A wide variety of therapeutic approaches and technologies for delivering therapeutic agents have been investigated for treating cancer. Recently, immunotherapy has achieved success in cancer treatment. Successful clinical results of immunotherapeutic approaches for cancer treatment were led by antibodies targeting immune checkpoints, and many have advanced through clinical trials and obtained FDA approval. A major opportunity remains for the development of nucleic acid technology for cancer immunotherapy in the form of cancer vaccines, adoptive T-cell therapies, and gene regulation. However, these therapeutic approaches face many challenges related to their delivery to target cells, including their in vivo decay, the limited uptake by target cells, the requirements for nuclear penetration (in some cases), and the damage caused to healthy cells. These barriers can be avoided and resolved by utilizing advanced smart nanocarriers  that enable the efficient and selective delivery of nucleic acids to the target cells and/or tissues. Here, we review studies that have developed nanoparticle-mediated cancer immunotherapy as a technology for cancer patients. Moreover, we also investigate the crosstalk between the function of nucleic acid therapeutics in cancer immunotherapy, and we discuss how nanoparticles can be functionalized and designed to target the delivery and thus improve the efficacy, toxicity, and stability of these therapeutics. Nucleic-acid-mediated immunotherapies have demonstrated efficacy in cancer treatments . DiffereThe innovation of smart nanocarriers that enable the use of nucleic acids for cancer immunotherapy indicates a major opportunity, particularly for protecting nucleic acids from degradation and enhancing targeted delivery. In contrast to other delivery systems, such as electroporation methods, gene guns, and sonoporation, the versatility and the unique magnetic, optical, chemical, and structural properties of nanoparticles offer numerous advantages to overcome biological barriers, including improved targeted nucleic acid delivery, appropriate intracellular processing and trafficking, a beneficial biodistribution and pharmacokinetic profile, and a controlled release through intelligent nanoparticle design ,9. ApproThere are several types of nucleic-acid-mediated immunotherapeutics for the treatment of cancer, including immune stimulators (nucleic acids derived from pathogen-related molecular patterns) and plasmid, mRNA, aptamer, and immune modulators that act through gene regulatory mechanisms. Innate immunity is triggered by the recognition of immune stimulators and pathogen-associated molecular patterns (PAMPs) . FurtherCircular RNA (circRNA), a novel non-coding RNA, is produced by the back-splicing of mRNA precursors. CircRNAs lack free 3’ and 5’ ends and have covalent closed-loop structures . CircRNA+ T cell and CD4+ T cell populations is crucial in cancer immunotherapy. The modularity of mRNA allows for the simple integration of multi-epitope antigens and synergistic immunostimulatory signal peptides into a single mRNA vector for efficient induction of a wide range of antitumor immune responses [mRNA has recently sparked considerable interest in drug research, particularly for cancer immunotherapeutics . mRNA isesponses . Similaresponses . Aside fesponses . OverallDNA-based cancer immunotherapy is a potent method for activating the immune system to combat cancer cells. Plasmids are used as the carrier of genetic material DNA. Generally, synthetic plasmids acquire more than one selective marker gene and a single synthetic polyclonal site sequence, which consists of more than one restriction enzyme recognition site . The chiOne immunotherapeutic that is frequently explored is CpG ODN, which belongs to the PAMP family of nucleic acids. CpG ODN consists of short synthetic DNA with an unmethylated CpG motif . In contDouble-stranded RNA (dsRNA) and cytosolic dsDNA are other PAMPs. Cytosolic dsDNA stimulates cGAS and proinflammatory immune responses. Cytosolic dsDNA can activate cGAS to synthesize 2′3′-cGAMP, which activates the STING signaling pathway to promote type-I IFN responses . DiffereNanoparticle-mediated delivery for cancer immunotherapy can be categorized into two types based on their preparation: biologically synthesized nanoparticles and chemically synthesized nanoparticles. Biologically derived nanoparticles consist of biological components or cell derivative components, for example, exosomes and lipid-mediated nanoparticles, while chemically synthesized nanoparticles are categorized into polymers and inorganic nanoparticles . The folLipids are biological components that are the building blocks of the biological membrane . LiposomAccumulating evidence indicates the potential of circRNAs in the regulation of antitumor immune responses ,73. WhilMany bioengineered nanoparticles are under development for delivering mRNA for immunotherapy, and some have advanced to clinical trials . Nanoparticles protect mRNA from nucleases and increase the internalization of mRNA into APCs, which increases the efficacy . Lipid nFor the delivery of DNA, lipid nanoparticles are synthesized to prevent external hindrance. Delivery of plasmid-DNA-encoding costimulatory molecules and/or cytokines that stimulate tumor immunogenicity can be utilized efficiently by a nanoparticle because of its versatility. Indeed, a recent study has demonstrated the ability of a synthetic, biodegradable gene delivery nanoparticle platform to reprogram cancer cells in situ as tumor-associated antigen-presenting cells by inducing the coexpression of a costimulatory molecule (4-1BBL) and an immunostimulatory cytokine (IL-12) . ResearcExtracellular vehicles (EV) are small particles which help in therapeutics and are generally synthesized by live cells. EVs are approximately 30 to 150 nm in size and found in different biological fluids ,93. ExtrDue to the unique tumor microenvironment and external treatment stimuli such as hypoxia and thermal stress, tumor-derived extracellular vesicles are typically more productive than immune-cell-derived extracellular vesicles . AccordiDifferent types of polymers are widely used for the synthesis of polymeric nanoparticles which are used for cancer immunotherapy . These pHydrogel-mediated nanoparticles are particularly appealing for delivering hydrophobic compounds because of their exceptional capacity for hydrophobic molecules. Unfortunately, there are problems with current nano hydro gel platforms, especially concerning their unpredictable release characteristics. The physiological setting and inherent qualities of hydro gels prevent their further use in clinical research due to rupture release and short-term delivery caused by the expanded pore size and rapid degradation . To enabCancer immunotherapy can make extensive use of inorganic nanoparticles by way of the precise control over the size, charge, and surface modifications . They ofOf all the inorganic nanoparticles, gold nanoparticles (AuNPs) have undergone extensive research for tumor immunotherapy. They are excellent delivery candidates to deliver tumor antigens and immune adjuvants to the targeted site due to their compliant surface chemistry and customizable shape . InteracOther metallic nanocomposites, such as silver and iron, have demonstrated tremendous activity against cancer immunotherapy in addition to the well-established AuNP systems. Metallic nanoparticles (MNPs) are used for therapeutic purposes in ongoing or finished clinical trials due to the above-mentioned intrinsic benefits. A well-known nanomedicine called CYT-6091 has been investigated in early clinical trials for cancer immunotherapy. It is made of AuNPs functionalized with thiolated PEG and recombinant human tumor necrosis factor-a (rhTNF-a) . AdvanceEven with MNPs’ examination in ongoing clinical phase trials, their potential clinical applicability is debatable, mostly due to safety concerns such as the accumulation of AuNPs over time in the organs. After 10 months of research in dogs, AuNPs were found to be toxic; the results revealed pigmentation and accumulation in the liver, spleen, and lymph nodes . In addiHybrid nanoparticles can consist of both inorganic  and organic  components to exploit the advantage of both components to enhance their biocompatibility and efficiency and reduce their toxicity. Hybrid nanoparticle synthesis is based on two strategies: barge and tanker. According to barge and tanker strategies, liposomes, micelles, polymers, and noble metals are encapsulated (barge) or accumulated at the surface (tanker) of nanoparticles . MagnetiSpherical nucleic acids (SNA) are another class of smart nanoparticles that are synthesized by chemically modifying spherical cores with dense layers of single- or double-stranded DNA or RNA . SNAs haSelecting an appropriate nanoparticle core is crucial for the effective delivery of nucleic acids utilizing SNAs. The forms, sizes, and biological profiles of the core–shell assembly are directly influenced by this. For organized DNA/RNA grafting on their surfaces, inorganic nanomaterials have been employed, such as iron, gold, silver, Pd, and Pt nanoparticles ,120,121.3O4 nanoparticles) with a surface DNA coating [Gold nanoparticles (AuNPs), which are the most characteristic noble metal nanoparticles, have been extensively used as the primary material in SNA synthesis. The size and form of the final SNA products can be directly controlled by producing AuNPs using simple synthetic procedures to generate a wide variety of particle diameters . To crea coating ,128. Met coating .Even though inorganic nanoparticles are most frequently employed to make SNAs, their propensity to concentrate in organs such as the liver and spleen poses possible long-term health complications ,130. ODNLiposomeLiposomal SNAs (LSNAs) can be made with simple starting materials that are easily accessible . LSNAs aProteinA novel kind of SNAs are protein SNAs (Prot-SNAs), which are made up of a protein core and a thick ODN crust. They are capable of entering cells efficiently. To evaluate both their intracellular transport efficiency and catalytic performance simultaneously, Mirkin et al. immobilized ODNs onto the homotetrameric enzyme . ProSNA galactosidase demonstrated up to a 280-fold higher cellular uptake than b-galactosidase and decreased the enzyme optimizing concentration by up to 100 pM . Pro-SNANucleic acids can have an important role in cancer immunotherapy due to the multiple ways in which they can modulate the immune cell activity . Nanoparticles can enhance the transport of cargo and deliver nucleic acids, directly targeting immune checkpoint molecules  in a controlled way to extend their therapeutic efficacy. Indeed, emerging research has demonstrated that delivery methods based on nanoparticles enhance the concentration and retention of nucleic acids associated with immune checkpoint blockades in target immune cells and/or tumor tissues. For instance, liposome nanoparticles encapsulated with antisense DNA have been investigated for PD-L1 inhibition. In colon cancer, PD-L1 silencing was observed by SNA, in which both the surface and total PD-L1 expression were decreased, providing a promising path for cancer immunotherapy . The tarDifferent types of nucleic-acid-related therapeutics have been approved by the FDA for various diseases; these do not include nucleic acids for cancer immunotherapy. However, even after three decades of research, nucleic acids face numerous physiological barriers after being given systemically or locally . The phaIn this review, we have described the advantages and disadvantages of different types of smart nanoparticles for delivering cancer immunotherapy. Nanoparticles can shield nucleic acids from deterioration and excretion. Work is still ongoing to improve the stability and cellular internalization and protect them from lysosomal degradation. Recent advancements in modification techniques make nanoparticles an excellent and mature nucleic acid delivery technology, with advances in production at scale for certain classes of nanoparticles. In addition to cancer therapies, traditional treatments such as chemotherapy and immunotherapy to treat tumors, hereditary illnesses, infections, and immunological deficiencies have advanced thanks to the widespread use of nanoparticles.Many obstacles still exist despite success in numerous preclinical research and clinical situations. There are, however, safety concerns; for instance, some elements in nanoparticles may irritate the skin, produce inflammation, and trigger the body’s defense mechanisms. The limited circulation duration of the supplied nanoparticles and the potential cytotoxicity are additional difficulties that require careful consideration. More fundamental research is necessary to address these concerns.Among the other nanoparticle platforms that have been developed, lipid nanoparticles are the most advanced because they are the least toxic for in vivo delivery of nucleic acids, and the use of PEG in lipid nanoparticle synthesis increases the half-life of the nanoparticles. The manufacturing of lipid nanoparticles can be easily scaled up with a lower investment. Their long-term stability is an issue, but it is extended by using an appropriate storage temperature. Nanoparticle-based nucleic acid delivery platforms will become more promising and advanced in upcoming clinical applications as the understanding of nanoparticles for nucleic acid delivery is strengthened.


