Univariate and multivariate Cox regression analyses demonstrated that electronic TILs (eTILs) variables were independently associated with overall survival after adjustment for clinicopathological factors including age, sex, and pathological stage . Results analyzed in different subgroups showed that the eTILs variable was a strong prognostic factor that was not redundant with pre-existing clinicopathological features . (4) Conclusion: ML-driven cell classifier-defined TILs variables were robust and independent prognostic factors in two independent cohorts of MIBC patients. eTILs have the potential to identify a subset of high-risk stage II or stage III-IV MIBC patients who might benefit from adjuvant immunotherapy.(1) Purpose: Although assessment of tumor-infiltrating lymphocytes (TILs) has been acknowledged to have important predictive prognostic value in muscle-invasive bladder cancer (MIBC), it is limited by inter- and intra-observer variability, hampering widespread clinical application. We aimed to evaluate the prognostic value of quantitative TILs score based on a machine learning (ML) algorithm to identify MIBC patients who might benefit from immunotherapy or the de-escalation of therapy. (2) Methods: We constructed an artificial neural network classifier for tumor cells, lymphocytes, stromal cells, and “ignore” cells from hematoxylin-and-eosin-stained slide images using the QuPath open source software. We defined four unique TILs variables based on ML to analyze TILs measurements. Pathological slide images from 133 MIBC patients were retrospectively collected as the discovery set to determine the optimal association of ML-read TILs variables with patient survival outcomes. For validation, we evaluated an independent external validation set consisting of 247 MIBC patients. (3) Results: We found that all four TILs variables had significant prognostic associations with survival outcomes in MIBC patients ( Bladder cancer (BCa) is the most common malignancy of the urinary system and one of the top ten cancers worldwide, with approximately 573,000 new cases and 213,000 deaths worldwide in 2020 ,5. AccorTILs have high prognostic value in many solid tumors. Overall, a high abundance of TILs tends to be associated with better prognosis . SeveralIn recent years, the development of digital pathology imaging and advances in machine learning (ML) have greatly facilitated the discovery of cancer biomarkers. A growing number of computer image analysis methods are being developed for commercial or free open source use, such as QuPath . ML compIn this study, we developed a pipeline for automatic analysis of TILs in pathological images based on ML technology and QuPath open source software for prognostic prediction of MIBC patients. The goal of this work is not only to help pathologists more accurately assess TILs, but also to validate the potential pathologist-independent utility of this prognostic analysis method in a clinical setting to determine which MIBC patients might benefit from immunotherapy. Finally, we demonstrated in two cohorts that TILs are a powerful independent prognostic factor that can assist clinicians in risk stratification of MIBC patients and facilitate personalized treatment.https://portal.gdc.cancer.gov/repository, accessed on 24 November 2022). The RHWU cohort included 150 WSIs of 150 MIBC patients.We retrospectively evaluated independent cases from two cohorts from the following publication and institution, respectively: (a) The Cancer Genome Atlas (TCGA) and (b) Renmin Hospital of Wuhan University . Pathological images for both cohorts were rendered in whole-slide image (WSI) format. The TCGA cohort included 457 WSIs of 386 BCa patients, and each patient may have multiple WSIs (Inclusion criteria for both cohorts were as follows: (a) available clinicopathological information; (b) available follow-up information; (c) definitive pathological diagnosis of MIBC; (d) diagnostic slides, not tissue slides; (e) availability of clear Hematoxylin-and-Eosin (H&E)-stained pathological slides .https://xenabrowser.net/datapages/, accessed on 24 November 2022), and those in the RHWU cohort were obtained through the hospital management system and follow-up. Patients in both cohorts were reclassified according to the eighth edition of the TNM staging system developed by the AJCC  to represent the proportion and density of TILs in different cell types and areas analyzed. The cell segmentation method we used was unsupervised, and we followed this with artificial neural network-based cell classification. The advantage of this strategy is that it only requires less data to achieve better training results. However, its limitation is that the accuracy of classification and segmentation is susceptible to differences between WSIs, which might result in overfitting of the classifier during training. To address this limitation, we optimized and unified H&E staining for all WSIs, and strictly controlled the quality of segmentation and classification by urologic pathologists to avoid catastrophic phenomena. Finally, we confirmed the prognostic effect of all four TILs variables in both cohorts.In our study, we developed a cell classifier based on the QuPath platform for quantitative measurement of TILs and derived four different TILs variables [eTILs%, esTIL%, etTILs% and eaTILs  and intratumoral TILs (iTILs). Although iTILs account for only 1% to 3% of TILs in most circumstances, they are frequently disastrous when they occur. Hence, it is essential for pathologists to rigorously review these WSIs for exclusion or reanalysis in studies. Finally, our most important limitations are that both cohorts are retrospective, that patients in cohorts can have different treatments and that WSIs staining differs between cohorts. Even though pathological images from clinics are restricted, we only employed WSIs for analysis in our work and did not include tissue microarrays (TMA) images like . This isIn conclusion, we validated that the eTILs score was a strong independent prognostic marker in MIBC patients and was significantly associated with OS. The developed ML algorithm has the potential to be a convenient and useful quantitative tool for risk stratification. Through subgroup analysis, we confirmed that the eTILs score can assist clinicians in identifying MIBC patients who might benefit from immunotherapy or avoid overtreatment. In the future, TILs variables will be complemented with molecular typing of cells, and larger prospective cohort studies will be conducted to find the best approach for the subset of MIBC patients who might benefit from immunotherapy.


This study aims to identify implementation determinants, mechanisms of action, implementation strategies, and implementation outcome evaluation plans for a new theory-based rehabilitation goal setting and goal management intervention system, called MyGoals, using Implementation Mapping with community-based participatory research principles.We completed Implementation Mapping tasks 1 to 4 as a planning team consisting of MyGoals target implementers , MyGoals intervention target clients (adults with chronic conditions), and the research team. We are currently conducting mapping task 5. These processes were guided by the Consolidated Framework for Implementation Research, social cognitive theory, the taxonomy of behavior change methods, and Proctor's implementation research framework.MyGoals' evidence strength & quality, relative advantages) and OT-level determinants . We selected the MyGoals implementation outcome , outcome variables , and process outcomes. We also determined three performance objectives  and 15 change objectives . Based on the identified outcomes, objectives, and determinants, we specified the mechanisms of change . To address these determinants and achieve the implementation outcomes, we produced two tailored MyGoals implementation strategies: MyGoals Clinician Education and MyGoals Clinician Audit & Feedback. We developed evaluation plans to explore and evaluate how these two MyGoals implementation strategies perform using a mixed-methods study of OT-client dyads.We identified intervention-level determinants (We produced tailored implementation strategies for a rehabilitation goal setting and goal management intervention by using Implementation Mapping with community-based participatory research principles. The MyGoals implementation strategies may help OTs implement high-quality goal setting and goal management practice and thus contribute to bridging current research-practice gaps. Our findings can provide insight on how to apply implementation science in rehabilitation to improve the development and translation of evidence-based interventions to enhance health in adults with chronic conditions. Goal setting and goal management is a core routine rehabilitation practice that can determine overall care planning, quality of care, and health outcomes –5. EvideTwo major research-practice gaps in current goal setting and goal management include limited use of theory-based intervention components and poor client engagement throughout the intervention . CurrentEducation, Reflection, Find My Goals, Make My Goals, Make My Plans, and My Progress) that they can directly apply in their practice without considerable modifications. To facilitate active client engagement, MyGoals guides OTs to use an empowerment-based approach that involves supporting clients to make self-determined decisions and actions  to implement comprehensive theory-based, client-engaging goal setting and goal management for adults with chronic conditions in community-based rehabilitation. We developed MyGoals using Intervention Mapping combined with community-based participatory research (CBPR) –15. MyGo actions . These tComplex interventions like MyGoals require tailored and effective strategies to enhance their implementation , 18. If Implementation Mapping is an innovative implementation science approach that provides a set of systematic iterative tasks to guide implementation strategy development and evaluation . ImplemeThe purpose of this study was to use Implementation Mapping to identify MyGoals implementation determinants, mechanisms of action, implementation strategies, and outcome evaluation plans. The results from this study will provide insight into factors that influence the implementation of quality goal setting and goal management in community-based rehabilitation with adults with chronic conditions and how to address these factors to enhance its implementation. This study will also inform future efforts to apply implementation science and collaborate with community partners to develop and optimize rehabilitation interventions.This is a mixed-methods study involving five Implementation Mapping tasks as a part of the MyGoals implementation