Lassa fever (LF), a zoonotic illness, represents a public health burden in West African countries where the Lassa virus (LASV) circulates among rodents. Human exposure hinges significantly on LASV ecology, which is in turn shaped by various parameters such as weather seasonality and even virus and rodent-host genetics. Furthermore, human behaviour, despite playing a key role in the zoonotic nature of the disease, critically affects either the spread or control of human-to-human transmission. Previous estimations on LF burden date from the 80s and it is unclear how the population expansion and the improvement on diagnostics and surveillance methods have affected such predictions. Although recent data have contributed to the awareness of epidemics, the real impact of LF in West African communities will only be possible with the intensification of interdisciplinary efforts in research and public health approaches. This review discusses the causes and consequences of LF from a One Health perspective, and how the application of this concept can improve the surveillance and control of this disease in West Africa. The Coronavirus Infectious Disease 2019 (COVID-19) emergence since December 2019, and the subsequent pandemic, has highlighted that over recent decades changes in human and domestic animal demographics and their associated impacts on the environment have fundamentally affected ecosystem dynamics [Mastomys natalensis), a now semi-domesticated African rodent associated with human settlement in forested environments [There is an epidemiological link to domestic animals and/or captive wildlife in food systems, farms or trade, which incubate or vector evolving pathogens and bring them into close contact with humans. Free-living animals (wildlife) are not typically a direct zoonotic source of human disease, except for rare cases when the wildlife has adopted a peri-domestic behaviour, exploiting food and habitat created by humans . For insronments –6.Lassa mammarenavirus (LASV), an enveloped single-stranded RNA member of the Arenaviridae family [The infectious agent of LF is the e family . Its gene family . Both NPThis disease is endemic to West Africa with outbreaks reported from Nigeria, Sierra Leone, Liberia, Benin and Togo in recent years . NigeriaZoonotic transmission of LF caused by spillover from the reservoir species is the primary driver of human cases of the disease, however, human-to-human transmission chains have been described –14. ThesLassa fever is endemic in several countries of West Africa, primarily the Mano River Region states of Sierra Leone, Guinea, and Liberia . HoweverMolecular epidemiology has so far revealed seven distinct lineages of the LASV, including four confirmed and three proposed lineages –24 suggeIncreasing numbers of reported cases in the West African endemic region has raised concerns over the export of LF to countries outside the region . From thIt is noteworthy that LF cases exported from West Africa have been reported in various parts of the world. However, no local transmission has been recorded in the countries where the cases were identified , 19, 29.M. natalensis trapped in 12 villages in the Faranah area Upper Guinea, over 12 years  trapped in residents’ houses and surrounding gardens and fields [M. natalensis was first described in South Africa, it is now known to be the most widespread rodent species across sub-Saharan Africa [Mastomys spp. occur in many types of habitat. They breed frequently, produce large numbers of offspring, and are numerous in open grassland, mixed savannah and clearings in forests. They are also highly adaptable and can be expected to display variation in their ecology and behaviour, thriving in agricultural fields and human dwellings [Mastomys are also considered commensals and are often captured indoors [LASV was isolated from peri-domestic rodents for the first time in 1974, during an LF outbreak in Sierra Leone. The virus was isolated from the Natal multimammate mouse  in certain localities within Nigeria and Guinea, the African wood mouse (Hylomyscus pamfi) in Nigeria, and the Pygmy mouse (Mus baoulei) in Ghana and Benin, suggesting these species as viable hosts of the virus [Praomys daltoni) and Olivier’s shrew (Crocidura olivieri), are involved in incidental, spill-over infections because of their proximity to LASV-positive M. natalensis [LASV has also been detected in the Guinea multimammate mouse  used nine unlinked microsatellite loci to assess ive ones . Future ive ones . Such inerations . MHC claerations , 73.Mastomys populations across West Africa could be carried out together with concurrent neutral microsatellite characterisation to tease apart patterns caused by genetic drift from those shaped by pathogen-mediated selection. This would improve our understanding relevant to topics such as whether there are specific MHC alleles or MHC supertypes  associated with LASV infection status [Myodes glareolus to Puumala and Cowpox viral infections [M. natalensis revealed 21 different alleles with strong signals of balancing selection on the peptide-binding sites, showing that DQB seems to be a good marker to investigate pathogen-driven selection [MHC typing of key n status . For insfections . In factelection .M. natalensis and M. erythroleucus concerning alleles connected to LASV infection status. Phylogenetic analysis of MHC II DRB variability in two murid rodents which are sympatric in European forests, the Wood mouse Apodemus sylvaticus and the Yellow-necked mouse Apodemus flavicollis, showed that the sequences did not separate according to species, consistent with trans-species evolution of the MHC in these taxa [Another point of interest would be to find out whether there is trans-species polymorphism between ese taxa .A broad overview of LASV lineage patterns in rodents across the West African region now allows us to conduct more intricate investigations on spatio-temporal strain circulation within specific hotspots, and to more closely compare virus sequences between rodents and humans. Accomplishing this will involve the continuation of intensive, longitudinal rodent sampling in localities where this has already begun, supplemented by ad hoc trapping to fill in the gaps where connectivity to human data is required. When possible, whole-genome sequencing of the LASV to enhance phylogenetic rigour should be effected. Furthermore, beyond mitochondrial DNA to designate rodent species, additional markers should be typed; such as neutral microsatellites for population structure and MHC to throw light on susceptibility to LASV.A study conducted in Sierra Leone and published in 1987 evaluated the LASV serology in humans and rodents. The study estimated that annually, 100,000–300,000 people are infected with LASV with around 5000 deaths in West Africa . HoweverApproximately 80% of LF infections are asymptomatic, while symptomatic cases present with a variety of symptoms ranging from milder flu-like symptoms, fever, muscle aches, sore throat, nausea, vomiting, chest- and abdominal pain, to severe haemorrhagic manifestations of the liver, spleen or kidneys which often result in death . The surStudies have suggested that LF outbreaks are likely due to independent zoonotic transmission events from infected rodent hosts, whilst approximately 20% of cases result from secondary human-to-human transmission especially through nosocomial transmission in hospital settings , 88. FigHence, the number of LF cases is challenging to accurately determine, as diagnostics tests are crucial for differential diagnoses , 88. AsyWest Africa peri-urban areas have been witnessing an annual increase in the number of LF cases , 97–99. The impact of LF in West Africa is believed to be underestimated and compounded by a paucity of data in many countries . The casHuman-to-human transmission is most pronounced in healthcare settings, resulting in healthcare workers (HCW) having a high risk of infection and mortality , 106. InA common complication/sequelae of LF is sensorineural hearing loss (SNHL), although its the prevalence and impact in endemic regions may be underestimated. Studies have shown that approximately one-third of survivors suffer from SNHL , 86. HeaTreatment costs for LF infection may stretch the limited financial resources of patients who typically come from lower socio-economic positions within the community in endemic regions . PreventLF infection may be considered a neglected tropical disease due to its localised occurrence in West Africa. However, its morbidity and mortality in the region represent a significant socio-economic and global health concern. In 2018, LF was added to the “WHO Research and Development Blueprint” portfolio, a global initiative for preparedness and rapid research on severe emerging diseases. The strategy promotes research and development on laboratory diagnostic tests, vaccines and treatment for epidemic threats . A recenWhile a LASV vaccine is still unavailable, increasing insight into LF ecology, particularly where LASV rodent hosts are concerned, can provide a more dependable assessment of zoonotic risk. In this regard molecular analysis as a tool has proven useful, driving a series of advances in the mapping of LASV occurrence, lineage clustering and more accurate identification of rodent hosts . Most ofFurthermore, this review demonstrated that it is vital to incorporate system dynamics components in a broader One Health approach in order to identify appropriate interventions to control the critical driver of LF outbreaks. The integration of interdisciplinary methodologies including virologists, clinicians, veterinarians, epidemiologists, ecologists among others has shown how interconnected are human actions, climate and reservoir behaviour and how each of them affects the emergence and persistence of the disease in West Africa. Such approaches have also provided evidence and strategies that may be applied to restrain other zoonotic infections. Although humans are unable to control natural events associated with the (re)emergence of infectious diseases, embracing the responsibility of the anthropic impact will support well-elaborated and sustainable actions directed to prevent and control EID outbreak events.