Tumor microenvironment has recently been ascribed a new hallmark—the polymorphic microbiome. Accumulating evidence regarding the tissue specific territories of tumor-microbiome have opened new and interesting avenues. A pertinent question is regarding the functional consequence of the interface between host-microbiome and cancer. Given microbial communities have predominantly been explored through an ecological perspective, it is important that the foundational aspects of ecological stress and the fight to ‘survive and thrive’ are accounted for tumor-micro(b)environment as well. Building on existing evidence and classical microbial ecology, here we attempt to characterize the ecological stresses and the compensative responses of the microorganisms inside the tumor microenvironment. What insults would microbes experience inside the cancer jungle? How would they respond to these insults? How the interplay of stress and microbial quest for survival would influence the fate of tumor? This work asks these questions and tries to describe this underdiscussed ecological interface of the tumor and its microbiota. It is hoped that a larger scientific thought on the importance of microbial competition sensing vis-à-vis tumor-microenvironment would be stimulated. Cancer represents a class of complex, treatment elusive, multimodal diseases typically characterized by uncontrolled cell division primarily attributed to oncogenic mutations –3. An arHelicobacter pylori (gastric cancer), Chlamydia trachomatis , Salmonella typhi , Chlamydophila pneumoniae (lung cancer), Streptococcus bovis , Fusobacterium nucleatum (colon cancer), Bacteroides fragilis  etc. [What challenges or insults would microbes face while transitioning to a dynamic, harsh, and complex environment of tumors?How would microbes respond to such challenges?What would be the collateral impact of microbial response to such insults, on the tumor/TME? Would it be anticancer or oncogenic?Microbial association with oncopathology has in fact been discussed for decades, with reports of anti-cancerous activity of bacterial toxins dating back to a century ago . Discoveer) etc. , 16, 17.er) etc. . Attracter) etc. . Furtherer) etc. , 19. Sever) etc. , 20–32. er) etc. , 15. Preer) etc. . These ser) etc. , (ii) a er) etc.  and environment.Success of colonization of tumors by microbes is expected to depend primarily on two factors–(i)an influx of the micro-organisms(ii)availability of conducive conditions for them to survive, thrive and co-exist in the tumor microenvironment.While the influx can be driven by factors like luminal infiltrations Fig.  through Tumor microenvironment, in fact, can offer several challenges/insults to the visiting microbes as summarised in the graphical abstract and the Fig. Two key hallmarks of tumor are the hyperproliferation and hyperanabolism . The unrReactive oxygen species (ROS), the free radicals, bearing unpaired reactive electron in their valence shells, are normal byproducts of cellular respiration (oxidative phosphorylation). Redox homeostasis is critical for maintaining a balance between the reactive oxygen species (ROS) and antioxidants . The ant2O2 mediated cytotoxicity [Tumors are like wounds that never heal . Unlike toxicity . Evidenctoxicity , 49. It extracellular < pHintracellular), opposite to the normal tissues/cellular environments, where extra-celluar pH is higher than the intracellular pH. An alkaline intracellular pH helps tumors to proliferate and evade apoptosis within the physiological pH range (7.2–7.4), while an acidic microenvironment (6.3–7.0) enables activation of proteases and metastatic pathways, enabling cellular dispersion, immune-evasion, drug-resistance, and invasion of healthy tissues [The Warburg-effect or the preference for glycolytic metabolism is known to lower the pH of tumor-microenvironment , 50. Thi tissues , 52. It  tissues . Tumor-aIn addition to the intrinsic hallmarks of cancer offering a variety of stresses to the visiting microbiota, the extrinsic interventional regimens exert tremendous stress on the tumor, normal tissues, and the native microbiome in and outside the tumor-microenvironment. Cytotoxic and inhibitory effects of the xenobiotic chemotherapeutic agents on microbes, much of which are attributed to the DNA damaging traits of these chemicals, are infact well founded , 55. GivFurthermore, microbial genetic material can also be stressed by the ROS (as described earlier) and the pool of nucleases expressed in the tumor-microenvironment. Nucleases, the enzymes that can hydrolyse nucleic acids, have consistently been perceived as promising biomarkers for cancer. This is attributed to their frequently observed overexpression, with some reports of interindividual variability, in the cancers of various types . Nucleas‘the stress, the stress response and survival’ in the tumor micro(b)environment can govern the dynamics of crosstalk between ‘the cancer and the microbes’. Notably though, despite the microbial stress response being defensive and compensative in nature [Microorganisms have evolved over billions of years to develop regulatory machineries for mitigating environmental stresses through well-orchestrated gene regulatory networks . The strn nature , 67, it n nature . The comFor simplicity in describing the overarching theme of this article , bacterial ecology and stress response mechanisms will primarily be emphasized in the subsequent sections. Bacteria, the most abundant microorganisms inside human body, after all are prolifically studied, offering well founded and valuable models for understanding microbial response to environmental stresses. The terms ‘microbes and bacteria’ would therefore be used interchangeably.The stringent stress response (SSR) is an evolutionary conserved specific stress response mechanism, mediated by the alarmone ‘guanosine tetraphosphate (ppGpp)’, that allows bacteria to reprogram their transcriptional activities when faced with nutrient stress  , 71. Thi+), heightened expression of ‘amino acid decarboxylases, deaminases, proton pumping, biofilm formation’ for acid tolerance are few classical examples of GSR phenotypes [The presence of a global ‘General Stress Response (GSR)’ mechanism in bacteria, is however a key weapon in their arsenal of defence against a broad range of environmental insults . It is menotypes –84. It ienotypes .The diverse environmental insults offered by tumor microenvironment to the invading/thriving microbes are expected to trigger the expression of the aforementioned general stress regulon. This is particularly true for nutrient and oxidative stress (abundant in the TME) which are known to confer a broad cross-protectivity through the activation of general stress response . Table 1Bifidobacterium spp. [.Under the right tumor microbial composition , this GSR and stationary phase linked in-vivo production of compensative products may even support cancer-therapy by priming the onco-immune system towards anti-tumor effects. The reported role of intra-tumoral probiotic gut-microbes in facilitating immunotherapy through the secondary metabolite mediated triggering of the STING signalling (stimulator of interferon genes), highlights this significance of tumoral colonization by commensal bacteria like ium spp. .From an ecological point of view, insults like oxidative stress, DNA damage stress, physical stress and acid stress are perceived as instances of direct challenges interfering with the ability of the microbes to survive and thrive. This calls for an activation of interference competitive phenotype and hence release of antibiotics and strain-specific bacteriocins towards the microbe-kill-microbe response . The colEscherichia coli and Bft toxin in Bacteroides fragilis) can be pro-inflammatory and oncogenic [While Rudolph Virchow first linked chronic inflammation with tumor development , Harold ncogenic , 104. ThFusobacterium nucleatum) and stress resilient bacterial biofilms, a phenotypic response expected against nutrient, physical, DNA damage and acid stress, in initiation and progression of cancer  is worth consideration as well  microbial population and its functional potential. It is therefore important, as we next discuss, to ponder over the directions that can branch out of this school of thought and potential limitations in assuming the native microbial populations of tumors, including any microbe-tumor cross-talk.Human body essentially serves as an ecosystem to the colonizing microbes. The organ and tissue specific  territories of host microbiome are governed by the myriad of physiological, physical, metabolic and