strategy development and optimization process.This paper reports the Implementation Mapping tasks that were completed as a part of the larger MyGoals development project. In the larger MyGoals development project, we established a planning team consisting of two OTs, two adults with chronic conditions, and the research team to develop MyGoals using Intervention Mapping  and to dWe conducted a total of 10 virtual meetings using video-conference calls and in-person meetings at a research-based university in the Midwest, United States. The planning team members were asked to join the meetings when the mapping tasks and meeting agenda were directly applicable to them. The OT planning team members participated in all Intervention Mapping and Implementation Mapping tasks. The client members joined in all Intervention Mapping and Implementation Mapping tasks 4–5. Because our study first aimed to create and optimize MyGoals and its implementation strategy for community-based rehabilitation generally before targeting a specific site, we did not address the adoption and maintenance of MyGoals. The MyGoals Intervention Mapping process will be published elsewhere.Two OTs who met the following inclusion criteria participated as planning team members: (1) aged > 18 years old, (2) English speakers, (3) licensed OTs, (4) experience working in community-based rehabilitation settings with adult clients, (4) at least 1-year professional clinical experience relevant to goal setting and goal management with adults with chronic conditions. The exclusion criteria were (1) no access to the REDCap survey, e-mail, or internet and (2) <1 year of professional clinical experience relevant to goal setting and goal management with adults with chronic conditions to prevent a lack of clinical experience interfering with MyGoals' feasibility evaluation. The OTs were recruited by word of mouth.Two clients who met the following inclusion criteria participated as planning team members: (1) aged > 18 years old, (2) English speakers, (3) have one or more chronic conditions. The exclusion criteria were (1) severe cognitive impairment or dementia defined as a total Montreal Cognitive Assessment  score <2In implementation science, theories, models, and frameworks can be used to guide (1) the implementation process, (2) implementation determinant identification and strategy development, and (3) implementation outcome evaluation . In thisWe used Implementation Mapping  to guideWe used the CFIR  to identLastly, we used Proctor's implementation research framework  to deterAll Implementation Mapping tasks were completed through the planning team meetings. Throughout the meetings, we had a different agenda for each mapping task but used the same principles to maximize client and OT team members' participation in the tasks. Before the meetings, the research team prepared easy-to-understand and eye-catching meeting readings, presentations, drafts, etc. to facilitate all team members' understandings of topics and brainstorming. During the meetings, the research team reflected, summarized, and facilitated interactive discussions. The research team ensured that all members participated in discussions by explicitly asking individual members' opinions to reach a consensus for each task. After meetings, if the research team found any inconsistent content, they brought these points back and double-checked with planning team members to reach a consensus. Patient Needs & Resources, because other constructs such as External Policies & Incentives can vary considerably across OT inner work settings. Based on the identified determinants, we developed the change objectives and the matrices of change.In the first task, we conducted a needs assessment through informal discussions to identify who implements MyGoals  using the following question: “Who will implement MyGoals in community-based rehabilitation settings?” In the second task, we determined implementation outcomes, performance objectives , change objectives (what and how determinant needs to be changed to achieve the performance objectives), and implementation determinants. We choose all applicable implementation outcomes from Proctor's implementation research framework . To idenIn the third task, we selected mechanisms of action and implementation strategies that are deemed applicable and effective in targeting the MyGoals implementation determinants to achieve the change and performance objectives. To choose theory- and evidence-based mechanisms of action, we first reviewed all the taxonomy of behavior change methods that are suggested effective in targeting the identified determinants and then identified ones that are applicable with the chosen implementation strategies . To deteMyGoals Clinician Education and MyGoals Clinician Audit & Feedback. We first drafted the MyGoals Clinician Education content. Then we optimized the MyGoals Clinician Education content and delivery based on the developed matrices of action and chosen implementation strategies. After the initial development of MyGoals Clinician Education, we conducted pilot-testing with a new OT-client dyad (identified using the same eligibility criteria and methods described above for planning team members) to optimize MyGoals Clinician Education. The OT completed the following tasks in order: (1) two virtual MyGoals Clinician Education sessions, (2) deliver MyGoals activities 1–5 to a client, (3) MyGoals Clinician Audit & Feedback, (4) deliver MyGoals activity 6 to the client, and (5) implementation outcome evaluations. Based on the findings from this pilot-testing, we refined MyGoals Clinician Education, MyGoals Clinician Audit & Feedback, and MyGoals.In the fourth task, we produced In the fifth task, we specified the process evaluation question items, outcome indicators and measures, and the study design to evaluate MyGoals implementation outcomes. We are currently conducting the MyGoals implementation strategy evaluation using a mixed-methods study of OT-client dyads.Mapping task 1: We identified that the MyGoals implementers are OTs.Mapping task 2: We determined the MyGoals implementation outcome, OTs will deliver MyGoals completely and competently, and outcome variables including acceptability, appropriateness, and feasibility of MyGoals implementation strategies and acceptability, appropriateness, feasibility, and fidelity of MyGoals. Due to the early nature of our research, other implementation outcomes suggested by Proctor's implementation research framework ((1) Agree to implement MyGoals, (2) Deliver all MyGoals intervention components, and (3) Deliver all MyGoals intervention activities by using the empowerment-based approach.ramework  such as evidence & strength and relative advantages. This is because MyGoals is new, so OTs are not yet aware of its evidence and benefits over other existing systems. Thus, to facilitate MyGoals implementation, it will be crucial that OTs understand its evidence and its advantages over other existing systems. The OT-level determinants are their knowledge, awareness, skills, self-efficacy, and outcome expectancy. To target these OT-level determinants, we specified change objectives for each chosen determinant. We then explored MyGoals implementation determinants using all CFIR domains except the inner setting and found that intervention- and individual-level determinants are key determinants. The identified intervention-level determinants are MyGoals' Mapping task 3: Based on the identified change objectives, we selected the mechanisms of change using the taxonomy of behavior change methods  and how  they want to complete the MyGoals Clinician Audit & Feedback. This revision allowed us to tailor the MyGoals Clinician Audit & Feedback to the individual OT's learning style and preferences. We also extended MyGoals Clinician Audit & Feedback from 15-min to 30-min to provide enough time for OTs to discuss their feedback, concerns, questions, etc.MyGoals Clinician Education and MyGoals Clinician Audit & Feedback. The first education session aims to educate on overall goal setting and goal management concepts, practice, and application and evidence of MyGoals. The second education session aims to equip OTs to administer MyGoals with a client through role-playing with the research team member. The MyGoals Clinician Audit & Feedback aims to provide OTs with individualized feedback and consultation to enhance their MyGoals implementation.Mapping task 5: We identified measures, respondents, and time points to evaluate the selected implementation outcomes described in MyGoals Clinician Education more feasible?).MyGoals Clinician Education and MyGoals Clinician Audit & Feedback help OTs achieve each change objective and qualitative questions to explore how to improve them. The self-report quantitative question items were developed based on the change objectives outlined in I understand the evidence of MyGoals. Qualitative interview questions will be used to explore OT's perspectives on the change objectives . We are currently undergoing implementation outcome evaluation using a mixed-methods study of OT-client dyads to explore and optimize MyGoals implementation strategies in preparation for a future larger study.We also developed quantitative measures to explore how successfully the This study aimed to develop effective strategies to ensure high-quality implementation of a goal setting and goal management intervention called MyGoals in community-based rehabilitation with adults with chronic conditions. To do so, we used Implementation Mapping with CBPR principles to determine MyGoals implementation determinants, mechanisms of action, implementation strategies, and evaluation plans. To our knowledge, this is the first study to use Implementation Mapping with CBPR principles to develop implementation strategies for a community-based rehabilitation goal setting and goal management system. We found that Implementation Mapping can guide the development and optimization of theory- and evidence-based MyGoals implementation strategies and their evaluation plans. In turn, the developed MyGoals implementation strategies may support OTs in providing better goal setting and goal management in community-based rehabilitation with adults with chronic conditions. These findings can inform future research on how to use implementation science to develop and optimize rehabilitation interventions and their implementation strategies, and thus help bridge research-practice gaps to improve health in adults with chronic conditions.In our study, we enhanced the theoretical rigor and ecological validity of our research findings by using theories, models, and frameworks combined with CBPR principles. The collaboration and co-learning process with MyGoals implementers and MyGoals intervention target clients helped us (the research team) better understand the complex MyGoals implementation context from the end-users' perspective. If we did not actively collaborate with OT members throughout this research but merely interviewed them as research subjects, we may have been able to identify key determinants but then developed implementation strategies deemed feasible and effective from the researchers' but not clinicians' perspectives. At the same time, as much as the use of CBPR principles is important, it is critical to develop implementation strategies with theoretical rigor. To do so, we used theories, models, and frameworks as guidance to synergize the real-world and academic knowledge for developing effective MyGoals implementation strategies.We took a holistic approach to identify determinants that will play important roles in implementing MyGoals in community-based rehabilitation. We found that having the buy-in of individual OTs can be key to facilitating MyGoals implementation. Previous literature suggests that OTs' self-awareness about their interaction with clients can promote quality goal setting practice . Our finEnabling OTs to deliver MyGoals completely and competently as the implementation outcome. This outcome was chosen because achieving high levels of MyGoals' completeness and competency can facilitate the comprehensive use of theory-based intervention components and active client engagement. As a result, it can address the abovementioned two major research-practice gaps in community-based goal setting and goal management rehabilitation. In addition, we chose to evaluate MyGoals' and MyGoals implementation strategies' appropriateness, acceptability, feasibility, and fidelity of MyGoals. Good appropriateness, acceptability, feasibility, and fidelity are known prerequisites for high-quality intervention delivery to improve clients' health .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cognitive impairment after surgery is a common problem, affects mainly the elderly, and can be divided into postoperative delirium and postoperative cognitive dysfunction. Both phenomena are accompanied by neuroinflammation; however, the precise molecular mechanisms underlying cognitive impairment after anesthesia are not yet fully understood. Anesthesiological drugs can have a longer-term influence on protein transcription, thus, epigenetics is a possible mechanism that impacts on cognitive function. Epigenetic mechanisms may be responsible for long-lasting effects and may implicate novel therapeutic approaches. Hence, we here summarize the existing literature connecting postoperative cognitive impairment to anesthesia. It becomes clear that anesthetics alter the expression of DNA and histone modifying enzymes, which, in turn, affect epigenetic markers, such as methylation, histone acetylation and histone methylation on inflammatory genes  and genes which are responsible for neuronal development (such as brain-derived neurotrophic factor). Neuroinflammation is generally increased after anesthesia and neuronal growth decreased. All these changes can induce cognitive impairment. The inhibition of histone deacetylase especially alleviates cognitive impairment after surgery and might be a novel therapeutic option for treatment. However, further research with human subjects is necessary because most findings are from animal models. Main hypotheses of the review:-Cognitive impairment is a common problem after surgery-Epigenetic dysregulation may play a role in its development-Anesthetics alter expression of DNA and histone-modifying enzymes-This causes an altered epigenetic profile of genes involved in neuroinflammation and neuronal maintenance and development-Epigenetic drugs may be a novel therapeutic option for the treatment of postoperative cognitive impairmentThe first reports of long-lasting cognitive impairment in older patients after surgery were published more than six decades ago . DespiteThe pathophysiology of POD and POCD is closely related to neuroinflammation . The bioThe current understanding of the development of POD and POCD is that surgery causes trauma of the surgical site accompanied by the release of damage-associated patterns ,28 Figu. The mosThe association of the use of special anesthetics regarding cognitive impairment has been studied extensively, but results are sometimes contrary. In general it is estimated that the shorter the duration of action of the anesthetic agent, the shorter the duration of cognitive impairment in the immediate postoperative period . A recenIt has been proposed earlier that epigenetics might contribute to cognitive impairment for several reasons. However, until 2013, no heritable, genomic indices of persistent POCD or postoperative dementia after surgery had been identified .inter alia, exposure to general anesthesia, hypotension, hypoxia, psychoactive drugs and hippocampal inflammation induced by the surgical intervention. In addition, earlier studies indicate that these factors might induce epigenetic dysfunction in the brain, as chromatin remodeling is required for memory-associated gene transcription and expression [The risk factors identified as contributing to cognitive impairment are, pression . Additiopression .It has recently been suggested that unknown, novel, epigenetic-related mechanisms could cause anesthetic-induced neuronal toxicity to human neurons, and that epigenetic modifiers, such as DNA-methyltransferase (DNMT) and histone deacetylase inhibitors (HDACis), might be promising targeted therapeutics to mitigate the neurotoxic effects of anesthetics in the developing brain .However, little is known about whether anesthetics induce epigenetic changes in genes related to cognitive impairment, and further research is needed to elucidate the epigenetic mechanisms completely and their role in this field.Epigenetic modification generally includes variations in DNA methylation, histone acetylation, histone methylation and noncoding RNA  and plays a crucial role in several diseases, but most of the studies have involved in vitro experiments . The epiWe summarize the epigenetic effects, detected mainly in animal studies with mice and rats in the last few years, in We searched Medline with the following search term: “postoperative AND (delirium OR cognitive OR neuroinflammation) AND (epigenetics OR DNA methylation OR histone OR chromatin)” and received 35 results covering the years from 2011 to 2022 . Mainly,Bdnf exon. This BDNF reduction leads to an inadequate drive for the synthesis of synaptic proteins, thus, contributing to the hippocampal synaptic and cognitive dysfunction [As an example, it is proposed that one of the main receptors of sevoflurane, the excitatory gamma-aminobutyric acid A receptor, is linked to the epigenetic mechanism in the developing brain. This can increase neuroapoptosis, elevate serum corticosterone levels and may contribute to sevoflurane-induced long-term cognitive abnormalities . Wu et afunction .DNA methylation is facilitated by DNA methyltransferases  and generally leads to the repression of gene expression through the addition of methyl groups to CpG sites of the gene promoters, which blocks the binding of transcription factors. DNA methylation is one of the most well-described epigenetic modifications, and regulates numerous diverse cellular processes including the silencing of transposable elements, X-chromosome inactivation and tissue-specific gene expression .In the first part of this section, we summarize studies including human subjects. It was demonstrated recently that neurosurgery significantly altered DNA methylation levels of 24 CpG sites of the TNF, IL1B and IL6 gene . In addiSadahiro et al. showed that major surgery induces acute changes in DNA methylation in peripheral blood mononuclear cells associated with immune response pathways that might influence the risk of postoperative complications, including cognitive dysfunction and delirium . ShinozaIn the context of neurological disorders, DNA methylation in astrocytes appears to be altered, which can impact on both the neuroprotective and neurodegenerative qualities of astrocytes and affects astrocyte differentiation and inflammatory response .Summarizing the effects seen after surgery mostly includes pathways which are related to immune response or neuronal growth .In the second part, we focus on animal studies that might help us to get a deeper view into the pathomechanisms of cognitive impairment induced by certain anesthetics.It was recently demonstrated that sevoflurane exposure leads to increased DNMT expression in pyramidal neurons in rats, which causes cognitive impairment and is accompanied by hypermethylation of Reelin genes and BDNF, and subsequently their downregulation, which finally leads to a reduction of dendritic spines in the pyramidal neurons of the hippocampus ,90 Figu.Zhong et al. demonstrated that sevoflurane-induced POCD in elderly mice induces compromised levels of global DNA 5′-hydroxymethylcytosine and ubiquitin-like effects with PHD and ring finger domains 2 in the hippocampus and the amygdaloid nucleus, when compared with non-POCD and control mice. In addition, the 5-hydroxymethylcytosin reduction of the promoters of genes associated with development and neural protection, such as BDNF, glial cell-derived neurotrophic factor, acyl-CoA synthetase short chain family member 2 and glucocorticoid receptor, activated the transcription of these genes and could be found in the hippocampus of POCD mice. Contrarily, increased 5-methylcytosine levels on the promoters of glutamate receptor 2 precursor GluR2 and decreased 5-methylcytosine levels of HMGB1 and MMP9 showed an inverse tendency with transcription of these genes . Zhu et Klenke et al. recently showed that DNA methylation in the DNA of mouse primary hippocampal neurons after isoflurane exposure alters the methylation of the genes chemokine (C-X-C motif) ligand 12, chemokine (C-X-C motif) ligand 14, GATA binding protein 3, IL11, IL13, and IL4 receptor alpha belonging to inflammatory pathway . GregoirHistone acetylation and deacetylation are epigenetic processes mediated by histone acetyl transferases and deacetylases (HDACs) . It is gA recent study indicated that propofol might be involved in the regulation of histone acetylation in cancer development. Holownia et al. showed that propofol regulates histone acetylation in rat astroglial cells by protection against tert-butyl hydroperoxide toxicity . Lin et In 2016, it was demonstrated in rat hippocampus after exposure to a sedative dose of midazolam followed by combined nitrous oxide and isoflurane, that anesthesia causes epigenetic modulations manifested as histone-3 hypoacetylation, with a 25% decrease in histone acetyltransferase activity. This was accompanied by a downregulation of the transcription of BDNF and