Conclusions: Surgical therapy in selected patients can lead to promising results, although further evidence is needed. On the other hand, the role of medical therapy remains controversial, often due to the lack of univocal curative protocols and variable responses depending on the drug used and the timing of administration. Therefore, further investigations are necessary to clarify the most appropriate therapeutic procedure.Background: Several treatment options have been proposed for pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANS/PANDAS). Still, no clear therapeutic protocol has been recognized to prevent these neuropsychiatric diseases. The study aims to report on the literature evidence and different treatment strategies related to these disorders. Methods: We analyzed the last 20 years’ English language literature and performed a comprehensive review of the PANS/PANDAS treatment, including studies reporting OCD outcomes post-treatment follow-up. Results: We covered 11 articles in our systematic literature review for a total of 473 patients, of which four studies included 129 surgical subjects and seven papers with 326 medically treated patients. Pooled outcomes analysis, surgical and medical treatment reported an OCD reduction, but no statistical significance was obtained ( Post-infectious autoimmune and neuro-inflammatory events have been recognized to cause acute childhood neuropsychiatric disorders and have been designed with different terms, but all presented with similar clinical-pathogenetic manifestations. These disorders were previously indicated as paediatric infection-triggered autoimmune neuropsychiatric disorder (PITND); pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS); paediatric acute-onset neuropsychiatric syndrome (PANS); and childhood acute neuropsychiatric syndrome (CANS) ,2,3,4,5.The clinical recommendations of the PANS Consensus Conference clarified the clinical evaluation and diagnostic criteria of patients with young pediatric acute-onset neuropsychiatric syndrome (PANS) .Borrelia burgdorferi (Lyme) disease . The reported overall effect Z score was 1.47 (p = 0.29) and disease recurrence  , the overall effect Z score 1.47 (From our analysis of the evidence reported to date on the treatment of patients with PANDAS, it is clear how evident limitations are present in the literature. The scientific evidence reported is scant, not sufficient to propose a clear line of treatment for PANS/PANDAS and related disorders ,41,42,43The available studies are characterized in almost all cases by study cohorts that are too small, with low-evidence study designs such as case reports or uncontrolled retrospective studies. Furthermore, if there are prospective controlled or randomized studies, these do not present clear patient selection criteria or standardized treatment protocols. Therefore, the treatments administered are too heterogeneous and the results obtained are arbitrarily evaluated both in prevention and after treatment, without a univocal rationale. In addition, although each author proposes a different line of treatment, most do not propose a specific biomarker that evaluates the effectiveness of the therapy administered but rather uses those previously known.Therefore, the main limitations set out so far require the implementation of new research protocols, designed with strict criteria for selecting patients and large study samples, to eliminate any confounding factor in the outcome of the treatment and to standardize and standardize the treatments administered according to appropriate analysis of the evidence present to date.Although PANS/PANDAS are disorders with well-defined diagnostic criteria, the proposed therapeutic protocols report conflicting data to date. Furthermore, the effectiveness of medical and surgical approaches on movements and behavioral disorders often does not reach significant differences and is frequently affected by the timing of administration. Finally, it is necessary to consider that the evidence in the literature does not follow a unified therapeutic protocol, leading to poor enrolled samples and unsatisfactory results.


Due to their “tumor homing” and “immune privilege” characteristics, the use of mesenchymal stem cells (MSCs) has been proposed as a novel tool against cancer. MSCs are genetically engineered in vitro and then utilized to deliver tumoricidal agents, including prodrugs and bioactive molecules, to tumors. The genetic modification of MSCs can be achieved by various vectors, and in most cases viral vectors are used; however, viruses may be associated with carcinogenesis and immunogenicity, restricting their clinical translational potential. As such, nonviral vectors have emerged as a potential solution to address these limitations and have gradually attracted increasing attention. In this review, we briefly revisit the current knowledge about MSC-based cancer gene therapy. Then, we summarize the advantages and challenges of nonviral vectors for MSC transfection. Finally, we discuss recent advances in the development of new nonviral vectors, which have provided promising strategies to overcome obstacles in the gene modulation of MSCs. Despite great advances in diagnosis and therapy, cancer is still a leading cause of death around the world . ConventSince the discovery of the tumor homing properties and immune privileged status of mesenchymal stem cells (MSCs), they have been considered promising tools for anticancer treatments ,3. MSCs Currently, there are more than 50 clinical trials investigating MSC-based cancer gene therapy that are listed on the clinical trial database of the National Institutes of Health, indicating the thriving progress in this field. However, some questions need to be addressed, such as the long-term safety and effectiveness, which are largely determined by the selection of candidate genes and delivery vectors. In this review, we focus on gene delivery vectors that have been used for MSC-based cancer gene therapy. The majority of studies have exploited viral vectors for transfection of MSCs . AlthougDue to developments in the fields of material sciences and nanotechnology, the low efficiency of nonviral vectors in MSC transfection may be overcome. Studies have combined classical vectors into new hybrid vectors or yielded new artificial materials as delivery vectors, which can greatly improve the transfection efficiency without a significant loss of cell viability ,13. In aIn this review, we first summarize recent advances in understanding the relationship between MSCs and tumors and discuss the advantages and potential limitations regarding the utilization of MSCs as anticancer tools. Then, we review the current knowledge about MSC-based cancer gene therapy. Moreover, we briefly comment on the main advantages and disadvantages of viral and nonviral vectors and point out the potential benefits and challenges of using nonviral vectors to engineer MSCs. Next, we review the different types of nonviral vectors. Finally, we highlight recent advances in MSCs engineered using nonviral vectors, representing promising strategies to address the current challenges in gene delivery of nonviral vectors.MSCs are nonhematopoietic stem cells with high differentiation potential and self-renewal abilities . They caMSCs can specifically migrate to wounds and actively participate in the wound healing process . Tumors,+ T cell activation [The low immunogenicity of MSCs is associated with the low expression level of MHC class I and lack of expression of MHC class II or costimulatory molecules  ,32. In ativation ; therefotivation , which ativation .Moreover, preconditioning MSCs have more recently been shown to increase their immunomodulatory potential . HypoxiaOwing to the properties of MSCs, they are ideal cellular vehicles for the delivery of anticancer agents, providing improved bioavailability compared to conventional approaches.We must clearly recognize that MSCs are not simple delivery vehicles but cells with active physiological processes. Although there are considerable discrepancies in the impacts of MSCs on tumor progression, most studies tend to believe that MSCs play active roles in tumor initiation and progression . NumerouWhen MSCs migrate to tumor sites and continuously remodel the tumor niche they undergo profound changes; however, there are two strikingly different views. On the one hand, some studies have demonstrated that MSCs undergo malignant transformation with exposure to tumor cells. In a glioma model, tumor-derived exosomes or cytokines induced a tumor-like phenotype in MSCs with enhanced capacity for proliferation and migration ,47. On tAlthough MSCs still have some defects, these do not preclude MSCs from becoming an ideal anticancer tool. More comprehensive knowledge of MSC physiology within the TME and the innovative genetic modification of MSCs might improve the proposed therapy. We always believe that MSCs could have bright prospects in cancer therapies, especially in advanced malignancies.Gene therapy is a promising and challenging approach in the treatment of cancer. The purpose of gene therapy is to transfect therapeutic genes into target cells to achieve beneficial biological effects ; howeverThis approach uses suicide genes to modify MSCs so that MSCs can express specific enzymes that convert nontoxic prodrugs into toxic products . Then, eActivated drugs are also highly toxic to MSCs themselves; thus, MSCs will die in the process. As such, most studies have used larges dose of genetically engineered MSCs, with the ratio of MSCs to cancer cells reaching as high as 4:1 . This moThis approach was first used in 2002. MSCs were modified to express interferon-beta (IFN-β), then the MSCs were administered to tumor-bearing mice and IFN-β was produced locally at tumor sites, which resulted in significant inhibition of malignant cell growth in vivo . Since tThe greatest advantage of this approach is that it can genetically modify MSCs and preserve their viability; therefore, with this approach, the number of MSCs needed can be reduced. In some studies, only a 1:20 ratio of MSCs to cancer cells could also achieve ideal anticancer effect. Notably, this approach will not have a fatal effect on the viability of MSCs, and MSCs can survive over long terms in the body; therefore, the long-term safety of this approach still requires further evaluation.The overwhelming majority of gene therapy preclinical and clinical trials conducted so far have used modified viral vectors, such as retroviruses, lentiviruses and adenoviruses, to deliver genes. Although the gene transduction efficiency of viral vectors has substantially advanced the field of gene therapy, security issues still need to be considered. Similar to lentiviral vectors and retroviral vectors, viral vectors can integrate into the host genome and induce insertional mutagenesis , especiaNonviral vectors seem to have great potential to overcome these limitations, particularly with respect to safety. For