conducted to determine whether aerosol inhalation of bone marrow MSC-derived exosomes is effective and safe in treating severe SARS-CoV-2 pneumonia and COVID-19 patients within 28 days of the initial treatment. A phase I/II clinical study (NCT04798716) is investigating the efficacy and safety of administering MSC-derived exosomes to severe COVID-19 patients on an ascending dose of 2:4:8 every other day. These clinical trial descriptions suggest that MSC-derived exosomes may lessen pathological impairment and lung inflammation. Only one trial’s findings have been released thus far (NCT04491240), following a 10-day period in which patients inhaled 3 mL of MSC-derived exosomes twice daily, and there have been no reports of any negative side effects. Due to their ability to elicit anti-inflammatory effects and alter immunological responses, MSC-derived exosomes may be useful in the design and development of future COVID-19 vaccines .Almost all of the vaccinations that are considered to be the safest and highly efficient are those that are centered on attenuated forms of live agents , which culminate in an infection but do not lead to diseases . ConversAs viral vector distribution has the potential to escalate public health concerns that might impede wider adoption, nonviral means of gene administration are rapidly being investigated. Nonviral vectors, such as NPs, are widely utilized in diagnostic imaging and medicine administration, among other uses. Intracellular uptake is made easier by the NPs’ small size, which is generally under 200 nm in diameter. Because viruses and NPs share a comparable size range, nanotechnology has the potential to have profound effects on vaccine development. It is possible to use NPs to encapsulate medications that may be delivered to diseased cells , and encNucleic acids are difficult to deliver into cells due to their susceptibility toward endogenous nucleases, heavy negative charges on the nucleic acids hinder cell internalization, and the unspecified interferon signal generated by the involvement of foreign nucleic acids inside the cytoplasm, all of which are substantial obstacles to clinical translation . ConsequOnly a handful of nanomaterial-based nucleic vaccine delivery systems have made it into clinical trials successfully, and none have been given the go-ahead for usage thus far. For the induction of specific humoral and cell-mediated immune responses, nucleic acid vaccine strategies have been found to be effective in human trials, but from a therapeutic point of view, there are still some limitations, as the dose regimen requirement in humans is much higher than the animal doses . VaxfectThe uptake of NPs and immunogenicity are quite closely related. When nanomaterials are introduced into the living system, the body evokes an immune response in the form of inflammation. Having greater insight into the correlation of NPs with the immune system would yield useful information about the possible health benefits and toxicity elicited by the NPs inside the body . FurtherCellular uptake into dendritic cells is significantly improved when delivered by using NP as a carrier rather than via the drug molecule alone; in some cases, an uptake increase of 30 times was found to be achieved ,283. TheIn addition to the extent to which they are absorbed by the cells, the mechanisms through which NPs enter cells will have a substantial impact on the type of immune response that is elicited . To achiThe uptake mechanism of NPs is also greatly influenced by the physicochemical properties of the particles . PolymerNanocarriers have a number of advantages over traditional vaccines in regard to the delivery of antigens. One of the major advantages is that NPs are identified as foreign materials by the immune system, leading to an enhanced immune response. Additionally, they increase the amount of time the antigen is exposed to the immune system by causing the formation of an antigen depot that releases antigen gradually ,317. It Even though a great deal of research has gone into making new delivery platforms focusing on nanotechnology, there are still few nano-based adjuvants in business. Existing research intends to design smart platforms capable of facilitating the detection and conveyance of multiple antigens plus warning signals, primarily to DCs and highly potent APCs . NanovacHowever, the scientific community, businesses and regulators face significant obstacles in promoting these products’ commercialization as well as in preventing their failure in subsequent phases of clinical testing. Despite the immense and innumerable prospective benefits, exhaustive study is still desired to determine the effects of the distinct physicochemical characteristics and modes of action of nanotechnology-based systems on bioavailability, intracellular signaling, cellular internalization, and cellular uptake ,332,333.Regarding the safety issues relating to physicochemical attributes and the ensuing interactions with biological systems, precise input should be given to regulators. The recommended route of administration for upcoming clinical usage must be studied, and rigorous toxicology investigations must be conducted for a vaccine lot generated utilizing the raw components and manufacturing techniques that will be used for the final vaccine product. Necessarily, the manufacturer is expected to provide information on local tolerance and repeated dosage toxicology conducted in preclinical studies with at least five male and female animals per batch and time course. It is important to provide information on the animal’s weight, feed intake, local responses, hematological status, and immunology. Additionally, the WHO mandates the reporting of histological evaluations of several tissues, particularly the injection site for vaccines made with novel adjuvants .The potential toxicity of NPs has been a concern with their integration into biomedical settings for a while in part because some materials that are normally thought to be benign change when they are in the form of nanoparticles and can sometimes become hazardous. Owing to their small size, NPs have easy access to numerous body tissues and organs, but they can be a double-edged sword. Injecting the nanovaccine into the skin may produce dermatological issues, consuming it orally may have gastrointestinal effects, and introducing it through the nasal route may provoke respiratory issues. Cardiovascular problems can also be brought on through the parenteral method. Additionally, if these nanomaterials are able to cross the blood-brain barrier, they may harm the brain ,336. Bas2O2 [Researchers have employed a variety of materials, including VLPs, metals, bioceramics, nonmetals, lipids and polymeric materials, to make nanoparticles with various physical, chemical and electrical parameters that interface uniquely with a selected organ or cell. Conversely, NPs may promptly penetrate lipid bilayers, interface with delicate human organs and have a variety of deleterious ramifications . By mean2O2 . Silicon2O2 . Other f2O2 . Surface2O2 .Even considering all of the prospective benefits of nanoparticles, only a few nanoparticle-based pharmaceuticals have obtained clinical licenses. This is due to a number of challenges encountered at various phases of nanoparticle research and fabrication. To fabricate a reliable material with ideal physicochemical and biological properties, the complex nature of NPs as multicomponent 3-D constructions demands a meticulous prototype and technology, an extensive analogous method of analysis and a scaled-up production procedure that can be replicated. Nanomedicines must be investigated thoroughly in clinical trials and in animal models, especially from the perspective of bioavailability, targeting desired areas and potential immunological toxicity. Minor variations in a variety of factors may impact the safety and effectiveness of nanomedicines . Three-dA broad range of NP delivery systems as vaccine carriers or vaccine adjuvants have been utilized, and each present benefits over existing approaches of vaccine delivery. The use of NPs to deliver vaccine components will be advantageous for treatment of various infectious and immunological diseases, as NPs can easily encapsulate target antigens, proteins, peptides, or nucleic acids and provide sustained release or target-specific release of the vaccine payload into immune cells after crossing biological barriers and long-lasting immunological effects. Many of the NPs mentioned in this review are efficient in provoking both cellular and humoral immune responses that would otherwise not be possible with conventional vaccines. Although these NP vehicles may provide exciting prospects for future vaccination strategies, it is also worth noting their potential drawbacks, particularly those associated with cytotoxicity. Since NPs have a comparatively short history in the practice of medicine, they do not have a long-lasting safety profile in human use. However, the recent success of LNP-based COVID-19 vaccines with high effectiveness and even a good safety profile build confidence in the medical community about nanovaccines. Nonetheless, the NP-based vaccine delivery strategy has strong potential as a delivery platform in human infectious diseases and could be adapted for other presently incurable diseases, such as cancer.