cellular Finkel-Biskis-Jinkins murine sarcoma virus osteosarcoma oncogene. Hence, the authors postulated that long-term impairments of neuronal development and synaptic communication could be caused by anesthesia-induced epigenetic phenomena .The incubation of THP-1 monocytes with isoflurane results in increased HDAC1 and HDAC2 expression and downregulates cytokine expression. These results were shown in primary human peripheral blood monocytes, where HDAC1 and HDAC2 gene silencing caused increased cytokine production and NF-κB nuclear translocation induced by isoflurane pre-exposure and lipopolysaccharide stimulation. These findings showed that anti-inflammatory effects of isoflurane in human monocytes involve the regulation of HDAC1 and HDAC2 . These rZhong et al. showed that neonatal isoflurane exposure-induced memory impairment is associated with the dysregulation of H4K12 acetylation, which may lead to less hippocampal activation and cognitive impairment in mice .Sevoflurane impairs synaptic plasticity and cognitive function in aged mice . It was The cognitive dysfunction after sevoflurane anesthesia can be alleviated by HDACi trichostatin A treatment via inhibition of the overactivation of astrocyte intracellular NF-κB signaling and the release of cytokines . HistoneThe role of the methylation of histones facilitated by histone methylases is not yet fully understood. It results in either increased or reduced gene expression, depending on the specific amino acid methylated on the histone tails. It is assumed that H3K4 tri-methylation is associated with transcription increase, whereas H3K9 tri-methylation leads to reduced transcription .Histone methylation has not been studied well in the context of cognitive impairment. Wu et al. showed that histone H3K9 trimethylation downregulates the expression of BDNF in the dorsal hippocampus and impairs memory formation during anesthesia with laparotomy under isoflurane inhalation and surgery in mice . Our groOther histone modifications exist in addition to methylation and acetylation, and include phosphorylation, ubiquitylation and sumoylation. However, not much is known about these modifications in the context of cognitive function, but existing studies indicate that astrocyte-specific histone phosphorylation, ubiquitylation and sumoylation could be important factors to examine in neurodegenerative diseases .All these studies indicate that epigenetic alteration may play a role in anesthesia-induced cognitive impairment. Hence, new therapeutic options for the treatment of POD and POCD might implicate epigenetic drugs, which might be inhibitors of HDACs and methyl donor compounds . As an eSeveral approaches for the use of HDACis can be found in the literature. Wu et al. demonstrated that the inhibition of HDAC in rats alleviates cognitive impairment after surgery. They showed that the reduction of HDAC2 expression and inhibition of HDAC activity decrease activated microglia levels and increase postsynaptic density 95 protein expression in the hippocampus. In addition, NF-κB-p65 protein expression and nuclear accumulation, as well as the neuroinflammatory response with the proinflammatory cytokines TNF-α and IL-1β in the hippocampus, was reduced by HDAC inhibition . Jia et 5-azacytidine or azacitidine (AzaC) is one of the most widely studied DNMT inhibitors, and is used mainly for managing myelodysplastic syndrome, in which it functions as a methyl donor-remover in vitro to weaken the gene silencing effect upon methylation . It was Anesthesia is usually considered to safely induce a reversible unconscious state, allowing surgery to be performed without pain. However, an increasing number of studies, especially preclinical ones, demonstrate that general anesthetics can cause long-term cognitive impairment . Since aWe have to think about the clinical implications of the described results. In clinical practice, explaining that an epigenetic change can induce post-anesthesia delirium might be hard to believe because of the chronology from direct damage to symptom onset and the time that would be expected to exist between the epimutation or epigenetic change and its translation into the clinical phenotype. This seems especially troubling when considering genes involved in neurodevelopment and neurogenesis. However, genes related to neurogenesis, such as BDNF, as mentioned here, seem to play a role in age related cognitive impairment as well . CompariMuch more future research is needed. This means that more systematic investigations are needed to determine the influence of different anesthetics depending on cell populations and in patients of different ages to analyze the precise effects. In addition, it should also be noted that large randomized prospective trials are currently missing to explore the exact epigenetic mechanisms and analyze possible influences on the patient’s outcome. This will help us to translate the findings from animal studies to clinical practice and can determine if anesthetics directly induce long-lasting epigenetic effects, which impact on genes of neuroinflammation and neurodevelopment. Furthermore, before epigenetically drugs can be used in clinical settings, it has to be clarified, how they can be used in a targeted approach . HoweverIn conclusion, epigenetic mechanisms seem to play a critical role in the development of POCD. Although the data are sometimes heterogeneous, it seems that epigenetic modifications effect neuroinflammation, neuronal development and the secretion of neurotransmitters. Surgery and anesthesia might trigger the epigenetic dysregulation of cognition-associated genes, which alter the hippocampal gene expression program associated with memory consolidation and, consequently, leads to cognitive impairment following surgery. The restoration of abnormal chromatin remodeling and DNA methylation might be a viable approach to therapeutic intervention in postoperative cognitive impairment.


The first 40 years of research on the neurobiology of sign languages (1960–2000) established that the same key left hemisphere brain regions support both signed and spoken languages, based primarily on evidence from signers with brain injury and at the end of the 20th century, based on evidence from emerging functional neuroimaging technologies (positron emission tomography and fMRI). Building on this earlier work, this review focuses on what we have learned about the neurobiology of sign languages in the last 15–20 years, what controversies remain unresolved, and directions for future research. Production and comprehension processes are addressed separately in order to capture whether and how output and input differences between sign and speech impact the neural substrates supporting language. In addition, the review includes aspects of language that are unique to sign languages, such as pervasive lexical iconicity, fingerspelling, linguistic facial expressions, and depictive classifier constructions. Summary sketches of the neural networks supporting sign language production and comprehension are provided with the hope that these will inspire future research as we begin to develop a more complete neurobiological model of sign language processing. Once sign languages were shown to be natural, full-fledged languages, it became clear that investigating their neural substrates could provide unique evidence for how the brain is organized for human language processing. Beginning in the 1980’s, case studies of deaf signers with unilateral left hemisphere damage revealed impairments in sign language production and comprehension; in contrast, deaf signers with right hemisphere damage did not exhibit aphasic deficits . In addiThis article builds on this early work and focuses primarily on what we have learned about the neural bases of sign language processing within the last ~15 years. The aim is to sketch a neurobiological model of sign language production and comprehension that includes linguistic phenomena that are fundamentally shaped by the visual-manual modality  and variables that are unique to sign languages . Production and comprehension processes are addressed separately in order to capture whether and how output and input differences between sign and speech might impact the neural substrates supporting linguistic articulation versus perception. By widening our scientific lens in this way, we move beyond classic models of brain-language relationships which focus on shared neural substrates for signed and spoken languages, and we can begin to develop richer models that map psycholinguistic processes and linguistic units that may or may not be shared with spoken language onto a functional neuroanatomical network that supports sign language processing.Psycholinguistic evidence indicates that production processes are largely parallel for speech and sign. For example, both sign and speech production require phonological assembly of sublexical units , as evidenced by systematic production errors  is another region known to be involved in sign language production. Finally, the recent ECoG study by Lexical sign production has been found to be more strongly left-lateralized than spoken word production . GutiérrLeft inferior frontal cortex (IFC) is one region that is consistently engaged during both single sign and single word production, and damage to left IFC results in impairments in lexical production. This region is associated with several linguistic functions in spoken languages, with more anterior regions (Brodmann Area (BA) 47) associated with lexical-semantic processes and more posterior regions associated with phonological processing (BA 45) . Corina With respect to the connectivity of the neural network for lexical sign production, evidence from cortical stimulation in another deaf signer suggests that the posterior, superior region of the left inferior frontal gyrus (IFG) is connected both functionally and anatomically to the superior part of the left SMG . StimulaFinally, studies that elicit sign (and word) production using picture-naming tasks typically report neural activity in left inferior temporal (IT) cortex . This neThe traditional view has been that iconicity  plays no role in sign language acquisition or processing . HoweverSTIR, BRUSH-HAIR) versus less iconic, non-handling verbs . Similarly, HAMMER, SCRUB) and non-iconic verbs  when ASL signers generated verbs associated with objects. In both PET studies, sign production engaged left IFG (compared to a baseline task), but this neural activity was not modulated by iconicity.Thus far, the evidence that iconicity impacts the neural network supporting lexical retrieval and sign production is mixed. In a PET study, In contrast to these neuroimaging studies, results from event-related potential (ERP) studies suggest that iconicity can modulate