example, nonviral vectors have lower immunogenicity than viral vectors and they will not be affected by the pre-existing immunity of the hosts . MeanwhiPresently, two widely used systems for nonviral gene delivery are cationic organic carriers  and inorganic nanoparticles . Here, wLipid-based carriers are the earliest and most widely used for nonviral gene transfection. As early as 1980, Fraley delivered liposome-encapsulated SV40 DNA into cells . Over tiLiposomes are self-assembling systems. Generally, liposomes are composed of cationic lipids and helper neutral lipids such as cholesterol. They are spherical vesicles composed of phospholipid bilayers and have the ability to encapsulate nucleic acids . When anMonovalent or multivalent cationic lipids are composed of three principal domains: a hydrophilic head group, a hydrophobic tail and a spacer . The hyd® have been commercialized and even hailed as the “gold standard” for nonviral gene delivery by many studies [® reagents are Lipofectamine® 2000 and Lipofectamine® 3000, and their ease of use and low toxicity have been confirmed.Currently, the representative cationic lipid carriers on the market include DOTMA, DOTAP, DOSPA and DOGS; these carriers are characterized by low toxicity and immunogenicity . Among t studies . The mosCationic polymers can bind negatively charged nucleic acids through static electricity and then condense them into nanoparticles for gene delivery. Because the physical shape of cationic polymers can significantly influence the gene delivery efficiency, their vast chemical diversity and functional potential have aroused wide interest from researchers. At present, the most common polymers include poly-l-lysine (PLL), polyethyleneimine (PEI), poly(amidoamine) dendrimer (PAMAM) and poly (2-(dimethylamino)-ethyl methacrylate (PDMAEMA).however, it also affects the transfection efficiency of PLL, as the primary amines are often protonated at physiological pH [PLL is a synthetic linear polypeptide containing repeating l-lysine residues and was the first cationic polymer vector used for gene transfection . Becausegical pH . To overgical pH .PEI is a three-member ring of ethyleneimine, and according to its topology, PEI can be divided into linear PEI (lPEI) and branched PEI (bPEI); bPEI is more widely used because it contains primary, secondary and tertiary amines. Its unique amine groups can give it a stronger buffering capacity with a proton sponge effect ,111; howPAMAM is a kind of dendrimer-like, star-branched polymer with a central core . There aPDMAEMA is a water soluble polycation  and its Polymeric micelles with a specific core–shell architecture formed via self-assembly of amphiphilic polymers are usually more stable than classical polymers. Moreover, the size of polymeric micelles is smaller, with diameters ranging from 10 to 100 nm, which makes them become internalized more efficiently, making them better candidates for gene delivery . PolymerCompared with other nonviral vectors, peptides are generally less toxic. Currently, widely used peptides usually contain basic amino acids such as lysine, arginine or ornithine so that they can condense oligonucleotides effectively . HoweverThe incorporation of functional peptides seems to be a promising strategy. According to biological function, they can be divided into cell-penetrating peptides, targeting peptides, endosome disrupting peptides and nuclear localization signal peptides . These fCell-penetrating peptides (CPPs) belong to a class of short peptides that are able to penetrate across cell membranes and have been demonstrated to facilitate the transfection of nonviral gene delivery vectors ,132,133.In addition, other types of CPPs have shown great potential. For example, antimicrobial peptides (PEPs) can insert into the plasma membrane and have the potential to facilitate the cellular uptake of genes. As such, in our previous study, we used PEP to functionalize cationic gold nanoparticles (AuNPs) and integrated both advantages. AuNPs can effectively condense DNA, and PEP is beneficial to cellular uptake and internalization to achieve high transfection efficiency . Other CTargeting peptides can specifically bind to receptors on the cell surface so that the vectors can internalize via receptor-mediated endocytosis. For example, neural ganglioside GD2 is a special surface marker of MSCs; thus, in a previous study, the authors described scAbGD2 (GD2 single chain antibody) attached to PEI and the transfection efficiency was significantly improved . SimilarIn addition to enhancing cell adhesion and endocytosis, there are some targeting vectors that can improve intracellular trafficking. Nuclear targeting vectors play an important role . SV40 DNMore importantly, these functional peptides can be combined with each other through covalent bonds or combined with other types of nonviral vectors to form a new hybrid vector. The potential of this change gives peptides broader application prospects.Biocompatible inorganic nanoparticles are readily prepared, stable and nontoxic, and have been widely researched. Compared with organic carriers, they are smaller and it is easier to maintain their uniformity . Due to At present, the classification of inorganic nanoparticles mainly depends on the nature of the material, such as the metallic nanoparticles, iron oxides, calcium phosphate and carbon nanotubes. Different types of inorganic nanoparticles have their own advantages.Among metallic nanoparticles, gold nanoparticles (AuNPs) are the most widely studied. They share most of their attractive qualities with other inorganic nanoparticles. AuNPs can not only effectively condense DNA but also allow the surface to be modified by cationic molecules, such as amino acids and polymers . This prAlthough AuNPs have been more thoroughly tested for the delivery of nucleic acids due to their high stability and antioxidant properties, silver nanoparticles (AgNPs) could be a valuable alternative due to their higher reactivity and lower cost, which could increase the range of possibilities for surface functionalization . For exa2) have attracted much attention due to their pH-dependent antioxidant activity. One study found that PEI-associated CeO2 can improve the transfection efficacy and decrease the cytotoxicity compared with PEI [Additionally, cerium oxide nanoparticles (CeOwith PEI .3O4) or maghemite (g-Fe2O3), with magnetic characteristics being their main advantage [Iron oxides usually consist of a magnetic core  signal enhancers to track the movement of cells or genes in the body . In a prCalcium phosphate (CaPi) is a component of bones that has excellent biocompatibility; therefore, it is widely applied in bone tissue engineering.In addition, pH-dependent solubility is another important property of CaPi. It enables CaPi to degrade in acidic tumor microenvironments or endolysosomal organelles ,162,163 Carbon nanotubes are cylindrical graphene sheets that are characterized by a high length/diameter ratio ; therefoIn addition to the nonviral vectors mentioned above, numerous researchers have created novel hybrid vectors. The purpose of this strategy is to maintain or maximize individual advantages while neutralizing corresponding drawbacks. In this context, some vectors with unique functions have emerged. These functional nonviral vectors not only have the ability to deliver genes into cells but also have other functions, such as fluorescence imaging and ultrasonic or optical control . It is pUsing fluorescent visible vectors, we can effectively track and monitor the migration behavior and organ-specific accumulation of MSCs in the body. Multifunctional fluorescent carbon dots are representative fluorescent vectors that possess low toxicity and excitation-dependent fluorescence; therefore they hold great promise for bioimaging . In addiUltrasound-triggered vectors can be used as another safe and cost-effective strategy for gene therapy. In a previous study, the researchers designed an ultrasound-triggered phase-transition cationic nanodroplet, consisting of a cationic polymer as the core for loading perfluoropentane (PFP) and DNA and a shell for nanoparticle stabilization. The vectors were stable in serum-containing conditions, and with ultrasound irradiation microbubbles were generated, leading to a good US contrast effect. As a consequence, the gene transfection efficiency was significantly enhanced ..Photodynamic therapy is also an attractive research field. Researchers have designed vectors and codelivered them with a photosensitizer, ultimately achieving photoprogrammable gene delivery. Near-infrared light can result in reactive oxygen species destroying biofilms by activating photosensitizers . In addiBiomimetic vectors: The greatest challenge currently is determining how to improve the transfection efficiency of nonviral vectors. This will not only enhance the cellular uptake of genetic materials but also activate endosomal escape and nuclear import. The structure and function of the virus can provide insights. Biomimetic nonviral vectors are designed to mimic viral characteristics and overcome cellular barriers . For exaMultitarget vectors: At present, a vector usually delivers one therapeutic agent; however, nonviral vectors have the potential to deliver larger genetic payloads, meaning different anticancer factors can be transfected through the same vector to exert a synergistic anticancer effect;MSC-based immunotherapy: Tumor immunotherapy has made exciting progress, although it is still not a game-changing solution due to the low cancer immunogenicity in the TME; thus, inducing the immune response within the tumor seems to be an effective solution. Using MSCs to deliver tumor antigens, activate immune cells and induce local immune responses seems to be a promising antitumor strategy. In addition, tumor-associated immunosuppressive cells or signals can be targeted to enhance anticancer immunity. For example, MSCs can enhance the killing effect of immune cells on tumors by secreting PD-1/PD-L1 antibodies. Furthermore, chimeric antigen receptor (CAR)-redirected T cells have been proven to be efficacious in the treatment of hematologic malignancy; however, CAR-redirected T cells showed less capacity to eliminate solid tumors due to the barrier of the TME. As such, MSCs can be used to generate “tracks” and guide CAR-T cells into the tumor site while continually secreting supporting factors to maintain the activity of CAR-T cells .There is no doubt that MSC-based therapy holds much potential for anticancer treatments; the development of nonviral vectors represents a new era of cancer gene therapy, and the safety of these vectors gives this therapy more potential for clinical transformation. Based on the current research, we believe that therapy with nonviral vectors still has huge room for improvement in the following areas :BiomimetWe expect that these approaches will be promising strategies in the search for efficient and safe nonviral vectors.