nutritional conditions specific to the sites of microbial colonization. Tumor development needs to be viewed as an ecological disturbance and its micro-environment as a perturbed niche capable of reshaping the structure of individual microbial populations through systemic and localized environmental pressures. How prevailing microbiota responds and survives against the ecological stresses offered by tumor development/progression is expected to drive the compositional and metabolic variations observed in different individuals, across different types of tumors. Such an understanding is critical to drive the development of in-silico models of tumor micro(b)environment through due attention to the dynamics of underlying metabolic fluxes and multi-species interactions . A functional gradation and classification of key microbial players  identified inside the tumor micro-environment may enable validation of the well founded driver-passenger models of various types of cancer , 113. FuCancer however is a complex group of diseases characterised not only by abnormally dividing hyper-anabolic cells, unique micro-environment and location or site-specific manifestations but multifactorial confounders like specialized care and aggressive therapeutic regimens  , 122. ThHelicobacter pylori (gastric cancer), Salmonella typhi , Chlamydophila pneumoniae (lung cancer) and Fusobacterium nucleatum (colon cancer) [et al., in fact indicated a predominated intracellular localization of microbial 16S rRNA and LPS inside the cytoplasm of cancer cells, a discovery warranting further reproduction [Nejman and colleagues identified tissue specific distinct territories of tumor microbiota, highlighting the anatomical diversity in the microbial signatures of the cancers of different body sites . For exa cancer) , 16, 17.oduction . HeterogFusobacterium spp. and Bacteroides fragilis in colorectal cancer [The quantum of environmental stresses in the tumor microenvironment are expected to depend on the stage or severity of the cancer as well. This in turn may dictate the shape of the community that can sustain and evolve at each stage of cancer. The cataloguing of lesional and non-lesional gut mucosal communities across different stages of colorectal tumorigenesis by Nakatsu and colleagues corroborates the same . It was l cancer . A recenl cancer . Evidencl cancer , 28, 122Significant research on cancer treatment and diagnosis is carried out in natural or artificial  preclinical models . PreclinClostridium, Bifidobacterium and Salmonella for example prefer hypoxic and nutrient rich necrotic microniche suitable to their anaerobic nature [Fusobacterium) in distinct niches with progressing cancer and suppressed immune surveillance [The TME is highly heterogeneous encompassing different cell types, extra-cellular matrix, necrotic regions, spatial gradients of free radicals, growth factors, cytokines and more , 9. The c nature . A receneillance . A unifoThe systemic implications of surgical (like Ostomy) and case-dependent dosages and durations of invasive therapeutic regimens like radiation or chemotherapy add to the associated complications of the disease and its ecosystem , 124. AsWorth consideration are the challenges associated with reproducing the results of microbiome studies (the reproducibility crisis), especially considering the compositionally sparse microbiota of tumor . Given tSurviving and thriving are key to organismal existence in the living world, microbes are no exception. Appreciating the challenges associated with colonization of an environment as complex and heterogeneous as the TME and linking them with what is well founded in microbial ecology can drive foundational understanding of microbial role in modulating the tumor microenvironment. Here an effort was made to characterize the relevant stresses in the tumor microenvironment that may serve as insults compromising the colonization and survival of microbes in the harsh environment of the tumors. Upon revisiting the classical evidence of microbial ecology/competition and stress response, it becomes encouragingly clear that collateral impact of microbial compensative responses to the consistent insults of the TME could hold an important key for developing functional models of tumor-microbe interaction. The success of various dietary regimens and microbial interventions (e.g. pre/probiotics), that attempt to channelize the host-microbial arsenal for cancer prevention or treatment may after all have roots in the basic concept of microbial competition sensing and their response to the environmental stimuli , 131. Un


Despite extensive research, the cognitive processes mediating the impact of psychotherapeutic interventions remain poorly understood, and as a result difficult to quantify. Identifying such mechanisms is likely to be extremely helpful: it could help target interventions better, could support dosing therapy through monitoring, and could heighten the speed at which new interventions can be developed. Mechanisms research in psychotherapy has described a number of key difficulties to achieving this. In this and the next talk, we ask whether advances in cognitive computational neuroscience might provide some support. Specifically, the question is whether precise cognitive probes might identify specific mechanisms of interventions. In support of this, I will first describe a pilot study in participants undergoing an adapted behavioural activation therapy. I will then move to present results from two strands of experiments examining whether interventions derived from components of cognitive-behavioural therapy (CBT) are able to shift computationally-derived measures of their proposed psychological substrates. Findings from both strands will be discussed with respect to challenges in developing brief, reliable, engaging, and user-acceptable measures of cognition. Overall, this outlines some early new results in using computational methods to understand therapeutic processes in the psychotherapy for depression.Q. Huys Grant / Research support from: Koa Health, Consultant of: Aya Technologies and Alto Neuroscience


Our prior research has demonstrated the effect of nurse driven fluid resuscitation on provider and nurse team dynamics. Our primary purpose with this new research on our nurse driven fluid resuscitation protocol is to determine the effect of the nurse-driven fluid resuscitation protocol on resuscitation associated complications , acute kidney injury (AKI), and abdominal compartment syndrome). The study hypothesis is that the rate of resuscitation associated complications will remain stable or not increase post-protocol implementation.Retrospective review for all patients within a one-year period pre-protocol implementation and post-protocol implementation was completed. 44 patients were included in the total sample, 22 in the pre-implementation group and 22 in post-implementation group. Exclusion criteria for patients included in nurse driven fluid resuscitation included delayed presentation, morbid obesity, electrical injury, cardiac history, DKA, polytrauma, and renal failure.Pre and post nurse driven fluid resuscitation implementation samples of 22 patients with total body surface area (TBSA) greater than 20% were analyzed. The incidence of serious complications including ARDS, compartment syndrome, and wound conversion was not statistically significantly different between samples. Rates of acute kidney injuries were similar across groups. In addition, the mean and median TBSA were not statistically significantly different pre and post implementation. The length of stay for the pre-implementation sample was on average longer than for the post-implementation sample. Our results are limited by the significant comorbidities of the pre-implementation group.Please note tables and graphs were not yet available by time of submission. Attached tables are from prior analysis at approximate half-way of study. Updated graphs and tables will be complete by conference time.As hypothesized, there were no differences in outcomes between patients receiving nurse driven fluid resuscitation. Our results indicate that nurse driven fluid resuscitation is a safe and clinically effective practice in the burn center. Coupled with our previous results that indicate a significant increase in nurse satisfaction with interdisciplinary communication associated with nurse driven, these results signal the importance of implementing nurse led resuscitations.Nurse driven fluid resuscitation is a safe and effective. Further research into barriers to implementation is warranted.