the brain response during lexical production . BehavioIn fact, Fingerspelling systems that represent the alphabetic orthography of the surrounding spoken language exist for a number of sign languages and can be one-handed (as in ASL) or two-handed (as in BSL). Fingerspelled words differ from lexical signs because they require the production of sequences of hand configurations in neutral space without movements to the body (except to the non-dominant hand for two-handed systems). Thus, the articulatory demands differ for fingerspelled words and lexical signs. Compared to one-handed signs, Very few lesion or neuroimaging studies have examined the neural basis of phrase or sentence production in sign languages. With respect to neuroimaging data, there is only one study that targeted phrase-level sign production. n = 8) produced significantly more errors on classifier signs than lexical signs in a narrative picture description task, while left hemisphere damaged signers (n = 13) produced a similar number of errors for both types of signs. Neuroimaging research has confirmed that the right hemisphere  is engaged during the production of classifier constructions that express spatial relationships , almost nothing is known about the neural substrate that supports the production of non-manual sublexical components of sign , beyond lateralization to the left hemisphere  are likely involved in lexical selection and semantic processes, while the SMG is likely involved in phonological processing . Left pMLittle is known about the neural regions that support sentence and phrase production in sign languages. The aphasia literature clearly indicates that the left hemisphere is critical for sentence production , but thePerhaps surprisingly, the sketch of the sign language production network in Overall, output differences between sign and speech result in greater left parietal (SPL and SMG) engagement for sign compared to speech production , and greater engagement of left superior temporal cortex for speaking than signing (likely due to auditory feedback and auditory targets for speech production). Both sign and word production engage the left inferior frontal cortex, which is likely involved in lexical selection and lexical-semantic processes for both language types. At the sentence level, phrase production in sign and speech engage the same regions (left ATL and vmPFC), but much more research on sentence production by signers is needed to determine the extent of similarities and differences across modalities  .As for language production, psycholinguistic evidence points to many parallel processes for the comprehension of signed and spoken languages. For example, at the phonological level, both signers and speakers become tuned to the phonological units of their language, as evidenced by categorical perception effects , and botFor spoken language, bilateral auditory regions in superior temporal cortex differentiate speech from non-speech stimuli e.g.,  and do sElectrophysiological evidence also indicates that handshape and location parameters are processed differently in the brain, but this difference is not purely perceptual and can impact lexical-level processes. Using an ERP priming paradigm and delayed lexical decision, Non-manual features  constitute a non-trivial component of the structure of sign languages. At the phonological level, non-manual features can distinguish between minimal pairs, such as the ASL signs NOT-YET and LATE, which are distinguished only by tongue protrusion produced with NOT-YET. At the syntactic level, distinct facial expressions  mark different types of questions, and headshake marks negation in many sign languages, although the scope of negation (when and where the headshake must occur) varies cross-linguistically . Eye-gazTwo fMRI studies have examined how non-manual components of signs are processed in the brain. Finally, A MEG study by Neuroimaging studies targeting lexical-level processing in deaf signers of several different languages consistently report bilateral activation in posterior STC, typically with more extensive activation in the left hemisphere: ASL ; BSL Ma, CSL Li, German The neuroimaging studies cited above that investigated lexical comprehension in ASL, BSL, CSL, DGS, LSQ, and PJM all report additional neural activity within left inferior frontal cortex (IFC), often accompanied by less extensive neural activity in the homologous region in the right hemisphere. Left IFC includes Broca’s area (BA 44 and 45) along with a more anterior frontal region (BA 47); these regions have been associated with multiple functions for spoken word comprehension, including selecting among competing possible words, linking semantics with phonology, and maintaining words in memory . BilaterMost of the evidence to date indicates that iconic signs are not comprehended differently in the brain compared to non-iconic signs. Finally, a recent ERP study by Two studies have examined the neural underpinnings for the comprehension of fingerspelled words, investigating the two-handed BSL system  and the Neuroimaging studies of sentence-level comprehension in different sign languages report engagement of a similar bilateral fronto-temporal network as found for single sign comprehension, again with more extensive activation in the left hemisphere: ASL , BSL Ma, CSL Li, DGS Gi, JSL Sa, Langue N = 316) of seven different languages. The meta-analysis revealed bilateral IFG activation extending into lateral premotor cortex in the left hemisphere for sign comprehension compared to control/baseline tasks . Activation in Broca’s area  was strongly left-lateralized, particularly for BA 44. Further, a comparison with another meta-analysis of the perception of non-linguistic action gestures (by non-signers) indicated that sign language comprehension engaged left IFG (with a peak in BA 44) to a greater extent than human action observation, but the conjunction analysis revealed overlap in right IFG (BA 45). Based on these results, The role of the left IFG in sign language comprehension was further documented in a recent ALE (activation likelihood estimate) meta-analysis by A typologically unique feature of sign language syntax is the use of “agreeing” verbs that can be directed toward locations in signing space to express grammatical relations . It is possible that activation in right parietal cortex was not observed for the topographic sentences because only a handful of sentences required mapping the location of the hands in signing space to the location of figure and ground referents .As with production, results from lesion studies indicate that either left or right hemisphere damage can result in comprehension deficits for classifier constructions expressing spatial relationships . Howeverleft, right, in front of, behind) or a perspective-independent relationship  between a figure and ground object. In contrast to non-spatial control sentences, perspective-dependent sentences engaged SPL bilaterally for both ASL and English, consistent with a previous study using the same design with written English  failed to find activation in either left or right parietal cortex when deaf ASL signers comprehended sentences containing location and motion classifier constructions  versus matched sentences that expressed static location information . MT+ was localized individually for each deaf signer using motion flow fields. The results revealed greater neural activity in bilateral MT+ for motion compared to location sentences. This finding indicates that linguistic semantics modulates motion-sensitive cortex  . RecogniComprehending lexical signs engages bilateral inferior frontal, posterior superior temporal, and inferior parietal cortices e.g., . LexicalAlthough most neuroimaging studies of signed sentence comprehension find bilateral fronto-temporal activation in comparison to low-level baselines, studies that specifically target sentence-level computational processes find left-lateralized activation in superior temporal cortex. In particular, posterior STC and the left ATL may be involved in syntactic/semantic integration processes for lexical signs within phrases or sentences . Left IFNeuroimaging studies targeting comprehension of sentences with classifier constructions indicate involvement of left or bilateral SMG . In addiOverall, the input differences between sign and speech comprehension can be seen, not surprisingly, in the early involvement of occipital  versus superior temporal (auditory) cortices . SimilarIn the 60 years since Stokoe’s linguistic description of ASL, there is abundant evidence for overlap in the neurobiology of spoken and signed languages, particularly around perisylvian cortex. However, much work remains to understand the specific neural computations that are involved in the production and comprehension of sign languages. Although a given neural region may be engaged for both signed and spoken language, it is possible that the neural computations within that region are not identical for the two modalities. For example, it is possible that posterior superior temporal cortex performs somewhat different computations during sign versus word comprehension. For sign languages, this region might primarily be engaged in accessing lexical semantic representations, while for spoken languages this region may be additionally engaged in mapping auditory-vocal phonological representations onto lexical semantic representations. Similarly, left inferior parietal cortex may be involved in phonological processes for both sign and speech, but may perform different functions due to modality differences in the nature of phonological units.In fact, A comparison of the neural network for sign production  and compIn conclusion, there is clearly much work left to be done. The neural regions that support syntactic production in sign language are largely unknown, and this question is critical given that the nature of syntactic processing may differ for production and comprehension . FurtherThere are also open domains of inquiry that are unique to sign languages. We know almost nothing about the neural regions that support the production of non-manual components at the phonological, lexical, or syntactic levels. In addition, almost all of the research reviewed here has been conducted with deaf native signers , which constitute only 5–10% of deaf children . We knowIn sum, it is hoped that over the next few decades we will enhance and deepen our understanding of the neurobiological foundations of sign language, which will not only provide further insights into the neural basis of human language, but will also provide a translational foundation for treating injury to the language system, for diagnosing language impairment in signers, and for promoting healthy brain development in deaf children.