We highlight an unusual case of multifocal glioblastoma in an adolescent patient, manifesting as four discrete brain lesions, each distinct in appearance. Familiarity with the diverse imaging features of glioblastoma can reduce misdiagnosis and avoid treatment delays. A 17-year-old, previously well male was admitted to the emergency department with a 2-week history of progressive headaches, nausea and vomiting. This was followed by a single seizure with transient loss of consciousness. CT brain imaging performed on admission demonstrated several masses in both cerebral hemispheres . CT imagFour tumours varying in size and morphology were present within both cerebral hemispheres : Lesion Alpha-thalassaemia X-linked mutant retardation (ATRX) protein expression in tumour cell nuclei, and a very high Ki67 proliferation index ( the tumour was negative for rare IDH1 and for IDH2 (R172) mutations, BRAF (V600), or Histone 3.3  mutations. Epidermal growth factor receptor was amplified (18 copies) and the methyl guanine methyl transferase (MGMT) promoter was unmethylated. The unusual presentation of a tumour, which is most commonly found in adults in their fifth-seventh decade, prompted us to perform a methylation array with subsequent algorithmic classification. This investigation confirmed the presence of a classical IDH wild-type glioblastoma with the methylation subclass receptor tyrosine (RTK) kinase II. The copy number profile (The patient was transferred to the teenage and young adult (TYA) cancer unit, and a biopsy was performed. Histological examination showed morphological evidence of glioblastoma (WHO Grade IV). Post-operatively, the patient suffered a rapid clinical deterioration with increasing headaches, vomiting, blurred vision and new left arm paraesthesia and was commenced on steroids to help alleviate these symptoms. Upon histopathological assessment, immunohistochemical tests showed absence of the most common mutation of isocitrate dehydrogenase (IDH) 1 (R132H) , retaineon index . On mole profile  showed ii.e. when the lesions involve multiple sites and are embedded in deep structures, rapid arc intensity-modulated targeted radiotherapy (54 Gy) was administered alongside adjuvant temozolomide, with palliative intent.As a patient with this histological diagnosis and extent of disease is unlikely to be cured by resection, Initially, a partial radiological response to treatment was observed, with complete symptom resolution. However, at 3 months into treatment a new gadolinium enhancing lesion developed in the dorsal medulla, indicating progressive disease. This new deposit and one of the previously treated cerebral lesions continued to grow. Temporary effective symptom control was achieved with further focal radiotherapy to the site of new disease, but disseminated ependymal and parenchymal disease followed, with death at 11 months post diagnosis. and it may be considered low on the differential list - more so if the imaging findings are perceived as atypical. We would like to draw attention to this case, in which the coexistence of several tumour morphologies could create a diagnostic dilemma. A learning point is to consider the possibility of malignant glioma in cases of multiple brain masses with different imaging appearances.Glioblastoma is a relatively uncommon diagnosis in adolescence,T2 weighted (circumscript vs diffuse) and diffusion-weighted  features encountered in this case are all known to exist within the phenotypic spectrum of glioblastoma, but may be confused with other entities, even dual pathology, when occurring in combination.The diverse post Gadolinium ,  Importantly, rapid progression can occur in glioblastoma and should not deter radiologists from suspecting the diagnosis. Physiological MR imaging  can aid the diagnosis of glioblastoma, however, in this case tissue diagnosis was prioritised because of the fulminant clinical decline.Multifocal cerebral lesions may raise concern for infective-inflammatory aetiologies, especially in a young individual, metastatic disease or lymphoma. It is probable that diverse glioblastoma morphologies represent different stages of the disease. Moreover, evidence exists for significant genetic heterogeneity amongst synchronous tumours as well as within the same glioma through mutational evolution over time ; glioblastomas have been shown to originate up to seven years before diagnosis and acquire most of their driver mutations leading to genetic heterogeneity in this period (i.e. before treatment is initiated).In adult patients, multiple intracranial tumours are present at diagnosis in up to 34% of glioblastomas. ; in our case. the two lesions most closely related to the ventricular surface represented the sites of recurrence and progression.Tumours involving the subventricular zone, as the presumed site of neural stem cell origin of glioblastoma, have been postulated to be more often multifocal and to recur at distant sites associated with poor prognosis and limited response to maximum therapy. Multifocal disease may further shorten the dismal survival of glioblastoma, if gross total resection is difficult to achieve. At present, most high-grade gliomas in adolescence undergo standard glioblastoma therapy, consisting of radiation and chemotherapy (Temozolomide). In the future, rapid genetic and epigenetic tumour profiling may improve focused approaches, for which strategies in development include immune modulation and therapies directed against specific signalling pathways.Multifocal glioblastoma typically have the IDH-wildtype genetic signatureGlioblastoma should be considered as part of the differential diagnosis in young patients presenting with multiple brain masses. The disease may exhibit variable MR imaging features, which can coexist in the same individual.Glioblastoma should be considered in young patients presenting with multiple brain masses.Glioblastoma manifests with variable MR imaging features, which can coexist in the same individual.Imaging findings include enhancing and non-enhancing lesions, with or without diffusion restriction.


Cannabis is the most commonly used psychoactive drug, particularly among adolescents and young adults. Accordingly, to the European Drug Report 2021, the prevalence of cannabis use is about five times that of other substances, so that last year cannabis use among EU inhabitants aged 15 to 24y is estimated at 19.2 %. Even though most human research has concluded that Δ9-tetrahydrocannabinol (THC), tends to dampen rather than provoke aggression in acute doses, recent evidence suggests a relationship between cannabis usage and violent behavior, especially when associated with neurodevelopment stages.To review the existing evidence on the association between cannabis and violence in young adults and provide an overview of possible mechanisms explaining this relation.Literature review was based on PubMed/ MEDLINE, using key words inclusive for violence, cannabis and adolescence. Studies included focused the young-adults population and considered the relation between cannabis use and behaviors reported as acts of physical violence. Studies were excluded if they included self-harm behaviors.Recent studies, including case-reports, showed a global moderate association between cannabis use and violence. Preliminary data has even highlighted a potential larger effect in more frequent users. Also, the cannabis role in the central nervous system (CNS), with most expression in the limbic cortices, and especially as it participates in a variety of brain function modulations - including executive functions, inhibition/impulsivity, and emotional control, has been pointed as one of the main arguments for this relation.Further studies may shed light on the effects of cannabis use on behavior.No significant relationships.