Anyfanti et al.). Cardiovascular and hematological disorders, as well as hematopoietic cell transplantation, are considered key fields in which endothelial dysfunction has been studied. The list of endothelial injury syndromes is constantly updated, including not only toxicity syndromes but also novel entities, such as the coronavirus disease-19 (COVID-19)  –5.Despite the plethora of studies, the clinical significance of endothelial dysfunction remains under investigation. Better understanding of current concepts and significance in clinical practice emerges as extremely important to set the ground for the development of therapeutic approaches specifically targeting the endothelium. Several questions remain unanswered in this complex field.This Research Topic gathered Original Research, Brief Research Report, and Mini Review articles, focusing on endothelial dysfunction or endothelial injury studies in the following areas:Novel entities recognized as endotheliopathies, such as COVID-19Cardiovascular disordersHematological disordersHematopoietic cell transplantationChronic inflammatory disordersAll articles submitted to us for this Research Topic underwent a rigorous peer review process. Ultimately, eleven articles were published.Lalic-Cosic et al.).(i) In pre-eclamptic patients, phosphatidylserine exposing extracellular vesicles were increased and associated with global hemostatic parameters and fibrin clot properties .(ii) In systemic sclerosis, up-to-date knowledge of cellular and molecular aspects in vasculopathy, as well as therapeutic approaches were reviewed .(iii) In essential hypertension, pathophysiological evidence of endothelial dysfunction in cardiovascular diseases and potential innovative therapeutic strategies were reviewed .(iv) In pulmonary essential hypertension, vascular remodeling and its potential involvement of innate and adaptive immunity were reviewed .(v) In systemic sclerosis, uric acid was significantly associated with the capillaroscopic patterns, reflecting a progressive microvasculopathy .(vi) In the life-threatening field of thrombotic microangiopathies, complement-mediated damage was reviewed .(vii) In COVID-19, hematological abnormalities were associated with type I interferon pathway activation and disease outcomes .(viii) In Takayasu artiriitis, cardiovascular risk directly associated with diastolic dysfunction and inflammatory cell infiltration in the vessel wall .(ix) In psoriasis, circulating and vascular biomarkers of endothelial dysfunction were summarized, and the impact of systemic psoriasis treatments on endothelial dysfunction and patients' cardiovascular risk was discussed .(x) In secondary thrombotic microangiopathies, loss of glycocalyx integrity impaired complement factor H binding and cyclosporine-induced endothelial cell injury .(xi) In thrombotic thrombocytopenic purpura, the PLASMIC score was applied in risk prediction of a real-world cohort (Taking into account the multi-disciplinary character of this Research Topic, we hope that it will inspire researchers to continue their explorations into novel advances in their fields.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Engineered three-dimensional (3D) tissue constructs have emerged as a promising solution for regenerating damaged muscle tissue resulting from traumatic or surgical events. 3D architecture and function of the muscle tissue constructs can be customized by selecting types of biomaterials and cells that can be engineered with desired shapes and sizes through various nano- and micro-fabrication techniques. Despite significant progress in this field, further research is needed to improve, in terms of biomaterials properties and fabrication techniques, the resemblance of function and complex architecture of engineered constructs to native muscle tissues, potentially enhancing muscle tissue regeneration and restoring muscle function. In this review, we discuss the latest trends in using nano-biomaterials and advanced nano-/micro-fabrication techniques for creating 3D muscle tissue constructs and their regeneration ability. Current challenges and potential solutions are highlighted, and we discuss the implications and opportunities of a future perspective in the field, including the possibility for creating personalized and biomanufacturable platforms. Volumetric muscle loss (VML) refers to a significant loss of muscle tissue due to trauma or surgery, leading to the failure of intrinsic muscle regeneration and function and the healing of the defect area by fibrosis . The curTo find an alternative method, various regenerative therapies, such as stem cells delivery, scaffolds implantations, and engineered muscle tissue grafts, have been developed to address long-term functional deficits and various pathologic comorbidities caused by a large amount of tissue loss , 5. ThesPrevious reviews have primarily focused on muscle regeneration using stem cells and biomaterials as scaffolds , 10–13. Most of the cells in skeletal muscle are multinucleated, generating myofibers that are surrounded by ECM such as endomysium. ECM components, such as collagen , proteoglycans, and fibronectins, exist between myofibers, regulating muscle development and facilitating the transmission of mechanical forces . When thSkeletal muscles have a strong regenerative ability compared to other adult tissue, partly due to the presence of satellite cells, which constitute less than 5% of the cells in muscle tissue . These sFuture directions for stem cell research in skeletal muscle regeneration include exploring novel delivery strategies for satellite cells, such as gene therapy and tissue engineering approaches, to enhance their survival and integration into host tissue. Researchers may also investigate the use of combination therapies that include stem cells and other growth factors or biomaterials to further enhance muscle regeneration. Finally, the development of new technologies, such as organ-on-a-chip platforms, may provide new avenues for testing the efficacy of satellite cell-based therapies in a more physiologically relevant setting.Adipose-derived stem cells (ADSCs) are a prevalent, multipotent, adult mesenchymal stem cell type that may develop into tissues of the mesodermal lineage, such as cartilage, bone, adipose tissue, and skeletal muscle. Transplantation of ADSCs has been shown to lead to improved muscle strength and endurance in dystrophin-deficient mice , 27, as Although mesenchymal stem cells (MSCs) have demonstrated potential in promoting skeletal muscle regeneration by secreting growth factors and differentiating into skeletal muscle cells in various studies –38, one Human pluripotent stem cells (hPSCs), including human embryonic stem cells (hESCs) and induced pluripotent stem cells (hiPSCs), possess two key characteristics that differentiate them from adult stem cells. Firstly, they have an unlimited capacity to divide and create more cells, referred to as "unlimited proliferative potential." Secondly, they have the ability to differentiate into any type of cell in the body, including skeletal muscle cells (SMCs) . These cBiomaterials play a crucial role in skeletal muscle regeneration by providing 3D scaffolds for muscle tissue growth at the defect area. The scaffold provides favorable microenvironments that physically support cell attachment, proliferation, and differentiation, serving as a substrate for muscle tissue growth. Biomaterials can be engineered to deliver diverse biological factors, such as cells, growth factors, drugs, miRNAs, and other molecules, directly to the site of injury. This targeted delivery enhances the healing process and facilitates the formation of new muscle tissue, promoting muscle regeneration. Moreover, biomaterials can be designed to mimic the structure and mechanical properties of native muscle tissue, guiding the growth and organization of new muscle fibers and the maturation of newly formed muscle fibers. In cases of large-sized muscle defects, biomaterials can fill the defects and prevent the formation of fibrotic tissue that would natively occur, filling the voids of the defect spaces. This approach can improve the overall appearance of the muscle and prevent functional limitations resulting from the loss of muscle tissue. Therefore, biomaterials hold great promise in the field of skeletal muscle regeneration, as they can serve as a critical tool in repairing and restoring damaged muscle tissue. In this section, we will introduce the types of acellular and cellular biomaterials as scaffolds, delineated in Table Various biomaterials such as alginate, gelatin, and collagens have been used to engineer 3D acellular scaffolds , 50. TheDecellularized extracellular matrix (dECM) scaffolds provide an attractive way to overcome the hurdles of natural and synthetic biomaterials-based scaffolds. Compared to transplanted cell-laden tissue, dECM scaffolds have superior biological properties, with a lower risk of immune response due to the removal of almost all cellular DNA . TherefoCell-laden biomaterials have been shown to restore both morphology and function in the area where VML occurred , 73. MorIn recent research on developing advanced biomaterials, the application of nanotechnology, including providing precise control over surface characteristics, has become essential because it allows for creating scaffolds that closely resemble the structures and mechanical properties of the native ECM . This enCarbon nanotubes (CNTs) are cylindrical carbon tubes with high aspect ratios and nanometer-diameters that can be significantly longer than 100 nm . They po. [. [Graphene is an allotrope of carbon that exists in a 2D monolayer with a honeycomb pattern and has π-π bonds between carbon layers. The distance between carbon atoms in their hexagonal framework is around 140 nm, and the integral strong covalent bonding allows the structure of graphene to maintain a few hundred-folds higher tensile strength than steel . Graphen.  develope. [.  added rG. [. [. [Other nanoparticles, such as exosomes and gold nanoparticles (AuNPs), have been used in skeletal muscle regeneration. They can be used in combination with proteins for targeted delivery as they have unique properties. For instance, AuNPs exhibit high surface activity, strong antioxidant properties, and good biocompatibility, while exosomes possess innate stability, low immunogenicity, and excellent cell penetration capacity , 99. Exo.  anchored. , into th. . Huang e. [.  used M12. [.   bioprinting was invented to generate collagen microfibers with 100 μm diameter coated with MPCs or hMSCs resulting in a ring shaped structure around 10 mm in diameter, which had almost 1000 times higher tensile strength than normal collagen gels [The bioprinting strategy for muscle regeneration involves developing new printing methods or printing cells that interact with muscle, such as neural cells or endothelial cells, in a spatially heterogeneous manner. For example, Kang et al.  develope. , 120. In.   injury site using a partially-automated handheld bioprinter [in-situ bioprinting in muscle regeneration [In-situ bioprinting of human ADSCs (hADSCs) with collagen in the VML area was achieved using a bioprinter combined with a bioreactor called Pri-Actor [In-situ bioprinting represents a significant step forward in regenerative medicine, showing potential in muscle regeneration.t et al.  developeoprinter . The resneration . In-situri-Actor  -guided bioprinting can be used to replicate the tissue microarchitecture obtained from patient CT images following an injury, leading to the creation of custom scaffolds tailored to individual patients. Once proven effective in a mouse model, custom scaffolds will undergo Phase I testing before being considered for use in human patients (Fig. The biomanufacturing industry is another area that holds great promise in the production of functional tissues for direct implantation in patients. By using 3D bioprinting to digitally design the scaffold and establishing automated or semi-automated biomanufacturing processes, it can improve the quality of an acellular or cellular scaffold and ultimately lead to enhanced efficacy of implants and related clinical therapies. The ability to fabricate and culture tissues in a high throughput manner and in real-time can greatly improve the speed and efficiency of the biomanufacturing process, making treatments more accessible to patients in need.Looking towards the future, there are several avenues of research that are most relevant and productive. These include exploring the use of new materials and nanotechnology for tissue engineering, developing new methods for in vitro muscle maturation and neural integration, and investigating the use of iPSCs and gene editing techniques for personalized therapies. Furthermore, advancements in artificial intelligence and machine learning can help to optimize scaffold design and improve the efficacy of clinical treatments.In summary, the novel approaches discussed in this review have the potential to significantly enhance the patient’s quality of life. By continuing to invest in research and development in the field of skeletal muscle tissue engineering, we can accelerate the translation of these promising therapies into clinical practice, ultimately improving the lives of millions of people worldwide.


Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function—including fibrinolysis—to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states. Of the many descriptions of shock, the first by Samuel Gross in the year 1882 as when “the machinery of life has been rudely unhinged” remains concise and accurate . This naHere, the physiologic roles of the endothelium are detailed with particular emphasis on coagulofibrinolytic balance, glycocalyx function, and unique biomarkers. Understanding these endothelial functions offers insight to the pathophysiologic anomalies at the level of the endothelium in various forms of shock. Throughout this review, the viscoelastic hemostatic assays (VHAs) thromboelastography (TEG) and rotational thromboelastometry (ROTEM) receive particular attention for their ability to globally assay coagulofibrinolysis, thus enabling a precision-based medicine (PBM) approach to diagnosing and treating the spectrum of coagulopathies associated with SHINE . First, Among the etiologies of shock, septic and cardiogenic shock are the most common with an incidence of 171 per 100,000 population and 51.7 per 100,000 population, respectively . While tShock may be diversely defined, all definitions of which approximate the imbalance between tissue oxygen supply and demand . Shock hThis classification precludes a unified approach towards the spectrum of coagulopathies associated with shock. As opposed to the classic anatomic and pathophysiologic definitions, shock may also be described at the level of the endothelium . The sha2 between the brain parenchyma and blood  feedback mechanisms central to the endothelium’s role in maintaining hemostasis.The definition of an organ requires a collection of tissues that form a unit distinct in form and function . Endothend blood . The endnd blood . The endnd blood . The endnd blood . Far froThe endothelium is functionally and physically distinct and should thus be regarded as an independent organ system . Figure 2 transmits messages from one part of the body to another via many pathways  or base deficit (BD) in trauma , the Seqolamines . Perivasolamines . tPA relvia increased activation of protein C to activated protein C (aPC) which then inactivates Factor V (FV) and Factor VIII (FVIII). APC also inhibits plasminogen activator inhibitor-1 (PAI-1). The increase in tPA may also overwhelm circulating PAI-1 levels to provoke a pro-fibrinolytic phenotype. The glycocalyx layer may also become hyperpermeable because of sialidase-mediated disruption of the endothelial border in shock. Although not particularly evaluated for their role in shock, it has been reported that sialic acid residues embedded in the glycocalyx layer regulate the permeability of microvascular structures , P-selectin, and an increased ratio of Agpt-2:Agpt-1 . Glycocaructures .via tPA’s agonist action upon the N-Methyl-D-Aspartate (NMDA) receptor on the endothelial luminal surface of the blood-brain barrier (BBB), causing NO synthesis and vasodilation of cerebral arterioles  . SimilarThe direction of coagulation is driven not only by the coagulofibrinolytic mediators, but the endothelium is also influenced by the nature and severity of the initial injury, timing and methods of resuscitation, genetic hematologic makeup of the patient, underlying conditions  and medications, all of which determine whether the patient’s endothelium and blood will respond with either a pro- or anti-thrombotic phenotype . For exaDiffering shock etiologies cause different early responses by the endothelium. These responses often share hemostatic phenotypes but also demonstrate unique aspects which implicate the need for personalized resuscitation of the endothelium. For example, the hypotensive septic shock patient often manifests acute hypofibrinolysis, or so-called “fibrinolytic shutdown”, and thus does not benefit from administration of the anti-fibrinolytic tranexamic acid (TXA). On the contrary, a patient in severe traumatic hemorrhagic shock with a hyperfibrinolytic phenotype may benefit from TXA . The hypSHINE can alter hemostasis on a minute-to-minute basis by endothelial reactions , causing worsening microvascular injury and organ malperfusion. Serial bedside VHAs offer more timely goal-directed blood component therapy (BCT) and hemostatic adjunct therapy (HAT) when these coagulopathies may switch phenotypes rapidly. Therefore, assessment of endothelial function and injury pertaining to hemostasis cannot solely rely upon the plasma-based CCTs prothrombin time (PT), activated partial thromboplastin time (aPTT), as well as platelet count, fibrinogen, and D-dimer. Rather, point-of-care global hemostasis assessment with whole blood VHAs, bedside assessment of organ perfusion, and other laboratory markers for hypoperfusion such as serial arterial base deficit and lactate, enable timely physiologic and targeted hemostatic resuscitation of patients in shock .Much as SHINE is a recently proposed framework for classifying patients with shock-associated coagulopathies, a simultaneous expansion has occurred for the use of VHAs to better define the phenotype of these coagulopathies and offer goal-directed therapy . VHAs reThe remaining review describes the principles of VHAs and applying these principles to the monitoring and treatment of patients in shock afflicted by SHINE. Hemostatic phenotypes associated with SHINE are first delineated by applying the accepted pathophysiologic drivers of endotheliopathy for trauma-induced coagulopathy (TIC) and sepsis-induced coagulopathy (SIC). These prevalent causes of coagulopathy in critical illness set the foundation by which to contextualize the coagulofibrinolytic spectrum of SHINE. In turn, one may rationalize the application of VHAs for the diagnosis and treatment of all shock-associated coagulopathies. Here, we additionally emphasize VHAs for SHINE in post-cardiac arrest syndrome (PCAS), medical causes of hemorrhage, PPH, burns, and venom-induced consumption coagulopathy (VICC) . For manvia Resonance (SEER) technology with SonoClot, and the new generation cartridge-based devices  output tracings that plot the amplitude of clot strength in millimeters on the y-axis versus time in minutes on the x-axis. These tracings evaluate whole blood hemostatic competence by describing clot initiation, amplification, propagation, and termination by fibrinolysis (The mechanics of the cup-and-pin legacy devices (TEG 5000 and ROTEM delta), as well as the Sonic Estimation of Elasticity inolysis . The maxinolysis .A useful analogy to simplify TEG/ROTEM interpretation embodies the tracing as the shape of a shovel . With heUncontrolled hemorrhage accounts for about 25% of deaths after injury, and an estimated one-quarter of these deaths likely have a TIC element . TIC is Following major trauma, the release of tPA from endothelial cells may be involved in the initial activation of fibrinolysis in response to a burst of thrombin and fibrin generation and sympathetic outflow. This fibrinolytic phase ends within several hours by the production of PAI-1 by endothelial cells and platelets. This dynamic change is termed “fibrinolytic shutdown”  and may via PAI-1 inhibition. On the contrary, the TM-thrombin complex may activate the TAFI pathway resulting in hypercoagulation by inhibiting fibrinolysis  activity or decreased activation of A Disintegrin And Metalloproteinase (ADAM). VHAs have been recommended as a method to gauge the adequacy of targeted resuscitation with plasma  was directly proportional to survival and inversely related to CPR times and lactate. These data confirmed previous observations that the time to onset of clot lysis is an important marker for patient outcomes . High laOn the contrary, small increases in PAI-1 levels are measurable shortly after ROSC and may be owed to release by activated platelets or endothelium. PAI-1 levels have been shown to peak at 24 h after achieving ROSC, and increased levels correlate to multiple organ dysfunction and worse outcomes . The iniStudies of patients with PCAS who have attained ROSC have demonstrated the utility of TEG and ROTEM to predict intact neurologic survival as a reflection of reduced fibrinolysis. It has been shown that TEG values of R < 5 min or LY30 < 7.5% in early PCAS had more favorable neurologic outcomes. Higher D-dimer levels, PT, aPTT, lactate, and cfDNA were noted in the unfavorable outcome group. Therefore, in the earliest periods following ROSC, a normal hemostatic and fibrinolytic phenotype are early predictors of neurologically intact survival in successfully resuscitated out-of-hospital cardiac arrest patients . Early RThe use of mild therapeutic hypothermia (MTH) has demonstrated increased survival. TEG may be a useful technique to evaluate hemostatic integrity in cardiac arrest survivors undergoing MTH. However, the effects of MTH on PCAS-associated coagulopathy requires appreciation for the effect of temperature on fibrin (ogen) concentration and function. When compared to physiologic temperature patients who have survived cardiac arrest, MTH has shown to lengthen TEG R, reduce the coagulation index (CI), and attenuate clot fibrinolysis. Rather than performing the VHAs at 37°C, it is therefore suggested that VHA analysis be performed at 32°C during MTH to increase the accuracy of hypothermic coagulation impairment . Moreoveversus traumatic or surgery-related hemorrhage  hemorrhage and, to a lesser extent, retroperitoneal hemorrhage of anticoagulated or hypocoagulopathic patients. The state of the endothelium in many ways reflects TIC where the degree of hemorrhage dictates the hemostatic derangement at the endothelium. However, as in TIC, pre-existing hemostatic phenotypes  in part determine the evolution and response to therapy which requires VHAs to guide BCT and HAT for these patients . Patientmorrhage .VHA-guided BCT during PPH is expanding. TEG/ROTEM devices can be used to detect and treat clinically significant hypofibrinogenemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear . If ROTESevere PPH, such as with amniotic fluid embolism (AFE), often associates with hyperfibrinolysis like severe TIC. However, the etiology and treatment differ significantly from severe TIC and requires VHA-guided resuscitation. The mechanism for AFE-induced coagulopathy is the release of amniotic fluid TF into the systemic and pulmonary circulation, provoking a classic DIC of overwhelming thrombin generation, consumption of clotting factors and platelets, and hyperfibrinolysis .Treatment of AFE entails the immediate delivery of the fetus, VHA-guided resuscitation of the mother, and emphasis for early administration of fibrinogen to levels that are two to three times higher than normal to outcompete platelet and clotting factor consumption, and fibrinolysis . Early PAs with late TIC and SIC as well as late PCAS, fibrinolytic shutdown post-resuscitation of PPH remains a risk factor for venous thromboembolism (VTE). Therefore, VHAs may help guide the intensity and duration of DVT prophylaxis in postpartum women, particularly those who suffered hemorrhagic shock .Severe hyperthermia, which causes burn-induced coagulopathy (BIC), can present