Transfemoral amputees experience a complex host of physical, psychological, and social challenges, compounded by the functional limitations of current transfemoral prostheses. However, the specific relationships between human factors and prosthesis design and performance characteristics have not yet been adequately investigated. The present study aims to address this knowledge gap.A comprehensive single-cohort survey of 114 unilateral transfemoral amputees addressed a broad range of demographic and clinical characteristics, functional autonomy, satisfaction and attitudes towards their current prostheses, and design priorities for an ideal transfemoral prosthesis, including the possibility of active assistance from a robotic knee unit. The survey was custom-developed based on several standard questionnaires used to assess motor abilities and autonomy in activities of daily living, prosthesis satisfaction, and quality of life in lower-limb amputees. Survey data were analyzed to compare the experience (including autonomy and satisfaction) and design priorities of users of transfemoral prostheses with versus without microprocessor-controlled knee units , with a subsequent analyses of cross-category correlation, principal component analysis (PCA), cost-sensitivity segmentation, and unsupervised K-means clustering applied within the most cost-sensitive participants, to identify functional groupings of users with respect to their design priorities.The cohort featured predominantly younger (< 50 years) traumatic male amputees with respect to the general transfemoral amputee population, with pronounced differences in age distribution and amputation etiology (traumatic vs. non-traumatic) between MPK and NMPK groups. These differences were further reflected in user experience, with MPK users reporting significantly greater overall functional autonomy, satisfaction, and sense of prosthesis ownership than those with NMPKs, in conjunction with a decreased incidence of instability and falls. Across all participants, the leading functional priorities for an ideal transfemoral prosthesis were overall stability, adaptability to variable walking velocity, and lifestyle-related functionality, while the highest-prioritized general characteristics were reliability, comfort, and weight, with highly variable prioritization of cost according to reimbursement status. PCA and user clustering analyses revealed the possibility for functionally relevant groupings of prosthesis features and users, based on their differential prioritization of these features—with implications towards prosthesis design tradeoffs.This study’s findings support the understanding that when appropriately prescribed according to patient characteristics and needs in the context of a proactive rehabilitation program, advanced transfemoral prostheses promote patient mobility, autonomy, and overall health. Survey data indicate overall stability, modularity, and versatility as key design priorities for the continued development of transfemoral prosthesis technology. Finally, observed associations between prosthesis type, user experience, and attitudes concerning prosthesis ownership suggest both that prosthesis characteristics influence device acceptance and functional outcomes, and that psychosocial factors should be specifically and proactively addressed during the rehabilitation process.The online version contains supplementary material available at 10.1186/s12984-021-00944-x. Limb loss imposes numerous physical, psychological, and social challenges on the individual, with a heavy impact on global health and quality of life, thus demanding the development of new strategies for managing daily life and dealing with changes in social relationships . Among tpositive power , the adoption of which remains low due to the balance between weight, cost, usability, and functional benefit that it offers for most TFAs. Accordingly, TFAs continue to experience a host of mobility impairments and diminished quality of life ?” were analyzed qualitatively using the thematic analysis technique described by Braun and Clarke , which pGiven the real-world role of cost in constraining both the design and selection of TFPs, the variation in user priorities as a function of cost sensitivity was explored. To clarify the relationship between cost sensitivity and other user priorities, users across both NMPK and MPK groups were segmented into tiers based on their prioritization of cost: high (rank 1–3), medium (4–6), or low (7–10), and distributions of priorities were visually compared across Pr-GC, Pr-Fn, and Pr-AA categories. To further distinguish user priorities among the most cost-sensitive users, a post-hoc clustering analysis was performed via unsupervised K-Means clustering within the user segment rating cost among their top 3 Pr-GC priorities.85) capturing at least 85% of total variance. PCA for rank order data was performed via MATLAB function pcacov, using Spearman rank order correlations, with a rank of 10 (‘not important') imputed to all missing data points. Data were then reverse-transformed back into the original n-dimensional space, and clustering was then performed on transformed data using a non-hierarchical K-Means clustering algorithm (executed in MATLAB) for K = 3 clusters, with 100 random initializations per instance (k) and iteration run until convergence. As indicated for the standard K-Means algorithm, the net cost function for each segmentation was computed as the root-mean-square (RMS) distance from each n-dimensional data point to its respective cluster centroid [As a noise reduction measure to facilitate a cleaner segmentation of TFP users in each category, the dimensionality of raw survey data was first reduced using principal component analysis, via transformation into the minimum number of dimensions  during the period of February-April, 2018, with 75 excluded for incompleteness or failure to meet inclusion criteria . Summarized in Table Table For further reference regarding how additional prosthesis components  may influence user experience or priorities, the main types and features of these components among participants are summarized in Table Independent Prosthesis Usage  in the tasks of stair ascent, descent, and ramp walking. Notably, a majority of TFP users in both groups reported full functional autonomy in the tasks of dressing, bathing, driving a car, and schedule management.Concerning amputation etiology, stratified analyses within the traumatic and non-traumatic amputee sub-groups found the differences between MPK and NMPK users to remain evident for a majority of ADLs Table , though Falls 72% of the whole group (80% NMPK vs. 67% MPK) reported at least one fall within the past year, with stair descent and steep ramp descent cited as the most frequent situational causes of instability (Table difference in the attribution of instability between groups was for other (miscellaneous) causes, cited by more MPK (19%) than NMPK users (3%). Based on their attributions of specific recent falls in free responses, NMPK users most commonly cited the aforementioned environmental factors associated with instability, while MPK users commonly attributed falls to personal errors and controllable factors such as “distraction” (n = 6), “tripping” (n = 4), as well as (n = 1) attribution to “rapid transitional movements”.Satisfaction with the current prosthesis is summarized in Table Table Subjective Prosthesis Acceptance & Body Integration Thematic analysis of free responses to the question “what is the prosthesis for you?” revealed 3 semantic categories: “tool”, describing the TFP as a means to obtain a functional result; “part of me”, describing it as a naturalistic part of the body; and “obstacle/noise”, as an impediment to daily life. Across all subjects, approximately half  described the TFP as a “tool”, 38% as “part of me”, and only 6% as an obstacle. To evaluate between-group differences in subjective acceptance and body integration, an ad-hoc Kolmogorov–Smirnov analysis was applied by interpreting responses as an ordinal variable representing the distribution of the sentiment of prosthesis acceptance/integration across these 3 semantic categories . This analysis did not reveal a significant overall between-group difference in subjective prosthesis integration (p = 0.320), despite the notable differences in proportions of MPK versus NMPK users (46.2% vs. 30.2%) characterizing their prostheses as “part of me” and as obstacle/noise (1.5% MPK vs. 14.0% NMPK) – likely due to similar portions describing their prostheses as a tool (52.3% NMPK vs. 55.8% NMPK). 4% of MPK and 5% of NMPK subjects (respectively) did not complete this question item.User priority rankings for the features and functions of an ideal TFP are summarized in Fig. Regarding functional mobility (Pr-Fn), overall prosthesis stability was the highest-rated priority for the whole sample (including a majority of NMPK users ranking it in the first position), with lifestyle-related functionality ranking second Fig. . Gait spAs a first step to understanding how TFP users might best be distinguished and grouped based on their design priorities, Principal Component Analysis conducted separately in the areas of Pr-GC, Pr-Fn, and Pr-AA yielded the primary principal components (PCs) summarized in Table higher values of the PC denote higher values (i.e. lower prioritization) of positively weighted variables  of negatively weighted variables. Apart from the clear distinction between cost sensitivity clusters in the Pr-GC-PC3 dimension  users, their experience and satisfaction with their current prostheses, and their priorities for an ideal prosthesis, from which we can draw numerous insights pertinent to the user-centered design of technologically-advanced TFPs.The present study cohort presented a range of ages, limb loss etiologies, occupations, employment statuses, and income levels Tables  and 3, rdysvascular) amputations. Whereas traumatic amputations are commonly associated with accidents during rigorous physical activity, non-traumatic amputations are overwhelmingly the result of vascular disease occurring secondary to many years of chronic metabolic diseases such as type II diabetes [Given the difference in amputation etiology distribution between the MPK and NMPK groups, the observed differences in age at amputation and time since amputation may be partially attributable to the contrasting clinical circumstances and pre-amputation lifestyles commonly associated with traumatic vs. non-traumatic  relative to MPK users, both within individual ADL and across all ADLs Fig. ; Table 6As a concrete clinical outcome complementary to subjective autonomy, the higher reported incidence of falls among NMPK users in the present study did not reach significance Table , which mThe current study findings thus reinforce an integrated clinical picture in which technologically advanced TFPs can be powerful tools in promoting user mobility and autonomy, but one that must be employed as part of a comprehensive rehabilitation paradigm that emphasizes functional training in addition to proactive psychological support. Further evidence for such an integrated approach is found in this study’s observation that users of MPKs, via their common attribution of falls to personal and attentional rather than environmental or technical factors, exhibited a higher degree of control and ownership of their prostheses, thus highlighting the symbiotic relationship between psychological factors and functional outcomes. Based on the preponderance of past and present evidence, it is reasonable to infer that more advanced TFPs can be more effective than traditional TFPs at realizing user potential that depends simultaneously on various health and dispositional factors, and that thoughtful prosthesis selection and configuration based on individual user needs will thus remain necessary to maximizing the benefit of such devices.ownership (“part of me”) expressed by MPK users suggests that both naturalistic prosthesis function and the experience of using it in a synergistic manner may contribute strongly to the sense of body schema integration and corresponding acceptance. This implication echoes previous studies that have identified human interaction as a strong factor in improving the subjective sense of control of the artificial leg, thus enhancing the performance and management of ADLs [This study’s principal finding that strong majorities of TFP users in both groups regarded their prostheses either as useful tools for achieving personal autonomy or as extensions of their bodies is a positive indicator of successful functional rehabilitation and prosthesis acceptance in the study population. Moreover, the increased sense of anatomical  of ADLs , 53.demands and/or expectations, thus making the net effect of prosthesis type on satisfaction unclear a priori. This complexity implies both that TFPs should be designed with more than bare-minimum functional autonomy requirements in mind , and also that user satisfaction can be positively influenced by psychological counseling featuring proactive management of expectations and attitudes, regardless of prosthesis type. In sum, the weak-yet-significant positive correlations  The prevailing functional priority of general stability across all TFP users agrees with previous findings among MPK users [limitations of their current prostheses relative to their expectations of device capability. Moreover, we note that the highest-ranked functions were those applicable to a range of situations , with more specific tasks of gait on uneven terrain, stair ascent, and ramp walking (up and down) falling in the second tier. Based on our analysis of free responses, “lifestyle functionality” was interpreted by subjects in a variety of ways (some more task-specific than others), thus rendering this priority interpretable in aggregate as a measure of the need for TFP versatility and adaptability to different tasks and environments.PK users . Here, NNotably, “work-related functionality” represents an exception to the trend towards favoring versatility, ranking as a moderate-to-lower priority for both groups. The distinction in preference for lifestyle over work-related functionality is difficult to parse, given that potential differences in functional demands between lifestyle and work environments are not easily generalizable, nor discernible from survey data. What may be inferred regardless is that TFP users consider the ability to maintain their desired personal lifestyle a more important determinant of their satisfaction than their vocational ability.Priorities for Active Assistance (Pr-AA) Overall, TFP user priorities for AA agree well with those for functional mobility, with the top functional priority of overall stability corresponding to the preference for AA during moments of instability. Likewise, the whole-sample trend towards prioritization of ascent vs. descent functions versus their descending analogs in Pr-Fn  Current MPK and NMPK users expressed very similar priorities regarding both general device characteristics and socket design. Primary between-group differences in Pr-GC tended to concern more technical, higher-performance TFP traits such as battery life and water resistance , these metrics could potentially serve as both ‘benchmark’ measures to inform the optimal design of advanced TFPs, and as a tools for clinical care personalization. By evaluating TFAs along the primary dimensions of variation in personal priorities, such a survey could be a powerful tool in the selection and personalization of the available prosthesis that best fulfills the individual’s needs, thus offering dramatic improvement over the “K-Levels” used currently for this purpose, which are limited by their lack of both objectivity and standard assessment criteria .all variables, so the functional interpretation of PCs Table While useful for visualizing and conceptualizing the similarities, differences, and variance in user priorities between different user subsets, this method of generalizing PC interpretation presents a number of limitations. First, the largely contiguous (non-separated) nature of some clusters highlights that user priorities fall along a continuum, making it difficult to draw distinct design boundaries corresponding to discrete performance tradeoffs. Second, each PC encodes information from Cost sensitivity sub-analysisWhile the segmentation of TFP users by their prioritization of cost did not result in a clean separation of users in the overall priority space summarized by the primary PCs Fig. , the detThe targeted sub-clustering of users within the most cost-sensitive user segment Fig.  providesFinally, regarding the influence of demographic characteristics on cost cost-sensitivity, the lack of significant correlation between income and cost priority is explained by the significant correlation between the cost priority and subjects’ level of financial support (insurance) in purchasing the prosthesis. This finding simultaneously emphasizes the important role of health insurance in prosthesis selection, both via direct influence on user priorities and via potential differences in reimbursement of different devices, which can vary significantly by region. Furthermore, we note that the individual user’s sensitivity to cost may not fully capture the net cost constraint imposed by healthcare systems and medical payers.The safety and reliability of the TFP across a wide range of ADLs are fundamental design priorities for a strong majority of TFA users, preserved across all prosthesis types and other design priorities.Individual user needs and priorities vary significantly based on clinical characteristics, personal attitudes, and lifestyle, thus demanding modularity and/or customizability of various prosthesis components and characteristics, such as the dimensions, socket fit, and cosmetics. Indeed, a comprehensive design process should account for the interactions between these components and their net effect on both functionality and satisfaction, as recent studies have found components such as the socket to play a significant role in overall user function with the prosthesis—including gait speed and risk of falls .A high prioritization of “lifestyle-related functionality” may be interpreted as a desire for functional versatility and adaptability to different activities and unstructured real-world environments. This presents a host of complex design challenges that calls for a combination of modular TFP designs and intelligent adaptive control strategies, enabling device personalization based individual user capabilities and preferences, with the understanding that performance tradeoffs are inevitable. The exploration of such tradeoffs—including the dynamic, interdependent relationship between prosthesis hardware and control—has been well exemplified and further enabled on a larger scale by the recent development of open-source bionic leg by Azocar, Hargrove, Rouse, and colleagues .ascent, and higher-velocity walking.The prospective value of active (i.e. positive power) assistance to TFP users varies by task, with assistance desired preferentially during moments of instability, stair/incline Based on the leading prioritization of shape/volume adaptability among both MPK and NMPK users, the ideal TFP socket design should enable routine modulation of shape and/or volume to accommodate changes in residual limb volume and tissue properties, thus improving comfort and minimizing skin problems. In conjunction, socket designs that achieve smart regulation of temperature and humidity  remainsThe prioritization of cost as a factor for prosthesis selection is highly variable among TFAs, depending more strongly on insurance reimbursement than on income per se. While user priorities regarding prosthesis functionality and general prosthesis characteristics do not vary significantly according to cost sensitivity, the most cost-sensitive users are distinguished from the least cost-sensitive users by their lower prioritizations of prosthesis weight, transportability, noisiness, and cleanability. Given the limiting role of cost with regard to prosthesis functionality, lower-cost TFPs intended for cost-sensitive users should thus focus on overall stability, reliability, and comfort as characteristics with the greatest impact on quality of life, while maintaining secondary priorities within a safe, functional, and user-acceptable range.For the efficient diversification of low-cost prosthesis designs, we recommend that design alternatives be developed in alignment with the functional groupings of user priorities represented by the dominant variable weights in the leading principal components identified in this study.Following from the above discussion, this study’s findings may be synthesized into the following recommendations for the user-centered design of an ideal TFP:To fulfill these requirements in the development of future TFP systems, they should be used by TFP researchers and developers as design inputs to a rigorous user-centered design framework such as that proposed by Beckerle and colleagues , which pprocess. First, the survey’s ranking of user design prioritizes without any corresponding measures of relative priority weighting favored the delineation between TFP features of similar priority, with the tradeoff of reducing the power to evaluate the absolute importance of specific design features. By contrast, non-static ranking schemes such as Best–Worst or MaxDiff scaling [satisfaction and autonomy, making them imprecise as indicators of absolute functionality. Though this perspective is suitable for a user-centered design process that holds user satisfaction and wellbeing as its ultimate objectives, subsequent TFP research and development efforts should further investigate the relationship between specific design characteristics, objective functional performance, usability, and user satisfaction. Finally, future studies should evaluate user priorities in a manner that more directly aligns with the actual technical tradeoffs that constrain TFP design, such as the fundamental tradeoffs between weight, power, and functional versatility.In addition to the above recommendations regarding TFP design characteristics, the present study reveals several valuable insights regarding the human-centered design  scaling , 62 may While supportive of the current clinical understanding that more advanced TFPs promote higher levels of user mobility, function, and overall health, this study’s central findings of higher overall functional autonomy and satisfaction among MPK relative to NMPK users must be interpreted within the context of two main study limitations. Most notably, owing to the survey’s limited characterization of numerous health-related co-factors such as participants’ overall health, lifestyle (via pre- and post-amputation occupation), and objective functional capacity , the study was not able to conduct a thoroughly controlled test of the hypothesis that MPKs confer independent improvements in outcomes relative to NMPKs, which was beyond the scope of objectives for which the survey was designed. Indeed, perceived autonomy, satisfaction, and user priorities may all be expected to depend significantly on the relationship between the individual’s pre- and post-amputation occupation and lifestyle, which strongly influence personal identity. Satisfaction and priorities may further be influenced by the individual’s conception of what level of functional recovery is possible in the context of the current clinical and technological state of the art. Irrespective of these survey-specific constraints, it remains likely that the effects of MPK-TFPs on clinical and personal outcomes cannot be thoroughly isolated from general health and human factors even by controlling for primary indicators of such factors, due to the number and the limited quantifiability of personal factors that influence prosthesis selection.following outfitting and initial rehabilitation with an NMPK-TFP may introduce an additional “healthy user bias” [marginal benefit for users with lower baseline abilities, as suggested by autonomy data among non-traumatic amputees  is the leading orthopedic rehabilitation center in Italy, where the intensive, integrative standard of care creates a patient population likely more functionally advanced and engaged with their prostheses than the global TFA population. Indeed, the time course, quality, and user engagement in prosthetic rehabilitation is known to strongly influence clinical and functional outcomes irrespective of prosthesis type, thus influencing a range of psychosocial outcomes as well. This center’s standard care practice of prescribing MPKs er bias”  among MPes Table . Nonetheenabling, maintaining, and/or reinforcing healthy mobility and lifestyle among TFAs.This study provides an extensive new characterization of transfemoral amputees (TFAs), encompassing their demographic and clinical characteristics, psychosocial attitudes and lifestyles, functionality and satisfaction with their current prostheses, and user needs and priorities for an ideal transfemoral prosthesis (TFP). Overall, users of TFPs with microprocessor-controlled knee units (MPKs) reported higher levels of activity, prosthesis use, and functional ability compared to those with NMPKs, corresponding to higher satisfaction and greater functional autonomy. Significantly, While likely reflective of differences between MPK and NMPK users in terms of age and amputation etiology , these results are consistent with the hypothesis that more advanced, actively controlled TFPs positively influence not only the safety and functional mobility of TFAs, but their overall sense of prosthesis acceptance and ownership, personal autonomy, and overall health and wellbeing. Moreover, this study’s finding that significant differences in ADL-related autonomy for MPK vs. NMPK users were higher in magnitude among non-traumatic relative to traumatic amputees suggests that TFP users with a lower overall health status may in fact obtain greater marginal benefit from the use of advanced TFPs, and that the current standard-of-care guideline of prescribing MPK prostheses selectively to more capable users should thus be more carefully evaluated. Based on past and present findings, it may be reasonably generalized that advanced TFP functionality, in conjunction with a variety of underlying clinical and personal factors, plays a significant role in Finally, a set of user-based design principles are synthesized based on survey data analysis. Future investigations should continue to develop, validate, and standardize measures of the functional abilities and personal priorities of TFAs, based on this study’s survey and findings. In this way, this study may serve as a foundation to build a clinical evaluation tool to optimally select and configure TFPs to fulfill the needs of individual users.Additional file 1: Table S1. Principal Component Loadings—User priorities for general characteristics of an ideal TFP (Pr-GC). Table S2. Principal Component Loadings—User priorities for functionality of an ideal TFP (Pr-Fn). Table S3. Principal Component Loadings—User priorities for active assistance in an ideal TFP (Pr-AA).