Hydrogel biomaterials in combination with living cells are applied in cell biology, tissue engineering and regenerative medicine. In particular, poly(acrylamide) (PAM) hydrogels are frequently used in cell biology laboratories as soft substrates for 2D cell culture. These biomaterials present advantages such as the straightforward synthesis, regulable mechanical properties within physiological range of native soft tissues, the possibility to be biofunctionalized with ligands to support the culture of living cells, and their optical transparency that makes them compatible with microscopy methods. Due to the chemical inertness and protein repellant properties of PAM hydrogels, these materials alone do not support the adhesion of cells. Therefore, biofunctionalization of PAM gels is necessary to confer them bioactivity and to promote cell-material interactions. Herein, the current chemical strategies for the bioconjugation of ligands to PAM gels are reviewed. Different aspects of the existing bioconjugation methods such as chemo-selectivity and site-specificity of attachment, preservation of ligand’s functionality after binding, user-friendliness and cost are presented and compared. This work aims at guiding users in the choice of a strategy to biofunctionalize PAM gels with desired biochemical properties. Hydrogels are crosslinked polymeric networks that can uptake and retain large amounts of aqueous fluids. This high water swelling ratio, their softness, and the possibility to regulate their biophysical and biochemical properties have made hydrogels the preferred biomaterials to mimic the extracellular matrix (ECM) that supports living cells in their native microenvironment. Therefore, hydrogels with regulated properties are extensively used as supporting materials in cell biology, tissue engineering and regenerative medicine applications.in vitro models allow to investigate how cells sense and respond to variations in this synthetic microenvironment. For instance, the effects of hydrogel’s elasticity and/or biochemical cues on cell adhesion, spreading, migration, differentiation and protein expression have been reported. (Poly(acrylamide) (PAM) hydrogels are synthetic matrices widely used as substrates for 2D cell culture. These reductionistic eported.  PAM hydrPAM hydrogels are typically synthesized by the acrylic-based free radical polymerization (FRP) of acrylamide (AM) and the crosslinker bis-acrylamide (bis-AM), using persulfate and TEMED as redox initiators . For comFor robust experimentation and reproducible outcome during culture of adherent cells on PAM gels, precise tailoring of mechanical and biochemical features of PAM substrates is desirable. Mechanically tunable PAM gels  can be obtained by adjusting the bis-AM crosslinker concentration and/or the total content of acrylamide monomers in the precursor solution, , and numIn this mini review, the most used chemical strategies developed for controlled biofunctionalization of PAM gels for cell culture are presented and compared. Commercial PAM hydrogels have become available; thus they are also introduced. Advantages and limitations of the diverse approaches are discussed, especially in terms of chemo-selectivity and site-specificity of binding, preservation of ligand’s functionality after conjugation, user-friendliness and cost (wherever known).After gel fabrication, PAM chains are (photo)chemically activated, generally under harsh conditions, to introduce reactive groups that are later used as anchoring groups for biofunctionalization. In a second step, the bioligand is covalently coupled to activated PAM gels .PAM hydrogels are photochemically activated by short wavelength UV light irradiation  that forms ozone as well as peroxides and other reactive species on the PAM chains.  The subsThis method is simple and has been reported to enable biofunctionalization of PAM hydrogels in a reproducible and homogeneous fashion. However, this procedure uses harsh photoirradiation conditions that might alter the mechanical strength of modified vs. bare PAM gels. Finally, the lack of chemo-selectivity might lead to poor control of the ligand loading and functionality.via hydrolysis. Using this strategy, different ECM proteins such as collagen I were bound to PAM gels to mediate cell adhesion, for example, to study the traction forces generated during cell migration  and has short shelf life. There is a lack of consensus on the experimental conditions for the photo-illumination step, e.g., in terms of light intensity and irradiation time. Consequently, highly variable irradiation doses can be found in the literature, which is reflected in high variability in the efficiency of bioconjugation. Additionally, poor site-selectivity of the NHS ester/amine binding has been suggested to cause poor binding efficiency and impaired ligand’s bioactivity, leading to inconsistent results in cell response. The amide groups of PAM chains are chemically converted to hydrazide groups by reaction with hydrazine , followed by treatment of the gel with acetic acid . The formed hydrazide groups are subsequently coupled to aldehyde or ketone groups located in biomolecules, forming hydrazone bonds.  AldehydeThis simple procedure has been reported to facilitate uniform, reproducible and efficient protein conjugation on PAM surface using inexpensive commercial chemicals. Additionally, the PAM-hydrazide hydrogels can be produced in big batches and are stable for 2 months.  However,alt-maleic anhydride) (PEMA), and incubated overnight . The anhydride groups of PEMA react chemically with amide groups of PAM hydrogel via covalent imide bond formation that leads to the attachment of a PEMA monolayer onto PAM.  copolymers, such as poly (ethylene-nto PAM.  Subsequento PAM. . The PEMorption.  (Pompe eorption.  Through orption.  Similar orption.  It was forption. .An advantage of this approach is that a stable PEMA layer on PAM surface can be achieved using the inexpensive PEMA (∼70 € per 100 g) in a relatively simple procedure. Spin-coating ensures a thin and uniform layer but could also be a limitation in scaling up production. The lack of specificity and the instability of the ligand binding to the PEMA layer could be a disadvantage for those applications requiring fine control of ligand loading. However, reversible physical interaction between the bioligands and the PEMA layer is advantageous for mechano-transduction studies that require mobility of the adhesive ligands on top of PAM substrates. Acrylic comonomers that present an additional functional group are copolymerized with AM and bis-AM to synthesize hydrogels with pendant functional groups. After polymerization, such groups are used to immobilize bioligands through covalent or non-covalent interactions . In prinvia non-covalent, strong supramolecular interactions between streptavidin and biotin (Streptavidin-acrylamide (streptavidin-AM) is commercially available (∼370 € per 1 mg). After copolymerization, the PAM-streptavidin gels are functionalized with biotinylated ligands d biotin . Convenid biotin  Neural cThe advantages of this approach are its simplicity, the use of well-established and user-friendly supramolecular chemistry to bind the ligands, and the compatibility with microcontact printing. Diverse biotinylated ligands can be attached, for which there is good availability of commercial options. In addition, the formed hydrogels are highly hydrophilic and nondegradable. However, the streptavidin-AM comonomer and the biotinylated ligands are expensive, and other PAM functionalization alternatives may be more suitable when micropatterning is not needed. In addition, the (to our knowledge) lack of material characterization on PAM-streptavidin hydrogels may restrain its utilization towards further cell studies.Acrylic acid (AA) is commercially available and cost-effective (∼40 € per 1 L). After copolymerization, carboxylic acids of PAM-AA gels are activated with EDC/NHS to form NHS esters, followed by covalent coupling with amine-ligands . The biovia NHS ester/amine coupling, the biotin groups can mediate supramolecular binding of streptavidin followed by attachment of site-controlled biotinylated ligands . Using this strategy, hydrogels micropatterned with biotinylated anti-CD3 antibodies by microcontact printing, at tunable ligand density and variable gel stiffness were used to study the interplay of receptors and forces in T cell activation.  (∼40 € per 1 g) is commercially available and used to prepared PAM-NHS gels for immobilization of amine-ligands. In relation to PAM-AA gels, PAM-NHS gels skip the AA activation step and can be directly used for NHS ester/amine bioconjugation  is inexpensive (∼60 € per 1 L). PAM-HEA hydrogels have been modified with fibronectin and laminin  and usedComonomers bearing a methylsulfonyl (MS) group enable the chemo-specific covalent coupling of thiol-containing bioligands under physiological conditions  . In geneThe performance of PAM-MS gels for bioconjugation has been compared with that of sulfo-SANPAH gels.  