with early hyperfibrinolysis and hypocoagulability. With treatment of shock, these patients most often develop a hypofibrinolytic and hypercoagulable state as manifested by VHAs . The devHemostatic profiles of patients with BIC and hyperthermia have been studied with VHAs and demonstrate superiority to CCTs for detecting BIC . AdditioAn interesting therapeutic phenomenon has been reported whereby hyperthermic patients have been treated with plasma rather than crystalloids in attempt to protect the endothelial glycocalyx. Since plasma has shown to protect the glycocalyx layer of the endothelium for TIC patients, it has been proposed that plasma is a better resuscitation fluid for patients with burn wounds for its dual abilities in restoring intravascular volume and therapeutic effect on the endothelium .At the other extreme, hypothermia alters fibrinogen and platelet function as measured by VHAs. Plasma composition which is reflected by VHAs can determine the type of coagulopathy associated with hypothermia. Even moderate hypothermia can impair thrombin generation as determined by VHA analysis. Significant hypothermia demonstrates inhibition of thrombin generation as manifested by prolonged R/CT, a reduction in the α-angle, and a significant reduction of platelet function as determined by multiple electrode aggregometry (MEA) .VICC uncommonly causes hemorrhagic and/or distributive shock in the western world, but much more commonly afflicts rural areas and low-to-middle income countries. However, there is also increasing frequency in urban areas in Western countries due to an interest in exotic pets. In addition to the immediate treatment with antivenom to neutralize lethal toxins, transfusion of plasma, cryoprecipitate, and specific clotting factors has been clarified by using VHAs which have demonstrated procoagulant and anticoagulant effects of snake venom. It has therefore been proposed that VHAs should goal-direct hemostatic resuscitation in patients with VICC . Using TCrotalus atrox envenomation using human whole blood samples. TEG accurately evaluated coagulopathies caused by in vitro pit viper envenomations,confirming that VHAs are useful clinical adjuncts for evaluating VICC  and myeloproliferative disorders such as polycythemia vera best exemplify the extremes of this spectrum. APL most often manifests a hypocoagulable hyperfibrinolytic phenotype, whereas as patients with polycythemia vera are hypercoagulable . PatientFor patients with non-malignant etiologies such as hemophilias or thrombocytopenias who are in shock, VHAs may direct resuscitation by defining the hemostatic phenotype and guiding BCT and HAT .Coagulopathy of traumatic brain injury (CTBI) perturbs primary hemostasis, and VHAs can be used to monitor the progression of platelet dysfunction . Early aAnother area where definition of coagulopathies based on endothelial changes will result in much different treatments than reliance on CCTs alone is the pediatric patient whose endothelium differs significantly from the adult or PPH patient with SHINE. VHAs for decades have guided resuscitation of pediatric patients undergoing liver transplantation, cardiac surgery, cardiac transplantation, and traumatic injury. In addition, VHAs have been monitored hemostasis for patients on ECMO, VADs, continuous veno-venous hemofiltration, and continuous veno-venous plasma filtration . The endvia suppression of the glycocalyx core protein glypican 1 . Abnormal levels of angiopoietin-2, sE-selectin, and VWF antigen correlate with the vasoactive and inotropic score in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related MIS-C with shock . For MISThe appropriate treatment of shock-associated coagulopathies mandates a personalized approach to hemostatic resuscitation. VHAs empower the clinician to appreciate the patient’s position along the spectrum of coagulofibrinolysis, and it is this appreciation of the various hemostatic phenotypes which enable the accurate diagnosis and physiologic treatment of patients with all forms of shock. Until recently, VHAs for hemostatic monitoring of patients in shock was limited to operative settings of liver transplantation and cardiac surgery. Subsequent evidenced-based protocols have validated VHA-guided resuscitation for TIC. VHAs have likewise recently expanded use to treating medical causes of bleeding associated with PPH, GI bleedings, liver failure, and septic shock. Earlier identification of coagulopathic and endotheliopathic patients with VHAs and endothelial biomarkers may enable more timely and targeted resuscitation for those patients in all forms of shock. However, further investigation is needed to elucidate the causal or correlational relationship of endotheliopathy with progressive shock, and whether restorative endothelial therapies manifest a mortality benefit.


Nutrition knowledge, confidence, and skills are thought to be important elements in the role of healthcare professionals in obesity prevention and management. The Upstream Obesity Solutions curriculum goes upstream with a multidisciplinary approach to supplement nutrition education among health professional trainees. Educational strategies of didactics, teaching kitchens, and service-based learning were employed for medical, dental, and nursing students and resident physicians. Pre/post participation surveys assessed knowledge, attitude, and practices; lifestyle habits; and culinary skills among 75 trainees in this cross-sectional descriptive study. There was variability in statistically significant improvement in knowledge, attitudes, and practices about obesity management and nutrition education, lifestyle habits, and culinary skills among learner groups.  The prevalence of Americans with elevated body mass indexes in the United States (US) was 18.5% among youth and 39.8% among adults, as noted by the US Centers for Disease Control and Prevention National Center for Health Statistics in 2017 . Yet, moGiven the role different HCP play in nutrition counseling, training programs must keep pace with nutrition education. Nutrition education is complex and diverse including the factors and contexts that influence the individual, environment, society, and culture. The social-ecological model illustrated in the USDA Dietary Guidelines for Americans attempts to explain how these factors combine to shape dietary behaviors . Thus, tFurthermore, current trends in graduate education include merging classroom and clinical training for earlier clinical exposure, more hands-on experiential learning, and small group experiences ,12,13,14Teaching kitchens are an emerging experiential concept where participants learn evidence-based nutrition information, culinary skills, self-care practices, and other subjects in a hands-on kitchen environment. A study at Tulane University found nutrition education through a teaching kitchen significantly increased medical students’ competencies in patient nutrition counseling . VariousBuilding upon the successes of these other teaching kitchen curricula in the literature, the Upstream Obesity Solutions (UOS) Teaching Kitchen curriculum was implemented at an academic university center. It was informed by a 2017 pilot involving a small cohort of HCP students, which demonstrated significant improvements in culinary skills and confidence in advising patients about nutritional habits and meal preparation. Given the success of the pilot, we proceeded to disseminate the curriculum to a larger group of HCP trainees. In this report, we describe how we conducted the UOS Teaching Kitchen curriculum with trainees from three disciplines  and across two levels of training (undergraduate and graduate), and the evaluation outcomes of this program. We delivered the training across these disciplines given the recognized role these health professionals play in nutrition counseling.The UOS program utilizes the conceptual framework of experiential learning to train the next generation of HCP with the knowledge, skills, and confidence in culinary skills and nutrition counseling. The aim of this study is to investigate the impact of the UOS program on the knowledge acquisition, attitudinal shifts, and practical application of healthcare trainees pertaining to nutrition education, lifestyle habits, and culinary skills.The UOS team included university faculty and staff members with expertise in medical, nursing, nutrition, public health, culinary, and dental education and representing diverse disciplines including physicians, researchers, chefs, dietitians, and health sciences students. This team collaborated to develop the UOS curriculum. Learning objectives and educational content were based on national guidelines, existing literature, and key informant interviews. We considered learners from different disciplines and training levels to develop an educational product that would be adaptable across specialties and training levels. Lastly, we integrated experiential learning with a train-the-trainer model for an interactive approach centered on the HCP trainees as the targeted learners .Given the commonly encountered barrier of time limitations within the different professional schools, we employed multiple modalities to deliver the educational curriculum while ensuring the three core components were similar across all courses. The educational approach included hands-on learning coupled with a train-the-trainer model to equip trainees with the knowledge, attitude, and skills to promote healthy lifestyles for themselves and their patients. The aim was for trainees to ultimately share and apply their gains in knowledge and skills with future patients utilizing the “see one, do one, teach one” methodology common across training.The three core components across all the courses were the following: the teaching kitchen experience, the service-based learning experience, and the didactic session. The teaching kitchen experience encompassed a series of two-hour live hands-on interactive cooking lesson delivered by a professional chef and registered dietitian. Each course used the same lesson plan that included nutrients, foods, and recipes associated with the prevention of chronic disease and the promotion of healthy meals based on the US 2015–2020 Dietary Guidelines for Americans. Each course also used the same teaching kitchen skills lessons to prepare healthy meals such as knife skills and reading nutrition labels.The second core component was a service-based learning experience that consisted of newly trained learners delivering their recently acquired culinary and nutrition skills in a cooking demonstration to patients and their families at a federally qualified health center. Lastly, the third component was didactic sessions designed for synchronous and asynchronous learning and accomplished using traditional lectures and self-study modules . The UOS team delivered the multidisciplinary curriculum through four courses. All sessions occurred during the 2019–2020 academic year. The first was the Spring Sizzle, a five-week not-for-credit course offered through the Medical School and Dental School composed of first and second year medical and dental students. Students