The focus of this brief review is to describe the application of nanoparticles, including endogenous nanoparticles  and exogenous nanoparticles  in cancer therapy and diagnostics. In this review, we mainly focused on EVs, where a recent study demonstrated that EVs secreted from cancer cells are associated with malignant alterations in cancer. EVs are expected to be used for cancer diagnostics by analyzing their informative cargo. Exogenous nanoparticles are also used in cancer diagnostics as imaging probes because they can be easily functionalized. Nanoparticles are promising targets for drug delivery system (DDS) development and have recently been actively studied. In this review, we introduce nanoparticles as a powerful tool in the field of cancer therapy and diagnostics and discuss issues and future prospects. Cancer is a disorder that is hard to cure because it is basically a rebellion of self-cells, making it difficult to target only cancer cells in therapy. The basic approach against cancer is early detection, followed by chemotherapy and/or physical removal of the tumor if possible. Physical removal can be achieved by surgical operation or radiation therapy; both of these methods are highly invasive and require information about the tumor location. Chemotherapy is a less invasive therapy; however, it is only effective against certain types of tumors. In addition, chemotherapy has non-negligible risks of adverse effects ,2. Most EVs, also known as microparticles or lipid vesicles, are secreted from cells with a lipid bilayer or multilayer structure. All living cells secrete EVs, which are generally categorized into several groups based on their origin, such as exosomes, microvesicles, and apoptotic bodies , Table 1The therapeutic use of EVs has been proposed because they can modify the state of target cells. In particular, EVs derived from immune cells can prime early T cells, differentiate mature T cells, and develop effector functions, such as antigen presentation and activation of immune cells . The EVsIn addition to using EVs as drugs, EVs may deliver cargo into target cells, and the use of EVs as drug delivery system (DDS) carriers is gaining interest in the medical field. When using EVs as therapeutic DDS carriers, it is necessary to load the drug to be delivered into the vesicles ,21. This3O4 iron oxide that can be used as a contrast agent for MRI; magnetite generates heat when stimulated with alternating magnetic fields [For the delivery of EV cargo into target cells, especially when the drug of interest is encapsulated inside EVs and is unable to penetrate the lipid bilayer by itself, the drug must be released from the inside of EVs to exert its biological function after cell entry. Since EVs are mostly internalized by endocytosis, membrane fusion between the endocytic membrane and the EV membrane must take place. Whether EVs exhibit membrane fusion activity is a subject of considerable debate ,32,33,34c fields . Agents c fields . Variousc fields , since ec fields . The gloc fields ,45.As all cells secrete EVs, cultured cells are the best candidates for fabricating EVs for therapeutic use. In general, the medium used for mammalian cell culture contains serum, including animal derived EVs. Thus, the use of a defined medium without a serum component is indispensable . The souBoth biochemical and physical properties are used to evaluate the quality of EVs. Biochemical analysis uses proteomic, genomic, and lipidomic approaches . WesternAs mentioned in the previous section, EVs also play important roles in intercellular communication involved in tumor development and are expected to be a promising source of biomarkers for biofluid -based cancer diagnostics, called liquid biopsy . For insDue to the heterogeneity of samples, as well as the small quantity of target analytes, sensitive and selective analysis of EVs in a facile and inexpensive way has been a challenge in the field of diagnostics. In addition to widely used methods, such as enzyme-linked immunosorbent assay for protein markers as well as quantitative real-time polymerase chain reaction (qRT-PCR) and next-generation sequencing for nucleic acid markers, highly sensitive and selective EV analysis methods using nanoparticles have recently been investigated ,76. NanoAntibody surface modification is the main strategy for targeting synthetic nanoparticles to cancer-related exosomal surface proteins. Aptamers, which are short sequences of artificial DNA or RNA that bind a specific target molecule, have been another choice owing to their smaller size and lower cost compared with those of antibodies. Binding of synthetic, functional nanoparticles to target exosomal surface proteins through these targeting moieties enables their effective capture and sensitive detection via nano size-derived functions.For example, LSPR-based detection of exosomal surface proteins utilizes the strong optical absorbance of plasmonic nanoparticles at a specific wavelength around the red color, which can be blue-shifted by their aggregation. Jiang et al. non-covalently coated gold nanoparticles (AuNPs) with a panel of aptamers that can specifically bind to exosomal surface proteins, i.e., CD63, EpCAM, PDGF, PSMA, and PTK7 . After m10–1011 times, enabling their sensitive detection at the single-molecule level. This phenomenon is called surface enhanced Raman scattering (SERS) and has also been used for exosomal surface protein detection. Li et al. developed Au-core/Ag-shell nanoparticles (Au@Ag NPs) modified with antibodies for the exosomal cancer protein marker, migration inhibitory factor, as SERS tags [−19 M. The developed SERS assay enabled the classification of pancreatic cancer patients and healthy individuals, metastasized tumors and metastasis-free tumors, and tumor node metastasis P1–2 stages and P3 stage.When metal nanoparticles bind to molecules, Raman scattering from the molecules is significantly improved by up to 10ERS tags . ExosomeIn addition to LSPR and SERS, other nano size-derived functions of synthetic nanoparticles have also been utilized for the analysis of exosomal surface proteins ,80,81,82While exosomal protein markers are mainly expressed on the cell surface, exosomal nucleic acid markers, including miRNAs, are encapsulated inside exosomes. Analysis of exosomal miRNAs usually requires RNA extraction, followed by amplification and detection of target miRNAs using the qRT-PCR method . Recent AuNPs exhibit strong quenching against a wide range of fluorophores via Förster resonance energy transfer (FRET) when they are close to the particle surface. Together with their large surface area to load signal amplification agents, AuNPs have been used as a platform for fluorescent detection of biomolecules, including exosomal miRNAs . Zhai etIn addition to direct labelling, amplification of fluorescent signals is a promising strategy for sensitive miRNA detection. Degliangeli et al. reported an AuNP-based fluorescent amplification and detection platform for cancer-related miRNA markers, miR-21 and miR-203 . AuNPs wIn addition to the above strategies, SERS and electric signals have been used for synthetic nanoparticle-based miRNA detection ,92. FurtAs mentioned above, EVs are prospective targets for cancer therapies and diagnostics. While the liquid biopsy-based analysis of EVs provides information for the origin and characteristics of cancer, the size and location of tumor are also important information for cancer therapy and diagnostics. In particular, for non-invasive cancer therapy methods, such as anticancer drugs and radiation, this monitoring information is important for evaluating the treatment effect. This information is also essential for the efficiency and safety of surgical procedures in the surgical therapeutic field. For achieving the accurate monitoring of tumor size and location, exogenous, synthetic nanoparticles can play important roles. In this section, we introduce synthetic nanoparticle-based in vivo imaging technologies for cancer therapy and diagnostics.To visualize formed tumors, molecular imaging has attracted much attention as a powerful technology for understanding cancer biological phenomena and medical applications as non-invasive diagnostic techniques. In particular, nanoparticulated imaging agents have been explored as versatile probes for molecular imaging because they have characteristic functions derived from their size and can be modified with ligands that are well-suited to target specific biomolecules. Numerous functionalized nanoparticles have been developed and proposed as imaging agents for various imaging modalities such as magnetic resonance imaging (MRI), X-ray computed tomography (CT), positron emission tomography (PET), and fluorescent imaging. Regardless of the modality, nanoparticulated imaging agents have demonstrated outstanding performance enabled by fine-tuning the nanoparticle size, surface properties, composition, and other characteristics.” have been approved by the Food and Drug Administration in the United States for liver cancer detection; however, a higher spatial resolution is required for a more accurate diagnosis. Furthermore, PET has emerged as a clinical imaging modality because of its advantages, including excellent penetration depth and quantitative capability. PET imaging via radiolabeled nanoparticles has improved PET contrast efficiency and accelerated the quantitative evaluation of drug delivery to tumors because of the reduced risk of radioisotope detachment [MRI, CT, and PET imaging technologies have been widely used as powerful tools for noninvasive diagnostic imaging because of their excellent penetration depths. Paramagnetic gadolinium (Gd) complexes have been commonly explored as MRI contrast agents, mainly for vascular visualization and brain tumor detection. Nanoparticulated Gd contrast agents improve the circulation time and target specificity; however, the relatively low relaxivity and high dose requirement are potential issues. Superparamagnetic iron oxide nanoparticles are expected to improve contrast efficacy compared to conventional Gd-based nanoparticles, which can be further tuned by adjusting the size and composition of the nanoparticles . Their utachment .Fluorescence imaging is also a powerful modality for molecular imaging because of its high spatial and temporal resolutions. Although many techniques for fluorescent imaging have been proposed as advanced modalities of molecular imaging with higher spatial resolution, these technologies face limitations in