When botvia sequential bifunctionalization exhibited higher maturation at comparable culture times than when both ligands were incubated simultaneously  are undisclosed. The lack of information in composition, poor control over bioligand density and unsure retention of ligand’s functionality may lead to inconclusive results on cell culture results. Another limitation is the high cost of these substrates .In this mini review, diverse strategies for biofunctionalization of PAM hydrogels were introduced in the context of these biomaterials’ usage for 2D cell culture. New users should select a convenient strategy after consideration of the advantages and disadvantages of each strategy, the existing capabilities in the laboratory and, most importantly, specific user’s needs in view of the biological question under investigation. The showcased methodologies present various levels of complexity, costs and requirement for especial equipment. Additionally, these strategies enable different degree of control over the loading density on the gels, as well as over stability and preserved bioactivity of the attached ligand. An overall qualitative comparison is presented in Two main approaches were distinguished: those based on the direct activation of the side chains of PAM after FRP, and those where reactive comonomers are incorporated during FRP. In general, PAM direct activation strategies are based on the use of commercial reagents, use relatively simple  modification conditions without the need of highly specialized equipment (being thus more user-friendly). Unfortunately, they often offer limited control on the ligand loading, lower preservation of bioactivity and variable stability of the coating over time.Within strategies mediated by introduction of comonomers during FRP, the use of AA and MS-acrylamide comonomers are generally more chemically controlled, the latter being more chemo-specific and site-selective, ensuring good control of ligand loading and good preservation of ligand’s activity. However, MS-acrylamide strategy is more labour intensive and prohibitive for cell culture laboratories without organic synthesis infrastructure and expertise. Interestingly, we noticed that copolymerization strategies often do not report how the mechanical properties of the resulting functional PAM gels compare to pristine PAM gels. This could be a point of attention for future developments, to demonstrate to which extent a new methodology offers the possibility to independently tune mechanical from biochemical properties.Although out of the scope of this article, specific needs such as patterning of PAM or high throughput handling could be other aspects to consider. Several methodologies allow ligand patterning using various chemical strategies as shown in previous sections.  Notewort


Chemotherapy is one of the primary treatments for most human cancers. Despite great progress in cancer therapeutics, chemotherapy continues to be important for improving the survival of cancer patients, especially for those who has unresectable metastatic tumors or fail to respond to immunotherapy. However, intrinsic or acquired chemoresistance results in tumor recurrence, which remains a major obstacle in anti-cancer treatment. The high prevalence of chemoresistant cancer makes it urgent to deepen our understanding on chemoresistance mechanisms and to develop novel therapeutic strategies. Multiple mechanisms, including drug efflux, enhanced DNA damage reparability, increased detoxifying enzymes levels, presence of cancer stem cells (CSCs), epithelial mesenchymal transition (EMT), autophagy, ferroptosis and resistance to apoptosis, underlie the development of chemoresistance. Recently, accumulating evidence suggests that lipid metabolism alteration is closely related to drug resistance in tumor. Targeting lipid metabolism in combination with traditional chemotherapeutic drugs is a promising strategy to overcome drug resistance. Therefore, this review compiles the current knowledge about aberrant lipid metabolism in chemoresistant cancer, mainly focusing on aberrant fatty acid metabolism, and presents novel therapeutic strategies targeting altered lipid metabolism to overcome chemoresistance in cancer. Cancer is fundamentally a disorder of uncontrolled cell growth, continual unregulated proliferation, blockade of differentiation and resistant to cell death caused by genetic and epigenetic abnormalities . DespiteEnhanced drug efflux is one of the most widely studied mechanisms contributing to drug resistance, which is mainly regulated by the ATP binding cassette (ABC) superfamily to reduce the intracellular drug levels . The ABCAlkylating agents such as platinum agents kill cancer cells by inducing DNA damage . DNA damThe dysregulation of cell cycle is intensively involved in tumorigenesis and cancer chemoresistance. On the one hand, cell cycle arrest often leads to insensitivity of tumor chemotherapy. Though fast-dividing cancer cells give anti-cancer drugs more opportunities to contact and damage the nuclear DNA , cancer Autophagy is a conserved metabolic recycling mechanism intensively implicated in cancer development . AutophaEpithelial mesenchymal transition (EMT) refers to a biological process originally observed during embryogenesis, in which epithelial cells turn into mesenchymal phenotype cell by specific program . EMT preCancer stem cells (CSCs) are sub-populations of cells which possess the ability of self-renewal and differentiation, appearing in most tumors . CSCs haApoptosis is an intrinsic programmed cell death process contributing to the regulation of important physiological and pathological processes. In apoptosis, activation of caspases, breakdown of DNA and protein and changes of membrane are main biochemical changes . Both inTumor dormancy is recently recognized as a tactics of malignant cells to survive, recur and metastasize. In the dormancy state, cancer cells are clinically undetectable, undergoing G1–G0 growth arrest and surviving the exposure to cytotoxic drugs . The dorMetabolic reprogramming is one of emerging hallmarks of cancer . Tumor cIn terms of lipid metabolism, among the diverse categories of lipid, FA is regarded to be fundamentally involved in the development of malignant biological properties in cancer cells . In the The lipid biosynthesis is an intricate process which is controlled by complex, cross-linked regulatory networks including enormous regulatory factors and regulatory pathways . Enhancede novo lipogenesis. It is a cytosolic homotetrameric enzyme that catalyzes mitochondrial derived citrate into acetyl CoA, the precursor of FA synthesis, thus connecting glucose metabolism to lipid metabolism  , taxane-In resistant breast cancer cells, increased FASN-catalyzed endogenous FA biogenesis was related to HER2 overexpression . In trasIn gastric cancer cells, MaCC1, the upstream regulator of FASN, decreased the chemosensitivity to oxaliplatin by enhancing the expression of FASN . Moreovein-vivo toxicity like TVB-3166 exhibited potent anti-tumor effects in chemoresistant cancer cells  levels, ACC presented a significantly high basal level . The up-Lipid desaturation is an integral modification in cancer cells to limit lipotoxicity and generate unsaturated FAs . Monounsvia activating SREBP-1c, which increased MUFA/SFA ratio in estrogen-sensitive breast cancer , recognized as a multi-functional organelle in most eukaryotic cells, is composed of a neutral lipid core mainly including triacylglycerols (TAGs) and sterol esters (SEs) with a phospholipid monolayer membrane . LD fulfThere exists a close relation between FA metabolism and LDs. The excess FAs generated by lipogenic enzymes are then esterified and stored as TAG and cholesterol esters (CE) in LDs, which help cancer cells evade the harmful effect of the excess free FAs and survive under starvation by liberating FAs from LDs to mobilize into mitochondria for oxidation . LD has KRAS and BRAF mutated colon cancer cells, which had poor response to erlotinib, an EGFR-inhibition treatment , a glycolytic regulator that also regulated a key step to control glycolytic rate by mediating fructose-2,6-bisphosphate  levels . PFK158,Since LDs contain different neutral lipids, it is important to clarify the precise effect of these components and networks. Not only FA metabolism but also cholesterol metabolism is emphasized in LD-induced chemoresistance. It has been shown that enhanced LDs and cholesterol esters were observed in carboplatin-resistant laryngeal carcinoma cells . MoreoveLipid catabolism, also known as β-oxidation, yields ATP, NADH and acetyl-CoA to maintain energy balance, reduce oxidative stress and support (histone) protein acetylation . Enhancein vivo  oncogenicity and chemoresistance (+ chemoresistant leukemic stem cells (LSCs), a higher FAO rate was found, indicating a close relationship between FAO and chemoresistance  resistance, with an upregulation of CD36 and FAO to maintain high OXPHOS state to survive the chemotherapy  and peroxisome proliferator-activated receptor gamma co-activator-1 (PGC-1), are associated with chemoresistance via modulating FAO. There are three isoforms of PPARs, including alpha, beta/delta and gamma belonging to the nuclear receptor superfamily which are modulated differentially by endogenous ligands, drugs and other xenobiotics . In termRecent investigation into the altered FA metabolism in chemoresistant cancer cells seen  has reveApart from the chemotherapy, immunotherapy is a breakthrough for cancer treatment, which activates natural defenses to eliminate malignant cells . PD-1/PDTo improve the bioavailability and tolerance of drugs, recent advances in nanotechnology promote the development of nanoparticle-based drug delivery systems, which is widely used in cancer chemotherapy . Nanoparin vitro with several limitations and more data in vivo is necessary. Drug efficacy and safety need to be further tested by clinical trials.Lipid metabolism alteration in cancer has provided opportunities for cancer treatment. This review focus on the current knowledge of altered lipid metabolism especially the fatty acids metabolism. We have exhibited various experimental findings and theoretical arguments to show that the alteration of lipid metabolism has crucial effect on chemoresistance in cancer cells. However, many elusive challenges still exist due to the unclear mechanism and the pitfalls of these inhibitors. First, different cancer types may present different sensitivity to the inhibitors, which need biomarkers to predict sensitivity in chemoresistant malignant cells to guide the treatment. The high plasticity of the metabolic network in chemoresistant cancer also bother the treatment by inducing compensatory routes of biosynthesis to maintain survival status, which emphasizes the advantage of combination of multiple treatment targets or approaches. In addition, although some molecules have entered clinical trials such as FASN inhibitor Omeprazole , most of