voluntarily enrolled in the program and completed the self-study modules, the live teaching kitchen, and the service-learning kitchen.Next, the “Improving Health for You and Your Patients Selective” (Selective) was offered through the Medical School. Medical students from their first and second year of training electively enrolled in the course and received academic credit toward graduation. Over the seven-week elective, they received lectures, self-study modules, the teaching kitchen hands-on sessions, and the service-learning kitchen experience with children and families one afternoon per week.The “Public Health and Ambulatory Basics and Beyond” (PHABB) was a two-week elective rotation in the Pediatric Residency Training Program. Pediatric resident physicians were enrolled during their second year of training. Over the two weeks, the UOS curriculum was integrated so resident participants received didactic lectures, self-study modules, the teaching kitchen lessons and hands-on learning, and the service-learning kitchen experience.Lastly, the core components of the UOS curriculum were integrated into “Health Promotion: Nutrition,” a required course in the Nursing School. Over the 10-week course, nursing students were required to attend teaching kitchen sessions. The nursing students then delivered their respective teaching kitchen lesson to their classmates on the last day of class as their service-learning kitchen experience.Study participants were HCP trainees from the aforementioned undergraduate and graduate healthcare training programs. The recruitment varied across the different programs as participants enrolled through required or elective courses. All sessions occurred during the 2019–2020 academic year. Participants included in the data analyses were learners who completed their pre- and post-course surveys. We combined the Spring Sizzle and the Selective groups for certain data analyses because of the small number of participants and the similar core components of the curricula across the groups. Informed consent was obtained from all participants involved in the study. All procedures involving research study participants were approved by the University of California Los Angeles Institutional Review Board (UCLA IRB). The UCLA IRB’s Federalwide Assurance (FWA) with Department of Health and Human Services is FWA00004642 (IRB00004474).Course surveys were created by the investigators using portions of existing surveys published in the literature since no single validated tool was found that met the needs of the study ,23,24,25Next, the lifestyle survey was a self-evaluation of the dietary intake, cooking habits, physical activity, sleep, and overall well-being of learners. Questions were adapted from the baseline participant survey of the Teaching Kitchen Collaborative . We measLastly, the culinary skills survey was adapted from previously published psychosocial scales for evaluating the impact of teaching kitchens and culinary nutrition education programs ,25. The Pre-course and post-course surveys were administered to the learners enrolled in each course . The SprDue to variability in implementation for each course because of the different professional schools, we conducted pre/post comparisons within each course only and not across the groups. We compared the paired pre-course and post-course measurements for participants who completed their surveys within each course. For the knowledge assessment portion of the KAP survey, we tabulated the total correct answers both before and after course participation. For the remaining items on the KAP survey, scores were based on participants’ answers to their level of agreement or confidence to each statement on a five-point Likert scale from “Strongly Disagree” to “Strongly Agree.”® where data cleaning and transformation occurred. We constructed the individual records to reflect measurements taken before the program started and afterward. Matched paired t-tests were used to assess changes in mean survey responses before and after participation. Additionally, Python® was employed to evaluate rank sum mean differences using the Wilcoxon rank test. For categorical and dichotomous data, McNemar Chi-Square was used to assess discordant pairs whose scores had changed from pre-course to post-course compared to concordant pairs whose scores had not changed.Survey data were entered in EXCEL and imported into SAS 9.4Study participants were a total of 75 learners who completed both their pre-course and post-course surveys. There were 21 participants from the Spring Sizzle and Selective courses consisting of medical and dental students, 37 nursing undergraduate students from the Health Promotion course, and 17 pediatric resident physicians from the PHABB course. Because of the small number of participants and the similar core components of the curricula, we combined the Spring Sizzle and the Selective groups for certain data analyses. The data presented in the tables report results from the participants with completed surveys.p < 0.05), and no improvement among the nursing nor medical/dental students. “Confidence in Knowledge about Obesity” and “Confidence in Counseling about Obesity” significantly improved in all the groups (p < 0.05). General knowledge about obesity significantly improved for nursing students and pediatric residents (PHABB) (p < 0.05) but not for medical students (Selective).p-values in p-value < 0.05). Consumption of whole grains significantly improved in the Selective group but not the others. Pediatric residents (PHABB) showed improved number of hours spent sleeping. “Advising patients about nutrition” and “advising patients about cooking” did not change significantly for any of the groups, nor did minutes per day for moderate exercise.From the self-reported lifestyle survey, p < 0.05).From Our program is timely because numerous medical education programs are currently revising their curricula . AddressIn this report, we describe the UOS Teaching Kitchen curriculum as an educational pilot aimed at delivering nutritional knowledge and culinary skills to HCP trainees across various disciplines. The different educational strategies UOS utilized seem effective in significantly impacting trainees’ self-efficacy related to counseling; cooking skills; confidence in nutrition knowledge; and nutrition literacy. It has been recognized that patients find motivation in providers sharing their own healthy habits . While tThe KAP surveys before and after participation revealed variations in responses related to “Provider’s Role in Managing Obesity,” “Confidence in Knowledge about Obesity,” and “Confidence in Counseling about Obesity” among participants. Notably, pediatric residents (PHABB) demonstrated a statistically significant improvement in their understanding of the “Provider’s Role in Managing Obesity.” This outcome may be attributed to their specific training in primary care and their advanced stage of training, aligning their roles more closely with the management of this prevalent primary care health condition.Furthermore, self-reported lifestyle behaviors of trainees before and after the course exhibited variations in responses. Some differences observed were situational, such as a decline in sleep hours reported by nursing students in the post-survey due to final exam preparation. Similarly, the PHABB group, consisting of pediatric residents, did not show significant changes in fruit, vegetable, and whole grain intake, likely due to their higher baseline consumption of these nutrients. For example, at baseline, 42.9%, 10.5%, and 43.8% of trainees reported consuming 0–1 servings of fruits/vegetables per day among the Nursing, PHABB, and Selective groups, respectively. A similar trend was observed in whole grain intake. The significant change in sleep hours was particularly noticeable in the pediatric resident group, likely due to a reduction in clinical demands during their rotation, resulting in fewer long hours and overnight shifts at the hospital.We do recognize limitations in the implementation and evaluation of the UOS curriculum. This descriptive cross-sectional report lacked a control group, and the findings cannot be generalized to other higher educational institutions or professional cohorts. Nevertheless, similar findings have been reported in the literature for teaching kitchen curricula, even in the absence of comparison controls ,22,29. FMoreover, while we observed short-term improvements in reported lifestyle behaviors, predicting long-term changes is challenging. Trainees’ lifestyle changes may have been influenced by the timing and circumstances surrounding their courses, such as reduced clinical demands or more stressful examination periods. Although all participation groups reported significant improvements in self-assessed cooking skills and nutrition literacy after their completing the educational program, trainees did not report significant changes in their self-reported practices of advising of patients about nutrition or cooking. We suspect that assessing behavioral changes in this context was challenging due to the limited number of clinical encounters that occurred during the course itself. Nevertheless, the significant improvements in self-reported measures of knowledge and confidence are encouraging because it may well translate into actual practice among our learners when they have the opportunity to apply it in a clinical setting.In summary, the ability to embed the UOS curriculum into existing courses provides a practical solution in addressing the various scheduling and logistical challenges in organizing and gathering different HCP trainees to learn together in the same setting. Next steps will investigate how the UOS Teaching Kitchen curriculum as an innovative approach to improving nutrition education across different HCP trainees can become a required component of formal training programs.Regarding our future direction, after successfully delivering the program in 2020, the unforeseen global pandemic prompted us to transition to online learning platforms. In the upcoming phases, we aim to assess and compare the effectiveness of in-person versus online program delivery during the years 2020 to 2022. This analysis will help us refine our approach to meet the evolving needs of our trainees. Additionally, within our institution’s educational landscape, we are actively exploring avenues for broader dissemination of this program. Our team’s presence in faculty roles on the undergraduate campus positions us strategically to expand our program’s reach even further upstream in the educational continuum. Additionally, we continue to advocate for nutrition education becoming a course requirement rather than an elective choice within healthcare professional training programs. The importance of nutrition education has already been brought to the forefront of the curricular redesign efforts within our academic institution. Evaluating the efficiency of remotely conducted training in comparison to live, in-person delivery is a valuable undertaking, particularly as the medical education literature delves into distance learning strategies.