Schistosoma infection and the success of control interventions. In projecting control outcomes, conventional modeling approaches have often ignored seasonality by using simplified intermediate-host modeling, or by restricting seasonal effects through use of yearly averaging.A seasonal transmission environment including seasonal variation of snail population density and human-snail contact patterns can affect the dynamics of We used mathematical analysis and numerical simulation to estimate the impact of seasonality on disease dynamics and control outcomes, and to evaluate whether seasonal averaging or intermediate-host reduction can provide reliable predictions of control outcomes. We also examined whether seasonality could be used as leverage in creation of effective control strategies.Schistosoma transmission control, and we identified the optimal timing for each intervention. Seasonal snail control, implemented alone, was less effective than mass drug administration, but could provide additive impact in reaching control and elimination targets.We found models that used seasonal averaging could grossly overestimate infection burden and underestimate control outcomes in highly seasonal environments. We showed that proper intraseasonal timing of control measures could make marked improvement on the long-term burden reduction for Schistosoma transmission less sustainable and easier to control than predicted by earlier modeling studies.Seasonal variation makes  Schistosoma transmission. We found the seasonal variation makes Schistosoma transmission less sustainable, and intraseasonal timing of interventions could improve the long-term outcomes of control measures in such communities.We used mathematical models to evaluate the impact of seasonality on  Schistosoma species parasites, is highly prevalent in the tropics. Like many infectious diseases, Schistosoma transmission is highly seasonal with a time-dependent transmission rate that varies during a year. Because schistosome parasites split their life cycle between humans (who harbor the adult forms of the parasite) and intermediate-host freshwater snails , human water contact, area contamination with sewage, and the presence of competent snail species all play significant roles in defining local transmission [Schistosoma transmission is often related to the variable abundance of intermediate host snail populations, which is linked to weather patterns , and/or the resulting availability and frequency of human-snail contacts [Schistosoma transmission was first proposed by G. Macdonald [Schistosoma transmission do not account for the effects of seasonality and this could significantly affect the accuracy of their predictions. A deeper understanding of the effects of transmission seasonality should provide additional insight into the optimal timing of interventions used in public health practice for schistosomiasis control. The current options for control include periodic mass administration of the drug praziquantel and, in some locations, control of intermediate host snails with the use of chemical molluscicides or environmental modification [Schistosomiasis, caused by smission . The obscontacts . The matacdonald  and lateacdonald . Howeverfication .Schistosoma transmission, one way to deal with seasonal variability has been to use seasonal averaging of environmental and behavioral inputs, making the resulting stationary Macdonald system amenable to direct analysis [In mathematical models of analysis . Howeveranalysis ). In genanalysis , becauseAnother commonly used procedure in modeling vector-host transmission is a reduction of the coupled human-snail transmission cycle to a single host equation via quasiequilibration of the snail equation. This can be justified by the relatively short duration of snail lifespan, relative to human and worm, but requires more careful analysis, both for the basic Macdonald system and for its extensions.Schistosoma control predictions, including those for programs relying on mass drug administration (MDA) and/or molluscicide-based snail control to achieve their public health objectives.In the present study, we aimed to perform a systematic assessment of seasonal variability and its implications for We modeled seasonal variability as seasonal changes of snail abundance, knowing that multiple environmental factors  bundance , 22, 23.Schistosoma transmission combines 2 variables: mean worm burden (MWB) The basic Macdonald model for A represents mean rate of worm accumulation per human host and B the force of snail infection [N, coefficient H, and its infectivity (egg shedding by mated worm pairs in the human population). Both coefficients are proportional to human-sail contact rates. Coefficients Here, transmission coefficient nfection , 24, 25.ifespan) , 27.The system (Equation 1) can be rescaled in dimensionless form, given by a single parameter ABγν see . ParametThe nonstationary  transmission environment, the subject of our present work, brings another important parameter—amplitude of seasonal variability . Such seMultiple environmental factors can affect snail population dynamics . They include temperature, rainfall , food reN and K was determined by their amplitude parameter In both cases, the variability of N, K) is trigonometric,The simplest mathematical form of periodic functions  in equal proportions and evenly spaced across high and low seasons. This type-I system has limited range of seasonal variability (amplitude or variance).However, in many cases, more extreme patterns of seasonality arise, for example, a short rainy season with high snail density, followed by longer dry periods of low density, or multiple seasonal peaks . A conveN becomes highly concentrated as a, but as amplitude increases, they depart significantly in their variability. Data on snail abundance supports both patterns [Such unction) . We refepatterns , 22, 23.The rescaled seasonal Macdonald system with a prescribed, variable snail population has the formThese equations are derived similar to the stationary case, but with modifications to account for nonstationary snail density, For dynamic-snail population Macdonald system, Equation 4 is supplemented with a logistic snail-growth equation for variable Here ortality . Snail dThe snail population in Equation 5 is thus decoupled from the standard Macdonald system of Equation 4. We note that snail infection typically has only a marginal effect on its overall population rates for reproduction/growth/mortality due to relatively low levels of patent (shedding) snails in natural environments , 35.As withT in a host community with MWB f) for treatment. Another possibility is systematic noncompliance whereby the same population is excluded from treatment. The latter requires an extension of the Macdonald system discussed in A single MDA session at time T. Snail control via molluscicide (at time T) was implemented in a similar fashion as an instantaneous event, whereby dynamic variables Instantaneous reduction of worm burden post MDA is due to short half-life (hours) of praziquantel relative to time scales of infection history (months to years). It is implemented via reinitialization of variable The nonstationary Macdonald system with seasonally varying snail population, a-axis depends on the transmission intensity  . The droThe periodic Macdonald system (Equation 4) behaves qualitatively similar to a stationary Macdonald case (Equation 1). Specifically, it has infection-free equilibrium  , 36. SpeWe found that different choices for intraseasonal MDA timing during the annual cycle  the basic reproduction number of the stationary  system, m mating  and the m mating , 38 withSeasonality can affect snail population dynamics and human behavior . The 2 factors are sometimes combined into a single seasonal transmission rate , 39. TheWe have applied our models to leverage seasonality for the optimal timing of repeated control interventions  to predict which approach could achieve maximal reductions in parasite burden over a limited time span (6–10 years). The optimal intraseasonal timing (For molluscicide-based control, the optimal timing of delivery was closer to the start of season, that is at the snail population peak. The overall effect of mollusciciding on human worm burden reduction was less significant than MDA at short duration, even at high snail killing efficacy. But the effect of optimal timing (fficient .In general, control outcomes depend on transmission intensity, strength and patterns of seasonality, drug and molluscicide efficacy, and control duration. A 6-year program is an intermediate-range based on WHO guidelines , 36. In We believe the basic conclusions on seasonal timing are robust and would hold in different environments, for different transmission intensity, all data , 35, 41.The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at jiaa746_suppl_Supplementary_InformationClick here for additional data file.


Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes could drastically improve outcomes. Since 1997, significant advancements have been made through the foundation of the ERAS Society, responsible for creating consensus guidelines on the implementation of enhanced recovery pathways. ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties. Carbohydrate loading, bowel preparation and patient education in the pre-operative phase, goal-directed fluid therapy in the intra-operative phase, and early mobilisation and enteral nutrition in the post-operative phase are some of the interventions that are commonly implemented in ERAS protocols. While many specialties have been quick to incorporate ERAS, uptake has been slow in the transplantation field, leading to a scarcity of literature. Recent studies reported a 47% reduction in length of hospital stay (LOS) in liver transplantation patients treated with ERAS, while progress in kidney transplantation focuses on pain management and its incorporation into enhanced recovery protocols. Enhanced recovery after surgery (ERAS) programs aim to optimise pre-, intra- and post-operative care in order to improve the quality and speed of recovery in surgical patients. ERAS protocols are complex, requiring organised care from a multidisciplinary team to ensure strong patient outcomes and provide an elevated level of care. Enhanced recovery pathways reduce length of stay (LOS) by an average of 2.35 days and total cost by an average of $639.06 in comparison with conventional perioperative procedures, according to a 2020 meta-analysis of ERAS across multiple surgeries and surgical specialties . DespiteRapid advancements have been made in many areas of surgery, with some interventions having been accepted as beneficial across most, if not all fields. Mainstays of pre-operative care include patient education and counselling , while dDespite marked progress in many subspecialties, the acceptance of ERAS has been slow in the field of solid-organ transplantation. Thus, there is limited existing literature in this area. Changes to USA organ allocation laws, which prioritise patients on the basis of pre-operative health, may disincentivise pre-surgical optimisation, an important aspect of many ERAS pathways . Among oThis review aims to explore the history of enhanced recovery, from its inception as ‘fast track’ surgery to its use today. It also aims to explore the key advancements in ERAS to date by looking at landmark papers in perioperative care and to take a focused look into the use of ERAS protocols in transplant surgery.The concept of enhanced recovery after surgery (formerly ‘fast track surgery’) was introduced by Danish surgeon Professor Henrik Kehlet in 1997 . Kehlet n = 46,539), which found that crude mortality from cardiac surgery varied from 1.2% to 21.5% across Europe [In 2001 came the formation of the Enhanced Recovery After Surgery (ERAS) Study Group—a group of six surgeons assembled by Professors Ken Fearon and Ollie Ljungqvist and including Professor Kehlet, which aimed to produce and interpret the best available evidence to fine-tune fast track surgery ,16. Opers Europe .Maintaining its focus on colorectal surgery, the ERAS Study Group published what are now seen as the first consensus guidelines for perioperative care, conducting a 2005 review of enhanced recovery protocols in colorectal resections . EnhanceIn 2010, the ERAS Study Group registered as a new non-profit organization in Sweden under the title ‘the ERAS Society’, with the hope of evolving to reach other countries and create an international collaborative effort to improve perioperative protocols. Since its inception, the ERAS Society has published continuous research and guidance, held multiple symposia, and taken a leading role in the expansion of ERAS protocols to many new surgical subspecialties. It has also created an interactive audit system to help hospitals comply with ERAS protocols, making it easier for new hospitals to begin improving perioperative care. The main events in the history of ERAS are presented in Pre-operative optimisation of patients, an essential aspect of ERAS protocols, allows the patient to prepare both physiologically and psychologically for surgery. Pre-operative interventions that have been studied include a reduced fasting period, carbohydrate loading and various forms of counselling.Carbohydrate loading (CL) through pre-operative solutions containing complex carbohydrates such as maltodextrin is recommended by the ERAS Society as well as the European Society of Anaesthesiology ,25. The Pre-operative CL ensures that the body enters surgery in a fed state, which is preferable to the catabolic state that occurs in patients who fast for the standard 8 h pre-surgical period ,25,26. TDespite these effects, CL appears to have no significant impact on rates of post-surgical complication . CL alson = 415) in comparison to ‘MBP group’ (n = 431) [The role of MBP prior to elective colorectal surgery is well studied but controversial, owing to contradictory data from two reviews . In 2009n = 431) . This leSubsequent trials in 2012 and 2015 found that OA plus MBP reduces the incidence of surgical wound infection by 40–57% (when compared with no OA or MBP), as well as reducing complications such as ileus and anastomotic leak ,34. Sett‘We recommend routine use of a combined isosmotic MBP with OA before elective colorectal surgery’.‘We do not recommend use of MBP without concurrent oral antibiotics before elective colorectal surgery’.‘We recommend against the use of hyperosmotic bowel prep solutions before elective colorectal surgery’.The final recommendation concerns the use of hyperosmotic bowel preparation solutions. The reason for this is that hyperosmotic solutions cause changes in plasma osmolality as well as phosphate, urea, calcium and potassium concentrations and can lead to renal impairment .It is widely accepted that pre-operative patient education and counselling should be included in many if not all ERAS pathways. This allows the patient to manage their expectations before undergoing surgery , helps tEducation and counselling have also been shown to improve pain control, especially in patients experiencing high levels of anxiety related to their surgery . This efOptimisation of intra-operative care is essential to avoid unnecessary intra- and post-surgical complications, which can have lasting medical effects as well as increasing LOS and reducing patient satisfaction. Important progress has been made in fluid management, antibiotic prophylaxis, minimally invasive surgery and intra-operative warming, to name a few.Goal-directed fluid therapy (GDFT) is used in perioperative care to optimise oxygen delivery to end-organs. This is because evidence suggests that excess fluid resuscitation increases rates of complications such as pulmonary oedema, delaying patient recovery, while inadequate resuscitation may lead to complications such as pre-renal acute tubular necrosis . GDFT maLiberal fluid therapy has been shown to be harmful to patients undergoing major surgery. Gustafsson et al. found that post-operative complications (particularly cardiovascular) in 943 colorectal surgical patients increased by 32% for every additional litre of fluid given . They aln = 734); however, no significant reductions were found in rate of complications or 30-day mortality with the use of GDFT [p = 0.07) [n = 2502) [Regarding research into GDFT, the OPTIMISE trial was the first multicentre trial to compare it to standard fluid management ( of GDFT . However = 0.07) . SubsequThe post-operative phase is the most heavily researched in surgical perioperative care, with the National Institute for Health and Care Excellence (NICE) identifying 342 post-operative enhanced recovery studies in comparison with 123 intra-operative and 150 pre-operative . They idEM is an essential aspect of ERAS pathways, with the ERAS Society recommending its implementation in elective colonic, rectal/pelvic and gynaecologic/oncologic surgeries . The ratn = 1170) fail to mobilise on post-operative day 1 [Despite these benefits, adherence can be an issue in implementing EM, as demonstrated by Grass et al., who found that 58% of patients  discussed the idea of early post-operative extubation. The earliest report was published in 1990 in a conference paper reviewing extubation of LT patients either immediately or within 8 h post-surgically . HoweverOwing to these advancements in early extubation, research has been carried out into full ERAS-type perioperative protocols in LT, with considerations such as fluid restriction, use of intra-operative sedatives and evaluation of anaesthetic agents ,67. BianThe uptake of ERAS into the field of renal transplantation has been equally slow. In 2019, Morkane et al. concluded that there was a high degree of heterogeneity between perioperative practises across 23 renal transplantation (RT) centres . They foIn recent years, multiple studies have assessed the feasibility and efficacy of ERAS protocols for patients undergoing RT. In 2016, Kruszyna et al. assessed the feasibility of an ERAS protocol in 45 deceased-donor kidney transplant recipients in a single-centre case series . They foMany of the recent advancements in RT focus on the potential for ERAS protocols to reduce pain perception and opioid requirements following surgery. Most notably, Campsen et al. assessed the effectiveness of an ERAS protocol that used pregabalin in pre-operative care to desensitise the patient’s nerves, before using ketorolac (an NSAID) intra- and post-operatively . This stIn addition to LT and RT, pancreatic, cardiac, pulmonary and intestinal transplantations are now common. The ERAS Society has published consensus guidelines for the implementation of enhanced recovery in lung , cardiacERAS pathways offer safe and cost-effective approaches to perioperative care, which improve patient outcomes without increasing rates of complication. Since the inception of ERAS in 1997, so-called ‘fast-track’ surgical pathways have become widely used in multiple specialties, and the standard of perioperative care has improved substantially, in no small part due to the work of the ERAS Society. Key advancements have been made, including pre-operative carbohydrate loading, patient education, GDFT and early enteral nutrition. However, the uptake of ERAS in transplantation surgeries has been slow, leading to a paucity of literature in the field. While recent years have seen some developments in ERAS relating to liver and kidney transplants, other areas of solid-organ transplantation—including lung, heart and pancreas transplantation—are yet to make notable progress. Future research should address the feasibility and efficacy of ERAS in these areas, and emphasis should be placed on the speedy incorporation of ERAS pathways into standard perioperative care for transplant surgeries.