Cancer has long been a hot research topic, and recent years have witnessed the incidence of cancer trending toward younger individuals with great socioeconomic burden. Even with surgery, therapeutic agents serve as the mainstay to combat cancer in the clinic. Intensive research on nanomaterials can overcome the shortcomings of conventional drug delivery approaches, such as the lack of selectivity for targeted regions, poor stability against degradation, and uncontrolled drug release behavior. Over the years, different types of drug carriers have been developed for cancer therapy. One of these is liposome-in-gel (LP–Gel), which has combined the merits of both liposomes and hydrogels, and has emerged as a versatile carrier for cancer therapy. LP–Gel hybrids have addressed the lack of stability of conventional liposomes against pH and ionic strength while displaying higher efficiency of delivery hydrophilic drugs as compared to conventional gels. They can be classified into three types according to their assembled structure, are characterized by their nontoxicity, biodegradability, and flexibility for clinical use, and can be mainly categorized based on their controlled release, transmucosal delivery, and transdermal delivery properties for anticancer therapy. This review covers the recent progress on the applications of LP–Gel hybrids for anticancer therapy. Regardless of their different preparation approaches, these processes follow a common pattern of three steps, which includes dissolution and dispersion in an organic solvent, addition of the lipid into an aqueous solution, and purification   have been widely investigated and used in drug delivery. Liposomes, as a CDDS, has attracted the most attention, mainly due to their amphiphilic nature, but also their advantages, including reduced toxicity, the capacity to load various drugs, and sustained drug release  , which react oxidatively with unsaturated phospholipid materials to disrupt liposomes. The generated ROS localized in the LP–Gel-attached tumor regions can also induce tumor cell apoptosis or necrosis for promising potential in photodynamic therapy. Chen et al. encapsulated a tumor-targeting photosensitizer, IR780, into liposomes, and then incorporated the liposomes into hydrogels. This hybrid system was applied for the systematic delivery of photosensitizers to subcutaneous tumors and deep metastatic sites via topical administration  can actively target tumors and release the loaded drugs on demand. When magnetic nanoparticles are complexed with liposomes, the so-called magnetic liposomes (MLs) can reduce the toxicity of MNPs while inheriting the magnetic-responsive properties  to act as a targeting ligand after its immobilization onto the surface of liposomes containing gemcitabine. HA specifically binds the cell surface receptor CD44, which is overexpressed in various tumors. HA is also chemically modifiable and biodegradable. HA-coated liposomes target pancreatic cancer cells expressing CD44, and the amount of HA (32 disaccharide units)-coated liposomes internalized was quantified and determined to be nearly ninefold more than that of naked liposomes at 24 h , the permeability of the liposomal membrane increases and then the drugs are released without destroying the liposome structure. Heating to temperatures over the Tm allows on-demand drug release  are capable of converting multiple near-infrared (NIR) photons to ultraviolet or visible photons via an anti-Stokes mechanism. UCNPs have been applied to loaded in liposomes or hydrogels for on-demand release via tissue-penetrating laser stimulation (Huang et al., Click here for additional data file.


Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders  who underwent chest reconstruction (mastectomy) and genital surgery  in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives  necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth. Transgender and gender non-binary individuals are a growing demographic worldwide  is an interdisciplinary body of health professionals that establishes Standards of Care (WPATH SOC) to advance transgender healthcare and surgeries through evidence-based medicine. The international consensus of WPATH SOC guidelines establish procedural safeguards to protect patients, families, and healthcare professionals caring for transgender and gender-diverse persons . The CenThe primary objective of this case series was to examine the patient characteristics, specific surgical techniques, and perioperative outcomes of masculinizing chest reconstruction and genital surgeries in a pediatric academic hospital. The secondary aim of the case series was to describe the evolution of a specialized anesthesia care team model known as the Gender Affirming Surgical Perioperative Program (GASPP).This study was approved by the institutional review board (IRB) of Boston Children’s Hospital, and the requirement for written informed consent was waived by the IRB. A retrospective case series analysis was performed to collect comprehensive data on all chest reconstruction and genital surgeries from January 2017 to August 2020. Boston Children’s Hospital is a pediatric academic hospital in the United States, providing gender affirmation surgery to patients aged 15 years to 35 years of age, including gender-affirming primary and multispecialty care involving inpatient and outpatient care.Patients included in the study were identified by the International Classification of Diseases (ICD)-10-code F64 for gender identity disorders. The following Current Procedural Terminology (CPT) codes were included: chest reconstruction procedures, vaginectomy and phalloplasty procedures, vaginoplasty surgeries, and metoidioplasty surgical procedures. This led to a total of 204 surgical cases included in this case series.Data was extracted from patient electronic medical records, anesthesia databases, and billing records stratified by surgical procedure type. Demographic data collected included age, weight, the American Society of Anesthesiologists Physical Status (ASA-PS) classification, and gender identity. Perioperative characteristics identified were discharge plan, intensive care unit (ICU) admission, documented adverse events (hematoma and airway event), readmission, and hospital length of stay. Post-anesthesia care unit (PACU) data on emesis and pain scores  were collected, and inpatient data on opioid equivalents and postoperative nausea and vomiting (PONV) were identified.Continuous variables , length of stay, pain scores) were described using medians with accompanying full ranges, and categorical data  were presented as frequencies and percentages. Missing data were denoted by different denominators presented within subgroups for categorical variables. Descriptive statistics of the case series were presented overall for all cases, and separately for chest reconstructions and genital surgeries. Descriptive statistics were obtained using Stata .Over the 3-year study period, a total of 204 gender affirmation surgical cases were identified: 177 chest/top and 27 genital/bottom surgeries . Most caOne of the most regularly requested surgical treatments for transmasculine and non-binary patients is masculinizing chest reconstruction, also known as “top surgery” and formally as “mastectomy” . The opeThe demographic and patient characteristics of chest reconstruction patients are summarized in Typical forms of genital reconstruction (bottom surgery) include phalloplasty and metoidioplasty procedure for transmasculine patients and vaginoplasty for transfeminine patients. For transmasculine patients, the surgical goals of bottom surgery depend on patient specific desires. These include the removal of female genitalia, the formation of male genitalia, standing to void, the consolidation of erogenous feeling to the phallus, and future erectile prothesis and testicular implants . The morTwenty-seven genital surgeries were performed and In this study, we present the first descriptive anesthesia case series of transgender youth undergoing gender affirmation surgery. From our study, we describe establishment of an anesthesia care service designed to meet the specific needs of gender-diverse youth undergoing gender reassignment surgery.Our perioperative services have seen an increasing number of transgender patients scheduled for procedures (gender affirming and routine). These patients present with significant complexities in the perioperative period . In respIn addition to emotional and behavioral issues, transgender patients frequently have co-existing morbidities such as obesity, substance abuse, and congenital disorders, which could affect surgical planning and outcomes . Prior tBeginning in June 2019, a GASPP attending anesthesiologist and CRNA were pre-assigned to each gender-affirming procedure to facilitate a multidisciplinary approach to patient care, and in-depth planning and communication. The goal was to provide consistent care through multi-staged procedures. The care coordination and anesthesia team-based approach was formulated after the Pediatric Perioperative Surgical Home model . FurtherThe GASPP team instituted several initiatives to improve the transgender perioperative experience . AnestheThe benefits of working with a gender-focused, dedicated anesthesia team extend far beyond the experiences of each individual patient. Multidisciplinary collaboration, continuity of care, and application of evidence-based care principles of pediatric anesthesia practice are fundamental to the success of the GASPP. McIntosh  advocateThrough a careful process of outcome evaluation, collaboration with surgeons, and