Doctors and nurses play a fundamental role in maintaining global health systems and achieving universal health care coverage. However, significant shortages persist, and little is known about the popularity of these careers among young people in various economies or the relative impact of personal inputs and contextual factors.Using data from the large-scale Programme of International Student Assessment (PISA) 2018, we showed the recent distribution of adolescents' medical (doctor) and nursing career expectations in 61 economies. With multilevel logistic and hierarchical linear regression, we examined the relative importance of economic indicators, health work conditions, and personal background factors in affecting adolescents' health career expectations.Approximately 11% of adolescents expected to be doctors in each economy, while only 2% expected to be nurses. Adolescents were attracted to health professions mainly by system-level favourable conditions (accounting for 1/3 variance), including (a) government health expenditure beyond that expected gross domestic product (GDP); (b) a safe working environment for doctors in wealthy nations; and (c) high salaries for nurses in less-developed economies. In contrast, adolescents' background  was less influential, explaining only 10% of the differences.In the technological and digital era, high-ability students are equally competitive for emerging careers other than doctors and nurses. In developing countries, a high salary package and societal respect are enough to attract adolescents to nursing careers. In contrast, for developed countries, extra expenditures beyond regular GDP allocation and a safe work environment are crucial in attracting adolescents to become doctors. Salary may effectively attract international-trained doctors and nurses, but the work environment will likely emerge as an essential factor in retaining migrants in their positions.Trial registration number: No human participants were involved in this study.The online version contains supplementary material available at 10.1186/s12960-023-00823-7. An adequate, motivated, and evenly distributed health workforce is essential to attain universal health coverage and realize the United Nations Sustainable Development Goals. However, the Global Strategy on Human Resources for Health: Workforce 2030 estimated a global shortage of 18 million health workers by 2030 ), health expenditures, and health working conditions ; (b) perceived distal environmental factors ; and (c) personal inputs  in shaping adolescents' expectations for medical and nursing careers.This outcome variable was measured by a single open-ended question: "What kind of job do you expect to have when you are approximately 30 years old". The answers were coded using the International Standard Classification of Occupations 2008 (ISCO-08). We specifically focused on students' medical and nursing (and midwife) career expectations and compared them against all other career choices. All examined occupations required Skill Level 4, which entails a first degree issued at a higher educational institution for a minimum of 3–6 years of study.M = 500, SD = 100), which are generally strongly related to students' medical/nursing career expectations, were averaged to become an indicator of students' academic ability (abbreviated as Sci below).The PISA assesses students' ability to apply their knowledge and skills in reading, math, and science to deal with real-life problems. Students' science and mathematics scores  were measured by (a) salary  , 33; (b)The differences in how students' background (SBkGd) might affect students' career expectations were measured by (a) girl preference ; (b) high SES preference ; and (c) high academic preference .In estimating the impact of personal backgrounds  in each economy, multilevel logistic regression models were adopted. Following previous research, the school average SES and the school average academic achievement  were controlled  . SpecifiIn the first step of PISA data analyses, for each economy, we examined the popularity of doctors and nurses and how individual students' factors  affected their expectations. In the second step using hierarchical regression, these students' characteristics  of each economy were used with their economic and HealthCon factors  a bell curve (quadratic) relationship indicating that the average economies might have higher (or lower) medical career expectations than the richest and poorest economies and (b) the various factors having very different effects in low- and high-GDP economies . Our hierarchical regression analyses (see details in the Results section) showed that (a) the GDP effect on medical career expectations was curvilinear and (b) the effects of injuries (for doctors) and salary (for nurses) were different in low- and high-GDP economies.As shown, the relative percentages of adolescents expecting to pursue medical and nursing careers were quite different, sometimes even opposite, in the same economy Figs. ; Table 1For medical careers, system-level factors were more critical, with economic factors accounting for 10% of the differences  and the health environment adding another 21% of the students' career expectations. Student-level background added an additional 10% Table .Table 3SGDP. In the analyses involving the nonlinear effects, adolescents' medical career expectations in the low- and high-GDP economies tended to be higher than those in the middle-GDP economies .Based on SCCT, we focused on factors conducive to attracting more adolescents to medical and nursing careers. The extra government expenditure on health (on top of the GDP) was the most important and probably the only critical factor in attracting students to nursing careers among the various predicting factors examined in this study. However, extra health expenditure did not help doctors’ career expectations.Favourable health working conditions were found to be vital in attracting adolescents to medical careers but not to nursing. Economies with longer working hours, fewer injuries on the job, and fewer doctors in the population  tended to attract more adolescents to medical careers.Whether an economy attracted more girls (or boys) or low (or high) SES students to medical and nursing careers did not affect adolescents' health career expectations in an economy. However, systems that could attract more high academic ability (HAcaPref) students to medical careers would in turn have more adolescents expecting medical professions, although this would not affect adolescents' choices of nursing careers.Statistically significant combinational (moderation) effects were noted, and subsequent simple slope tests were conducted . First, for medical careers, low injuries were critical to attracting more adolescents in high-GDP economies. In contrast, this factor was not influential in low-GDP economies (slope difference 0.684 for one standard deviation change of GDP). Second, for nursing, a high salary was comparatively more essential to attract students in low-GDP economies than in high-GDP economies (slope difference 0.748 for one standard deviation change of GDP).To tackle global health workforce shortages, knowing the human resource potential is as vital as channelling current medical students to proper specialties and locations. Adolescence is a critical phase when educational and occupational interests, beliefs, and choices are formed and stabilized . UnderstGuided by SCCT, we investigated the relative influences of personal inputs and contextual factors. We found that the local economy, health expenditure, and health working conditions account for the majority (one-third of the variance in choices) of adolescents' health career expectations. Specifically, conducive health working conditions  attract more students to medical careers, while favourable economic conditions and high health expenditure contribute more to forming adolescents' nursing career expectations. In contrast, personal background, in terms of gender, social status, and academic ability, was found to explain much less of students' medical (10% of variance) and nursing (1%) career expectations. In this regard, government-level environmental support is more crucial than personal characteristics in determining adolescents' expectations for health careers.In particular, a safe work environment for health workers was found to be more critical for attracting adolescents to become doctors than remuneration. The generally high-ability students, potentially aiming to be doctors, were highly competitive and would opt for other highly rewarded and trendy careers when the health work environment was unattractive . Thus, protecting health workers from medical injuries and other physical violence by patients' families is essential to attract adolescents to medical careers, especially in economically developed countries. Moreover, it was surprising to find that economies with longer working hours tended to attract more adolescents to medical careers, even when controlling for remuneration and work safety. The long working time probably reflects that the health profession is an extraordinarily challenging and specialized career that is highly valued and respected by the local community. The societal evaluation of health professions strongly influences young people's willingness to enter such careers .The results suggest a curvilinear relationship between GDP and medical career expectations, indicating that medical professions are particularly attractive in both the highest- and the lowest-GDP economies. In economically developed countries, medical careers attract many high-ability students partly because they are well-paid, challenging jobs with high status . ReportsNurses and midwives are the backbone of maintaining global health systems and comprise more than half of the global health workforce . IncreasNevertheless, a combinational (moderating) effect between nurses' salaries and GDP showed that higher income does not necessarily lead to adolescents' higher nursing expectations in economically developed countries. However, in less-developed economies, higher remuneration is critical in attracting adolescents to expect nursing careers. According to SCCT, financial incentives substantially affect adolescents' outcome expectations regarding nursing career choices and become a potent extrinsic motivation . Higher Interventions have been designed to train, recruit, retain, distribute, and manage health workers to achieve adequate universal health coverage . Based oThe proportions of adolescents expecting health careers were not found to be parallel to the professional density in the specific economies. This outcome could be due to the international migration of health workers, limited medical training places, and other local licensure restrictions. For advanced economies that lack prospective medical students, understanding context-specific push and pull factors aiming to reduce outmigration is a potential solution. Increasing in-migration through formal bilateral partnerships with less-developed countries is another common strategy, which has been successfully practised in Canada, Germany, and Finland . HoweverThis study used country-level indicators to investigate adolescents’ health career expectations which showed a general trend across examined 61 economies. However, this method neglects contextual-specific influences within each economy. To develop effective strategies for improving human resources for health planning, further analyses are needed for each economy using individual-level (student-level) data. In this way, unique associations between young people’s career expectations and different environmental and personal influencing factors will be found in each country.The persistent global shortage of doctors and nurses is hindering the achievement of universal healthcare coverage by 2030, and the largest deficit of health workers is found in low- and middle-income countries. It is thus essential to understand the health workforce potential in various economies and the associated influencing factors. The analyses of data from 61 economies have provided important results and policy implications. (a) Adolescents' expectations for medical and nursing careers vary substantially in different economies and do not resemble the professional density distribution. The international migration of health workers has been common, but we must proceed cautiously. (b) Health expenditure and health working conditions are the most deterministic factors. In contrast, personal background factors  play a less critical role in explaining adolescents' medical and nursing career expectations. Thus, more attention should be given to understanding system-level context-specific push and pull factors in attracting adolescents. (c) More students expect to become doctors in higher- and lower-GDP economies than in average GDP economies. Thus, middle-income countries must expand their outreach and financing programs to attract more students to health careers. (d) Work safety matters more in attracting adolescents to medical careers in wealthy nations, while remuneration is more crucial in attracting students to nursing careers in lower-income countries. For economies to widen the pool, contextual system-level influences on adolescents' health career expectations should be taken more seriously when making effective human resource strategies.Additional file 1: Table S1. Proportions of adolescents expecting medical and nursing careers in 61 economies in 2018.