the detection limit due to restrained brightness and the inevitable photobleaching of small fluorescent molecules. To overcome these limitations, many studies have focused on developing nanoparticle-based fluorescent probes. Quantum dots (QDs) consisting of semiconductor nanocrystals have been reported as effective imaging probes for visualizing cellular membrane proteins and intracellular components . Althoug64Cu-labelled and RGD (Arg-Gly-Asp) peptide-conjugated iron oxide nanoparticles were developed as PET/MR dual-modality imaging probes for tumor integrin expression, whereas the near-infrared fluorescent (NIRF) dye ZW800 loaded with silica nanoparticles labelled with Gd ions and 64Cu was developed as PET/MR/optical imaging probe for tumor-draining sentinel lymph nodes [3+, and 64Cu [These imaging modalities have various advantages and disadvantages. For instance, MRI, CT, and PET have high penetration depths, however, their spatial resolution is limited to the millimeter scale. In contrast, fluorescent imaging has high spatial resolution at the subcellular scale, however, its penetration depth is limited to a few centimeters. To benefit from each advantage, multimodal imaging has generated considerable research interest in increasing the accuracy of diagnosis using complementary information from different imaging modalities . The fabph nodes . In addiph nodes . For exaph nodes , while Sph nodes . Furtherand 64Cu . In vivoand 64Cu . This tyAs previously mentioned, various nanoparticles have been developed and applied in cancer therapy, diagnostics, and imaging. As therapeutic methods using biomolecules  are expected in the field of cancer therapy, developing innovative technology to deliver these materials to a specific place in the body (DDS technology) is essential. DDS is a key technology for improving the therapeutic effect of drugs by optimizing the physicochemical properties of active pharmaceutical ingredients (APIs), improving pharmacokinetics, and targeting specific cells . CompareDDS is mainly achieved using two methodologies: chemical and biological approaches. Chemical approaches involve the use of chemical substances or synthetic nanoparticles to deliver drugs. Pharmacokinetics can be improved via chemical conjugation of the targeting moiety to the APIs or attachment of the polymers  to APIs. Synthetic nanoparticles, such as liposomes, inorganic materials, and polymer materials, have been used to encapsulate APIs for delivery. In contrast, biological approaches use biomolecules or biological vectors to achieve efficient delivery of APIs. Biomolecules or biological vectors are nanometer-sized particles, similar to other synthetic nanoparticles. Nanoparticles, such as viral vectors, are powerful tools for delivering genetic information of therapeutic molecules in the form of DNA or RNA. Currently, adeno-associated virus (AAV) vectors are used for gene therapy, adenovirus vectors are used as prophylactic vaccines against infectious diseases, and lentivirus or retrovirus vectors are used for ex vivo gene therapy, such as CAR-T cell therapy. Virus-like particles (VLPs) mimic the delivery mechanism of viral vectors; moreover, they avoid genetic materials; thus, they are safer than viral vectors and are not involved in gene insertion into target cells . More reIt is well known that biotechnology and bioengineering are central disciplines when developing a biological DDS. Using technical knowledge from these disciplines, the above biological DDS could improve existing biologics and develop novel therapeutic modalities. Engineering of existing viral vectors is an emerging topic, and several studies have shown that in vivo tropism and functionality of viral vectors can be designed. Ogden et al. analyzed the fitness of the AAV vector using a mutant capsid library and found that certain mutations in the capsid protein affected the biodistribution of recombinant AAV vectors. This machine-guided design is a powerful tool for the identification of mutant AAV vectors with favorable properties for in vivo gene therapy . Mihara In addition to the importance of functional modifications, mass-scale production is a critical issue in the development of biological DDSs. Although the production process of biologics has already been established, the production and purification of biological nanoparticles, such as viral vectors and EVs, remain challenging because of the complexity and difficulties of the purification and scale-up processes . GeneralNanoparticle-based biological DDS, such as biomolecules and biological vectors, are a promising platform for the delivery of cancer therapeutics. Owing to recent fundamental discoveries in biology, such as gene-editing technologies, biological DDS could deliver a novel type of therapeutics to the target site in the body. Therefore, biotechnology-based biological DDS is the foundation for next-generation cancer therapeutics.This brief review summarizes the current approaches to cancer therapy and diagnostics using biological nanoparticles generated by cells and other organisms (endogenous nanoparticles) and artificial nanoparticles generated by chemical synthesis and other methods (exogenous nanoparticles). For endogenous nanoparticles, we introduced EVs and DDS technology using virus vectors, which have attracted particular attention in recent years for cancer therapy and diagnostics.Recently, gene therapy for cancer treatment has been highly anticipated with the improvement of genome editing technologies such as CRISPR/Cas9. The treatment strategy using genome editing technologies is to attack target cancer cells by returning genome-edited T cells to the body. This genome editing is performed in vitro. On the other hand, RNA interference technology has also been expected for cancer treatment. This technology specifically suppresses gene expression with a short double-stranded RNA (siRNA) by degrading its sequence-specific target mRNA . To enha


In Finland, austerity measures included an increase in medication and healthcare copayments and a decrease in many social security allowances. This study examines whether austerity coincided with an increase in socioeconomic inequality in access to medications (going short of medications because of lack of money) and whether medication access problems increased more than other forms of economic hardship (going short of food or physician visits).Pooled cross-sectional population surveys collected in 2013–2015, 2018 and 2020 (n=139 324) and multinomial logistic regression, with interaction between study year and economic activity (EA) , were used to estimate the effect of EA on the probability of experiencing economic hardship (no hardship/hardship including medication problems/hardship excluding medication problems) and how it varies across years.Working-age adults outside full-time employment have a higher risk of economic hardship than full-time workers, and old age retirees have a lower risk. In 2018, when austerity was most pronounced, economic hardship including medication problems increased for the disabled/ill (women and men), unemployed (women) and part-time workers/retirees (men), significantly more than for full-time workers. Hardship excluding medication access problems either decreased or remained unchanged.Austerity coincided with increasing economic hardship among vulnerable groups, thus exacerbating socioeconomic inequalities. Strengthening the role for medication access problems suggests that medication copayment increases contributed to this accumulating disadvantage. Healthcare coverage restrictions, including increases in patient payments, were a common feature of austerity in Europe after the 2008 financial crisis.In Finland, austerity was most pronounced in 2015–2019, and it included increases in health payments, including medication copayments, and decreases of social allowances.The effects of policies related to health payments and cash transfers have been evaluated separately in the context of each subfield; thus, the complementary and cumulative effects could be unnoticed.This study examined patterns of economic hardship related to costs for medications in relation to other necessities (food and physician visits) by economic activity.The study found exacerbating socioeconomic inequities during pronounced austerity, with working-age individuals with disability/illness, unemployed women and part-time working/retired men becoming even more disadvantaged in relation to their counterparts in full-time employment.Individuals in these groups were more likely to experience economic hardship during pronounced austerity, and economic hardship was more likely to include medication affordability problems.Disadvantage increased most among groups that are likely to have been exposed to several austerity measures simultaneously .To balance sustainability issues and health policy goals, policy-makers should pay attention on the effects of various austerity policies that accumulate in vulnerable subgroups.As a response to the global financial crisis affecting European economies since 2008, the European Commission, European Central Bank and International Monetary Fund unanimously promoted austerity measures. In Finland, austerity was widely applied throughout the 2010s, particularly in 2015–2019.Healthcare and other in-kind transfers increase household economic resources.Coverage restrictions refer to policy changes that shift healthcare costs from third-party payers to the patients, including increases in direct payments. Restrictions may result in increasing income inequality and recommodification of healthcare; that is, making access more dependent on an individual’s ability to pay and market position.In previous research, unmet healthcare needs have typically been measured in relation to doctor visits or other services, disregarding that households’ health spending is often driven by outpatient medications.Finland offers an interesting case to examine the patterns of economic hardship. In 2015–2019, austerity policies simultaneously increased patient payments for medications and healthcare and decreased the replacement rate of many cash transfers. Medication copayments increased notably, and these increases mainly affected individuals with chronic illnesses. Previous studies revealed coinciding decrease in medication consumption and increase in economic problems.Finland is a Nordic European country with a comprehensive social security system, including universal access to healthcare and prescription medicines. Nevertheless, patient payments disproportionately burden poorer households, comprising mostly retired, disabled or long-term unemployed.During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill.In terms of tax benefit policies, the three governments that operated during the period differed in their approaches. During Prime Minister (PM) Katainen/Stubb’s tenure (2011–2015), expansionary tax benefit policies reduced the poverty risk rate.Nationally representative repeated cross-sectional population surveys were conducted by the Finnish Institute for Health and Welfare to monitor the health, well-being and service use of population groups in Finland, nationally and regionally.