consultation with perioperative nursing teams, we enhanced and codified our individualized anesthesia considerations for chest and genital surgeries. There is a growing literature comparing Enhanced Recovery After Anesthesia (ERAS) pathways in adult surgical procedures, and a few reports of ERAS protocols are emerging to streamline pediatric perioperative care and improve patient outcomes. In a review and meta-analysis of Enhanced Recovery After Anesthesia (ERAS) pathways of adult breast reconstruction patients, the evidence supported the reduction in postoperative opioid use and a decrease in length of hospital stay with a mean difference of 1.7 days compared to traditional care . In a reAdolescents who identify as transgender and gender nonconforming experience a high rate of stigma in the hospital environment and face inequitable access to primary care and mental health resources compared to their cisgender peers . Severe Gender-affirming surgery has been shown to improve quality of life. Although current research has been focused mostly on adults, a study of 136 youth demonstrated significant improvements in chest dysphoria in transmasculine individuals undergoing chest reconstruction . A prospCare coordination between anesthesia and surgical staff has allowed GASPP team members to anticipate and plan for surgeries well in advance. As more gender-diverse youth require general anesthesia for dental, orthopedic, and other non-gender-affirming procedures, the GASPP team can offer continuity of care that fosters a milieu of trust and familiarity with their transition journey. The study by Kattari et al.  on transThere were several limitations in our study. It was a retrospective case series based on multiple anesthesia records and patient medical charts subject to variability on individual documentation practice and limitations of what data is routinely recorded. All records were manually audited to confirm the correctness of the perioperative, PACU, inpatient data, including gender identity, diagnosis, type of surgery, medications, and adverse events within the Anesthesia Information Management System (AIMS) record and medical records. The gender-affirming procedures were performed in a single center at our main hospital and satellite surgery center. Surgical techniques for genital procedures varied depending on the surgeons’ desired method and evolved over the course of this study.Future studies are needed to compare various anesthesia techniques for optimizing outcomes after different procedures for this population. Creation of this service and implementing population-specific anesthesia protocols may decrease opioid requirements and postoperative nausea and vomiting. The GASPP team is in the process of adapting anesthesia guidelines into formal Enhanced Recovery After Anesthesia (ERAS) protocols and working to develop prospective studies to follow perioperative anxiety, patient satisfaction, and quality of life for transgender children and adolescents.The collaboration between the GASPP and CfGS offered gender-diverse youth access to comprehensive, developmentally appropriate surgical care to meet their physical, mental, emotional, and spiritual needs that spans the entire consultation, perioperative, and postoperative period. Furthermore, the dedicated team approach supported improved perioperative care and outcomes. However, the reproducibility of this approach needs further studies to be proven. As more pediatric institutions develop their gender-affirming surgical centers, we present this model as a guide for pediatric anesthesia departments.


Giant cell arteritis (GCA) is an immune-mediated systemic vasculitis usually seen in the older population. We describe a case of a 75-year-old woman who presented with jaw claudication and temporal headache. A colour duplex ultrasonography and later biopsy of the temporal arteries confirmed GCA and she was commenced on oral steroids. She was subsequently readmitted with a new worsening vision of both eyes and confusion. Her brain images revealed acute bilateral vertebral artery thrombus with haemorrhagic transformation. She was loaded on intravenous steroids. The next day she developed vomiting, bilateral visual loss and a cardiac arrest from ventricular fibrillation. Following the return of spontaneous circulation, she was taken to the cardiac catheterisation laboratory for a coronary angiogram, which showed diffuse thrombus at the apical left anterior descending artery. A bedside echocardiogram revealed a sizable left ventricular thrombus. She was managed with heparin and antiplatelet therapy.This case presented a complex diagnostic dilemma to the medical team as vasculitis, atherosclerosis, and cardiac emboli could have contributed to her stroke and visual loss. This patient also had some vascular risk factors for occlusive cerebrovascular disease, potentially suggesting a clinical event with multiple aetiologies.Stroke and visual loss are rare but serious complications of GCA, which require a high index of suspicion and early treatment with corticosteroids to improve prognosis. Although a temporal artery biopsy remains to be the definitive diagnostic modality for GCA, the use of radiological investigations in the diagnosis of GCA is increasingly common. A non-invasive colour duplex ultrasonography of the temporary arteries could be used to assess GCA in highly suspected patients. Echocardiograms and contrast-enhanced body imaging should be performed in patients with suspected or established GCA to assess for secondary thromboembolic and vascular complications. Giant cell arteritis (GCA) is an immune-mediated, systemic vasculitis of the medium to large-sized arteries, predominantly seen in the older population over the age of 50. GCA is the most common form of primary vasculitis in Western Europe . Women aThe clinical manifestations of GCA are classified into intracranial and extracranial features. In addition, most patients with GCA may have one or more non-specific, constitutional symptoms including fever, lethargy, malaise, weight loss, and anorexia . Up to 9GCA is commonly associated with polymyalgia rheumatica (PMR), which presents as pain and morning stiffness in specific muscle groups, predominantly around the neck, shoulders, upper arms, and pelvic girdle . Both GCGCA is a medical emergency and patients with suspected GCA must be diagnosed and treated immediately to prevent irreversible consequences of large vessel vasculitis. There are some published case reports on patients suffering from rare complications of GCA such as bilateral visual loss, stroke, and coronary events. None of these however describe a case of co-existing cerebral-coronary manifestations, which presents a diagnostic dilemma that requires complex decision-making from the multi-disciplinary team. We present an exceptional case of a 75-year-old woman who was found to have bilateral visual loss and catastrophic vertebrobasilar stroke and coronary thrombus shortly after a diagnosis of GCA. Could these manifestations be solely attributed to her underlying GCA?Our patient was a 75-year-old, right-handed, Caucasian woman who presented to the emergency room with a three-month history of intermittent jaw claudication and right-sided temporal headaches, and a three-week history of blurry vision in the right eye. She had a past medical history of hypertension, transient ischaemic attack (TIA) in 2016, osteoarthritis, vertigo, rotator cuff injury to the right shoulder, and anxiety disorder. Her past surgical history was significant for a hysterectomy for fibroids in 2006. Her medications on presentation included Paracetamol 1 gram (g) twice daily, Amlodipine 5 milligram (mg) once daily, Atorvastatin 20 mg once daily, Bendroflumethiazide 2.5 mg once daily, Behahistine 8 mg twice daily, Clopidogrel 75 mg once daily, Dosulepin 25 mg once daily, Lorazepam 0.5 mg once daily and Fenbid Ibuprofen gel as required. She lived alone in a house with stairs and was independent with all her activities of daily living. She had been smoking 15 cigarettes a day for about 45 years. She denied any alcohol consumption.On examination, a right optic disc swelling was elicited. Systemic examinations were otherwise normal. Her laboratory results are shown in Table In view of the long duration (three months) and almost completely resolved symptoms during the outpatient consultation, she was discharged with eye lubricants and safety netting advice. Nevertheless, she was reviewed at the rheumatology clinic 10 days after and a colour duplex ultrasonography of her bilateral temporal arteries suggested GCA. She was started on high-dose oral prednisolone 60 mg once daily with a proton pump inhibitor and calcium and vitamin D supplementation for gastro- and bone protection, respectively.A routine chest radiograph Figure  was perfA day later, she presented to the hospital with new-onset, worsening vision of both eyes, vomiting, and confusion. On examination, a right pronator drift and right homonymous hemianopia were elicited. Her bilateral visual acuity was recorded to be hand movements on arrival. She was afebrile and the remaining of her vital signs were otherwise normal. As seen in Table A CT head scan and angiogram Figures , 3 were She went on to have an inpatient magnetic resonance (MRI) head scan, which revealed extensive haemorrhagic changes in the bilateral posterior territory infarcts Figures -6. It was believed that her stroke was secondary to GCA, she was started on intravenous methylprednisolone for three days and daily loading-dose aspirin. The results of her temporal artery biopsies came back on her third day of admission, confirming GCA with transmural inflammation and the presence of multinucleated giant cells in the arterial wall. Nonetheless, she continued to improve clinically at the stroke unit. Her vision had improved remarkably, although a residual