Myeloperoxidase is a signature enzyme of polymorphonuclear neutrophils in mice and humans. Being a component of circulating white blood cells, myeloperoxidase plays multiple roles in various organs and tissues and facilitates their crosstalk. Here, we describe the current knowledge on the tissue- and lineage-specific expression of myeloperoxidase, its well-studied enzymatic activity and incoherently understood non-enzymatic role in various cell types and tissues. Further, we elaborate on Myeloperoxidase (MPO) in the complex context of cardiovascular disease, innate and autoimmune response, development and progression of cancer and neurodegenerative diseases. Myeloperoxidase (MPO) is a lysosomal protein and part of the organism’s host-defense system. MPOs’ pivotal function is considered to be its enzymatic activity in response to invading pathogenic agents. During infection, the bactericidal and fungicidal properties of MPO contribute to pathogen clearing inside the phagosome.Crocodylus porosus), in which 39,19% of the orthologue sequence match the human MPO sequence ,7069,70]Likewise, neurons from patients with Alzheimer’s Disease (AD) expressed increased MPO levels  and MPO −/−) mice both cross-bred with Mpo−/− mice or reconstituted with MPO-deficient bone marrow after irradiation harbored severely advanced atherosclerotic plaques compared to controls [−/− mice, whereas MPO activity within the lesion is commonly found in human atherosclerotic plaques and thought to be a major facilitator of disease progression. This difference was explained partly by pointing out differences of both MPO and pathogenesis of atherosclerosis between humans and mice. Since in mice the neutrophil/lymphocyte ratio is inversed and MPO levels per neutrophil are five- to tenfold lower compared to humans, the biological impact of MPO might be generally underestimated when using mouse models. Additionally, the role of MPO in murine and human biology may differ as neutrophils of MPO deficient mice still possess residual candidacidal properties. The difference in plaque composition might also be based on the nature of the disease progression in mice and humans: whilst atherosclerosis develops for decades in humans, already young, genetically modified mice have atherosclerotic lesions. For some time, cardiovascular research on MPO in rodents focused on models of inflammatory remodeling in which neutrophils and MPO was present and active [−/− mice increased atherosclerotic lesion size similar to the results obtained in Ldlr−/− mice, but the atherosclerotic plaques shifted to a stable phenotype with a thick fibrous cap when MPO was absent or inhibited [−/− mice could detect MPO activity within plaques in vivo by visualizing its oxidative products with MRI [−/− mice might either be due to specific shortcomings of that model or the lack of sufficiently sensitive methods at that time.Currently, the main impact of myeloperoxidase on cardiovascular diseases is related to derivatives of its enzymatic activity . Many incontrols . This fid active . Nearly nhibited . Althougnhibited . Additiowith MRI . The lacThe mouse model and, eventually, the development of experimental therapeutics for MPO inhibition yielded additional insights into the role of the enzyme in cardiovascular pathologies that were accompanied by a growing body of clinical evidence. Besides atherosclerotic plaque formation, the enzyme possesses vasomotor properties, elevating systemic vascular resistance and interrupting endothelial function by direct and indirect nitric oxide consumption , accumulAdditionally, MPO takes part in the formation of oxidized LDL (oxLDL), which after transcytosis through the defective endothelial barrier is phagocytosed by aortic macro-phages. Once their capacity to clear lipids is exceeded, these cells store lipids in vesicles, which coins them according to their microscopic appearance as foam cells. Whereas native LDL is only sporadically taken up by macrophages, oxLDL extensively provokes phagocytosis . This in−/− mice, which displayed retardation of fibrotic scar formation and an overall beneficial functional outcome after permanent LAD ligation induced MI [−/− mice [Apart from its implication in multiple mechanisms of atherosclerotic pathophysiology, there is additional experimental evidence for a direct unfavorable influence of MPO on cardiac tissue homeostasis in the context of ischemic and hypertensive heart disease. The myocardial extracellular matrix is produced majorly by fibroblasts and to a lesser extent by cardiomyocytes and vascular smooth muscle cells. ECM degradation by MMPs triggers a release of proinflammatory cytokines that provoke transdifferentiation of fibroblasts to myofibroblasts . This phduced MI ; of noteduced MI ,113,114.duced MI . In a si−/− mice , furtherInterestingly, patients with heart failure (HF) also have increased plasma MPO levels ,117. DeuThere have been multiple strategies of MPO inhibition proposed, including small-molecule drugs, chelators, antioxidants, scavenger and natural products like flavonoids and polyphenols (reviewed here ). HoweveApart from the enzymatic role in reactive oxygen species (ROS) production and phagocytosis, MPO is actively participating in degranulation, and the generation of neutrophil extracellular traps (NETs), a process known as NETosis, where the positive charge of the protein is of high significance a.NETs are a meshwork of chromatin fibers with a diameter of 15–17 nm. DNA and histones form the major content of NETs, however, a variety of other neutrophil-specific proteins of mainly proteolytic or microbicidal activity such as neutrophil elastase, myeloperoxidase, cathepsin G, azurocidin, lactotranferin, lysozyme C and others encrust NETs as well .NET formation requires disintegration of nuclear and granule membranes from nuclei released of anucleated neutrophils or from neutrophils undergoing cell death ,125,126.Pseudomonas aeruginosa, Staphylococcus aureus, or Escherichia coli [MPO as part of NETs is an important component of the immune response to infection in vivo . MPO on hia coli . The NEThia coli ,133. Poshia coli  and reduhia coli . Moreovehia coli . This mohia coli . Of notehia coli .The positive charge of MPO was shown to recruit PMNs and evoke PMN motility solely dependent on the electrostatic interactions with the leukocyte’s surface . AnotherAlong with the capacity to bind negatively charged cellular membranes, MPO is able to transmigrate into various cell types, such as human umbilical vein endothelial cells (HUVECs) as well as into other endothelial (ECs) and epithelial cells ,139. In Interestingly, in the microenvironment of an inflammatory response, approximately 40% of MPO is rapidly inactivated by oxidation . EdwardsThe above-mentioned examples underline the importance of the yet poorly studied non-catalytic activities of MPO. At least three potential different mechanisms of non-enzymatic role of MPO might be of interest: (1) cationic MPO changes a negatively charged cellular surface and unmasks receptors on it, (2) when entering the cell, MPO might affect the autophagy flux and cause enhanced transcription of inflammatory genes through the activation of transcription factor TFEB, (3) when entering the nucleus, MPO might affect transcription directly by binding to the DNA, histones, or particular transcription factors.The signature properties of MPO and its function in different cell types and tissues is connected to its enzymatic activity and the generation of reactive oxygen species. As a partaker in the immune response, MPO demonstrates beneficial effects in anti-fungal responses or phagocytic activity of neutrophils and the hyperactivation of dendritic cells, however, increased MPO levels are also associated with autoimmune diseases such as lupus erythematodes and Kawasaki’s disease. The produced oxidants possess microbicidal properties, but are also engaged in oxidative tissue damage.Therefore, MPO expression is tightly regulated in a lineage-specific manner and dysregulation of its expression has been linked to multiple diseases, including cancer and neurodegenerative disorders. MPO expression and its enzymatic activity in the blood vessel seem to be detrimental for the progression of cardiovascular diseases.Recent studies accumulate knowledge on the non-enzymatic role of MPO in vessels and beyond. Due to its cationic charge, it can severely affect the endothelial glycocalyx properties and change the expression profile of endothelial cells, presumably causing endothelial dysfunction. Various cell types can internalize MPO, which leads to diverse and poorly studied mechanisms of cellular transformations, for example through autophagy activation. After prolonged administration, MPO can enter the nucleus of endothelial cells, where its role has not been studied so far.Through enzymatic and non-enzymatic capacities, MPO becomes an important contributor to the local regulation of immune responses in a variety of tissues. The over-whelming data on adverse effects of MPO in cardiovascular disease with respect to only few described beneficial functions raise the question of whether the physiological properties of the enzyme have been adequately explored and described. A better understanding of distinguishing useful and potentially necessary functions from excessive tissue damage may be useful in developing new therapeutic strategies for inflammatory diseases. Broad modulation of host-immunity is regularly accompanied by significant side effects, thus a leukocytic enzyme that shows predominantly negative effects and appears to have no ob-ligate functions is an attractive pharmacological target.Despite longstanding research on MPO, there is little understanding about the mo-lecular outcomes of MPO activity or its inhibition in vivo, in different tissues and during disease progression. Thus, additional work with the integration of several omic-approaches, such as single-cell transcriptomics, proteomics, epigenomics performed on mice and human tissues, as recently applied by Li et al. , is need