bilateral inferior quadrantanopia with macular sparring was found on examination. She was discharged five days later and continued on daily 75 mg of clopidogrel and 60 mg of prednisolone.She was readmitted the next day with headache, vomiting, and representation of bilateral visual loss, to the perception of light only. While waiting to be seen, she suffered from a cardiac arrest secondary to ventricular fibrillation. Following a return of spontaneous circulation, an electrocardiogram was taken, which demonstrated anterolateral ST-segment elevation. She was taken to the cardiac catheterisation laboratory for a coronary angiogram, which showed no significant stenosis of coronary arteries but diffuse thrombus at the apical left anterior descending artery. She was later transferred to the intensive care unit, where she was intubated and ventilated, and given vasopressors. A bedside echocardiogram revealed a sizable left ventricular thrombus and severe left ventricle impairment (ejection fraction < 35%). The decision to treat the coronary thrombus was difficult given a recent haemorrhagic transformation of cerebral infarcts in this patient with established GCA. She was medically managed with intravenous heparin followed by antiplatelet therapy. Her steroids were switched to tocilizumab given her heart failure. Contrast-enhanced CT scans of the head, neck, thorax, abdomen, and pelvis were performed Figures , 8, whicOn the same night, there were ongoing concerns regarding her dilated and unreactive pupils bilaterally. A repeat CT head and angiogram revealed stable appearances of the established posterior circulatory infarct. In view of her ongoing unresponsiveness, apnoea on trial without ventilation, anuria, and deteriorating blood parameters indicative of multiple organ failures, she was withdrawn from life-sustaining treatment two days after and she passed away peacefully.This patient presented with a sub-acute onset of classical GCA symptoms including new temporal headache, mandibular claudication, and blurry vision. New-onset headaches or gradually worsening pre-existing headaches in an elderly patient should always raise an alarm about the possibility of GCA or intracranial pathologies. Headache and jaw claudication is understood to be the results of inflammatory vasculitis of the temporary artery and maxillary artery respectively. Hypoperfusion of the mastication muscles causes discomfort and pain when chewing and talking, leading to jaw claudication .Our patient had mildly elevated inflammatory markers including CRP and ESR, which declined steadily with the administration of prednisolone. Serial inflammatory markers are important in establishing a diagnosis as well as monitoring treatment response. The presence of persistent systemic inflammation releases cytokines such as Interleukin 6 (IL-6), which induces the hepatic synthesis of acute-phase protein CRP . The marThe definitive diagnostic test for GCA remains to be a temporal artery biopsy. It should be considered when there is a clinical suspicion of GCA. Nonetheless, treatment with corticosteroids should not be delayed with this procedure. Furthermore, this procedure may be limited by a high false negative rate due to the presence of skip lesions, which are not uncommon. A large specimen may be required occasionally to increase the diagnostic yield, which in turn increases the risk of potential intraoperative bleeding.The established complications and high false negative rate of a temporary artery biopsy have led to the increased utilisation of radiological investigations in the diagnosis of GCA. A non-invasive duplex ultrasound scan is the first-line imaging modality for suspected GCA, given its availability and lack of radiation exposure. The presence of a hypoechoic wall thickening - “halo sign” around both temporal arteries represents inflammatory vessel wall edema and is suggestive of temporal artery inflammation . The senThe use of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) has gained popularity in the evaluation of vasculitis in patients with suspected GCA, demonstrating promising diagnostic performance, especially in medium and large-sized arteries such as the abdominal and thoracic aorta, and head and neck arteries and their branches. Common radiological findings of GCA are vessel wall thickening and systemic or localised contrast enhancement of the arterial wall secondary to mural inflammation . The useA systemic review and meta-analysis of cohort studies revealed that patients with GCA are at a 40% elevated risk of strokes . Its relOur patient experienced visual disturbances prior to her admission. Visual loss is one of the most feared complications of GCA as it is irreversible and can be bilateral if not urgently treated with high-dose corticosteroids. Visual complications are reported in up to 30% of patients with GCA . Visual Both GCA and the intraventricular thrombus could have contributed to this patient’s visual loss, which was preceded by amaurosis fugax to the right eye and rapidly progressed to bilateral visual loss. Intraventricular thrombus could contribute to central retinal artery occlusion. Her pre-existing vascular risk factors also suggested an atherosclerotic origin to her presentations. This patient was found to have homonymous hemianopia with macular sparing during her first admission. It is worth noting that a posterior cerebral artery infarct is the most common cause of such presentation of cortical blindness. An echocardiogram demonstrated an intraventricular thrombus, which further presents diagnostic uncertainties in the case - whether all these presentations could be due to a cardiac embolus being thrown into the cerebral circulation, precipitating a cerebrovascular accident? It is proposed that both vasculitis and cardiac emboli could have contributed to the presentations seen in this patient, who also had some vascular risk factors for occlusive cerebrovascular disease. Her cortical blindness is presumably secondary to the stepwise progression of the MRI-proven bilateral occipital lobe infarctions in the vascular territory of the posterior cerebral arteries, which could have been driven by both vasculitis from GCA and the pre-existing cardiac emboli. More importantly, the presence of a coronary thrombus could also be due to the superimposed coronary vasculitis from GCA. Even though our patient did have a past medical history of hypertension and transient ischaemic attack, she developed bilateral posterior circulation infarcts and coronary thrombus without significant stenosis of the coronary arteries. This suggested that her presentations were likely due to complications of GCA rather than atherosclerosis. Since our patient had experienced a sub-acute onset of symptoms of GCA, this suggested that systemic vasculitis could be the most likely culprit of her delayed presentations.The aetiology of GCA-induced stroke is much contested. The exact pathophysiology is unknown although several hypotheses have been proposed. It was initially attributed to atherosclerosis given the age groups and coexisting vascular risk factors in the affected patients. Recently, it was proposed that the presence of arterial inflammation may lead to endothelial damage and luminal irregularities that weaken the arterial wall, which can result in stenosis, dissection, and even aneurysms. Distal infarction or embolic occlusion may be secondary to dissection of the arterial wall or thrombosis. It is also important to recognise that ischaemic events and aortic aneurysms and dissections could be an initial, atypical manifestation of systemic GCA . FurtherRecently, there has been an increasing significance of an IL-6 inhibitor, tocilizumab, in the treatment of GCA, particularly in patients who are intolerant to corticosteroids. It is believed that GCA is associated with a marked elevation of IL-6, promoting a persistent inflammatory response in GCA. Tocilizumab, when combined with glucocorticoid therapy, has been found to increase remission rate and reduce total doses of corticosteroids over a year in a randomised control trial of 251 patients with GCA .The incidence of GCA-induced vascular events is rare, let alone a case with complex multi-system aetiologies of presentations in a patient who was recently diagnosed with GCA. To the authors’ knowledge, our study could be the first described case of co-existing cerebral-coronary manifestations in a patient with biopsy-proven GCA presenting with bilateral visual loss in the literature. There are, however, a few published cases that describe coronary thrombosis and stroke secondary to GCA, with the majority demonstrating fatal clinical outcomes or poor prognosis including recurrence despite treatment with corticosteroids ,14-17.Our report presented a clinically challenging and dynamic case that involved decision-making from multi-disciplinary teams. Our patient’s presentations may have been attributed to GCA, although atherosclerosis may also have a role. This case highlights the importance of detailed clinical assessments, biochemical investigations, and radiological studies in patients with suspected GCA, especially in a population otherwise susceptible to vascular events such as the elderly. In particular, we want to highlight to clinicians the use of imaging modalities including ultrasonography, contrast-enhanced body imaging, and echocardiography in patients with suspected or confirmed GCA. Temporary artery ultrasonography could be a useful, initial non-invasive assessment of GCA in highly suspected patients. Contrast-enhanced CT and MR imaging and echocardiograms are useful in assessing secondary thromboembolic disease and monitoring disease progression. A high index of suspicion is necessary and clinicians should be alert to the rare yet severe complications of GCA as early intervention with steroids may potentially improve prognosis.


Improving the diversity and representation in the medical workforce requires intentional and deliberate efforts to improve the pipeline and pathway for underrepresented in medicine (UIM) applicants. Diversity enhances educational experiences and improves patient care and outcomes. Through a critical review of the literature, in this article we offer evidence-based guidelines for physician pipeline and pathway programs (PP). Recommendations are provided regarding considerations on the types of programs and surrounding implementation to ensure a sound infrastructure and framework. We believe this guide will be valuable for all leaders and faculty members seeking to grow the UIM applicant pool in our efforts to advance diversity, equity, and inclusion within medicine. Diversity in medicine is an academic imperative. Incorporating diversity offers many benefits to the community, within and outside the walls of the emergency department (ED). 7Despite the increased recognition and efforts, only a small number of medical specialties have demonstrated statistically significant increases in representation, suggesting that current efforts are insufficient. 8Pipeline and pathway programs (PP)1The Council of Residency Directors in Emergency Medicine (CORD) Best Practices Subcommittee publishes a series of articles entitled CORD Best Practice reviews; this manuscript is ninth in the series. We created best practice recommendations based on the literature appraisal. Whenever supporting evidence was unavailable, consensus opinion and the authors’ combined expertise were used. The Oxford Centre for Evidence-Based Medicine criteria  and 2 18Barriers exist that hinder students from entering the health professions. Recognition of the barriers  for UIM,Simply recognizing these barriers is not enough. Deliberate actions to mitigate or remove these barriers is imperative, including creation of novel educational and training frameworks that focus on improving trainee performance. 26A scoping literature review found the most frequent approaches to increase minority representation in the medical workforce were PPs 43%), changes in affirmative action laws (23%), and changes in admission policies (21%). %, change3Pathway programs effectively enhance academic performance and increase the likelihood that UIM and other disadvantaged undergraduate students enroll in a health professions school. However, the long-term success when targeting high school students remains <20%, suggesting that work still needs to be done to bridge this gap. 28Pathway programs are a key strategy for increasing the enrollment of UIM students into medical schools. Elementary and high school programs help pre-college UIM students succeed through their primary and secondary education, to continue progressing down the pathway toward medical school. Early introduction and exposure to healthcare has been shown to effectively influence career decisions. 33Goals of these programs include preparing students for college life, 43College preparation is a significant component of many elementary-to-high-school PPs, and include exposure and guidance to the university admissions process, 44Mentorship is a crucial component of elementary-to-high-school PPs and may be provided by medical students, graduate students, or working professionals. 29Undergraduate level pathways serve to expose UIM students to the health professions. The structure of these programs vary in length, 51Longitudinal pathways exist to offer “living and learning communities,” consisting of a designated dorm floor for pre-health students to enhance networking and surround undergraduate students with a supportive cohort. 47The combined BS-MD program can be a high school or undergraduate school to medical school pathway. For example, the Premedical Honors College, an eight-year college-to-medical-school program targeting South Texas medically underserved counties, 53Other BS-MD programs offer undergraduates conditional acceptance to medical school. The Mount Sinai School of Medicine created a Humanities and Medicine program, an early admissions program that allows sophomore-year undergraduate students to apply and pursue their interests in humanities and social sciences prior to matriculating to medical school. 54Another undergraduate-to-medical-school route is the community college (CC) pathway. Defined as two-year post-secondary education institutions, CCs serve as a common pathway to the attainment of higher education for low-income and UIM students. Talamantes studied medical students’ educational path to better understand the use of CCs, 55Post-baccalaureate pathway programs (PBPP) are an important strategy for increasing diversity among medical school matriculants. The UIM and disadvantaged students tend to be at greater risk for academic difficulties and lower MCAT scores, which are known barriers to medical school admission. 38In 2014, 36% of national PBPPs identified themselves as having a special focus on UIM or economically or educationally disadvantaged students. 51Despite having academic profiles that were not promising for medical school admissions on entering the Medical/Dental Education Preparatory Program (MEDPREP) program, 83.3% of graduates successfully matriculated in medical school. 28Historically black colleges and universities (HBCU) and historically black medical schools (HBMS) have a significant impact on the diversity of medicine. 61The HBCUs were found to devote greater effort to premedical training, developing strong relationships with medical schools and offering a range of sponsored enrichment opportunities to their students. Box 1:Factors related to implementing PPs are important determinants of the success of these programs. Below, we explore the following implementation elements: frameworks and theories; funding; participant selection; academic enrichment and instructional design; and mentoring, advising, and networking.Several articles outlined PPs’ frameworks and theoretical underpinnings. Young built on the knowledge translation framework to generate a six-part framework for developing PPs . 64 When65Johnson and Bozeman constructed the asset bundles model from other models and theories that focus on human capital , social capital , and the ways in which institutions perpetuate marginalization. 49Sustainable funding is critical for the success and survival of PPs. Programs are usually funded from multiple sources, including federal, foundation, and institutional investments. The program budgets ranged widely from $2,600 (2007 dollars) for a student-run, specialty-specific initiative, to $25,000 (2018 dollars) for a two-day workshop, to several million dollars for a comprehensive collection of PPs. 58Most PPs aim to support and facilitate educational and healthcare career advancement for UIM racial and ethnic groups. 58Few programs stated they used holistic review to select participants. 58While most programs included interest in medical or science careers in their selection, The central feature of PPs are educational support and skills development. Many provided math and science enrichment and test prep through locally developed programs or professionally delivered courses 41Academic enrichment was provided in both didactic and experiential formats, using large- and small-group formats and employing multiple educational approaches . Clinica51Mentorship helps to transform students’ thinking, enhance knowledge, develop technical skills, broaden aspirations and confidence in a future scientific career, and improve “professional socialization.” 70Mentorship may be structured, small group-led faculty or one-on-one mentoring.In addition to formal mentoring, PPs also facilitate networking opportunities in small groups for students to interact with physicians, scientists, medical graduate students, and alumni. Box 2:This paper focused on pipeline, pathway, and outreach programs. Recognizing the vastness of DEI, other topics  will be covered elsewhere. It is possible that we may have missed some relevant articles in our search. To mitigate this, a comprehensive search strategy with the aid of a medical librarian was conducted, supplemented by bibliographic review and additional recommendations from topic experts. Much of the research on DEI is observational, and multicenter RCTs are often lacking. Our findings may represent associations as opposed to causation given the nature of the research available. Finally, much of the literature of pathways focuses on general fields in health professions education; there is limited literature specifically focused on pathways within EM.Pathway programs are critical to increasing diversity within medical schools. Increasing diversity in medical schools is critical to increasing diversity in EM and other specialties. This paper summarizes components of PPs and steps toward successful implementation through best practice recommendations. We hope this manuscript will inform readers on how best to form and sustain new PPs at their institutions.