–iii) were ‘(a) no’ and ‘(b) yes’. Observations with missing data for all three questions were excluded.Economic hardship was measured using the following three questions: ‘Have you within the past 12 months ever: (i) feared that you will run out of food before you can get money to buy more? (ii) been unable to buy medicines because you did not have any money? (iii) not visited a doctor because you did not have any money?’ The response options for each question  and the study year. EA was used to define individual’s market position, thus distinguishing population subgroups by their reliance on redistributive welfare state policies. In the Finnish context, labour market attachment also determines access to occupational healthcare services. All analyses were stratified by sex, because of the known differences in healthcare needs and use patterns.To determine EA, the following question was used: ‘Are you currently mainly: (a) in full-time work; (b) in part-time work or part-time retired (hereafter: part-time work/retirement); (c) retired due to age (hereafter: old age retirement); (d) on disability pension or receiving rehabilitation benefit (hereafter: disability/illness); (e) unemployed or laid off (hereafter: unemployed); (f) taking care of children at home (hereafter: family); (g) student; (h) something else, what? (with free text field). Free text answers were assigned to classes a–g when possible. Individuals on sickness leave/allowance were classified under (d) because sickness allowance can be paid in case of short-term disability for up to 300 days, and it also applies to the unemployed. Individuals aged 69 years or older were classified as old age retirees (c).First, a multinomial logistic regression model was fitted by regressing financial hardship (no hardship/hardship including medication access problems/hardship excluding medication access problems) on EA categories and the study year. Because austerity was most pronounced in 2018, it was used as the reference category.Second, to test the interactive effect of EA and study year, the product term (EA×year) was added to the model. The average marginal effects (AMEs) of EA (reference: full-time work) were calculated for each year. To formally test whether the year modifies the effect of EA, the difference in AMEs between 2018 and other years was calculated, with a test of differences, which also serves as a test for interaction.The study population included all individuals with no missing data on the variables used in the analyses. Respondents whose EA did not fall into the afore-mentioned groups a–g were excluded. Men in class f (family) had very few observations per year; thus, they were also excluded.All analyses were conducted using Stata V.16.0 statistical software , using packages estoutThe study population consisted of 139 324 individuals; therefore, 5076  responses were excluded. The estimated proportion of individuals with at least one type of economic hardship was 20%–23% among women and 17%–18% among men . OverallConversely, all groups with working-age individuals partly or entirely outside full-time employment had a higher probability of reporting hardship than their counterparts in full-time work. In terms of medication access problems, individuals with disability/illness were particularly disadvantaged: they had 24–25 ppts higher probability of reporting such hardship, and 3–5 ppts higher probability of reporting other types of hardship. The unemployed had a relatively high probability of reporting any hardship; however, their experiences were less skewed towards hardship including medication access problems. Compared with full-time workers, they had 16–17 ppts higher probability of reporting hardship including medication access problems, and 10–12 ppts higher probability of reporting other types of hardship.Second, Next, interactive effects were examined, that is, whether patterns of economic hardship developed differently over time across EA groups. The predicted probabilities of respondents reporting no hardship, or hardship including or excluding medication access problems, by EA and year are presented 10.1136/jech-2022-219706.supp1Supplementary dataTo further test whether the difference in the AME of EA varied statistically significantly between year 2018 and the other years , Widening gaps in hardship including medication access problems were also observed for women and men with disability/illness , and men working/retired part-time . In these groups, the gap in the probability to experience hardship including medication access problems mostly widened, whereas the gap in the probability of experiencing other types of hardship remained relatively stable or even narrowed slightly. This indicates that the role of medication access problems strengthened.This study examined patterns of economic hardship by EA over time in Finland using five cross-sectional, nationally representative population surveys. The focus was on medication access problems and their interplay with other types of hardship. The year 2018 represented pronounced austerity, to which other years were compared. The study found that economic hardship including medication access problems tended to increase in 2018; however, overall differences between years were small. In specific groups, marked increases were observed. Among the unemployed, disabled/ill and part-time workers/retirees, who were disadvantaged in relation to full-time workers throughout the period, pronounced austerity coincided with increasing inequality. In 2018, hardship in these groups included medication access problems more frequently than in other years; thus, the role of medication access problems in hardship strengthened.Healthcare coverage restrictions during economic downturns are perceived harmful because they increase unmet needs and financial hardship, particularly among low-income households, exacerbating socioeconomic inequities in access and undermining financial protection.Older age and longer unemployment duration are also associated with increasing healthcare needs.Nevertheless, unemployed men seemed less sensitive to annual variations in economic hardship than unemployed women. However, overall unemployment was associated with an even higher risk of economic hardship among men than women. Women may have been more sensitive to health payment increases because of their higher service use and need. Based on previous evidence from Finland, unemployed women were more likely than unemployed men to use services overall, and they had different service use profiles. Women used primary healthcare physician and nurse services more commonly, as well as physiotherapist services, whereas men were more likely to use social services, mental health services and services related to substance abuse.Of note, the probability of economic hardship tended to remain stable or even slightly decrease in 2020 in many groups, despite the COVID19-pandemic. This may be because of, for example, lower consumption possibilities and targeted policy measures.Equal access to healthcare is an important aspect of the right to health.A few caveats need to be noted. First, the survey data represented the community-dwelling population; thus, institutionalised individuals who often have high health needs were not included. Second, despite the large sample size, the specific groups examined were relatively small, and weighting might not fully account for attrition. Third, the data were cross-sectional; thus, interpretations of causality between austerity measures and economic hardship remain speculative.Based on the results, austerity coincided with an increasing gap in the probability of economic hardship between full-time workers and individuals with disability/illness, unemployed women and part-time working/retired men. In these groups, the role of medication access problems in economic hardship also strengthened, suggesting that copayment increases contributed to the accumulation of disadvantages. Sensitive groups are likely to have been affected by several austerity measures simultaneously because many depend on (minimum) social transfers for income and have high healthcare needs. In terms of the policy objectives of increasing employment rates, decreasing health inequalities and ultimately increasing equality of opportunities, the implemented policies seem contradictory. Inequitable access to healthcare and necessary medications may hamper the pursuit of all possibilities in life, including employment.


Postpartum depression (PPD) is the most common psychiatric disorder following childbirth and is characterized by maternal mood disturbances, impaired maternal responses, and disrupted caregiving- all of which negatively impact offspring development. Since PPD has detrimental consequences for both mother and child, clinical and preclinical research has focused on identifying brain changes associated with this disorder. In humans, PPD is linked to dysregulated mesolimbic dopamine (DA) system function and altered neural responses  to infant-related cues, which are considered hallmark features of PPD. In accordance, rodent models employing translational risk factors useful for the study of PPD have demonstrated alterations in mesolimbic DA system structure and function, and these changes are reviewed here. We also present two novel rodent models based on postpartum adversity exposure  which result in PPD-relevant behavioral changes  and attenuated ventral tegmental area (VTA) DA neuron activity consistent with a hypodopaminergic state. Furthermore, we highlight open questions and future directions for these rodent models. In sum, human and rodent studies converge in showing blunted mesolimbic DA function  in PPD. We propose that reduced activity of VTA DA neurons, resulting in downregulation of the mesolimbic DA system, interferes with reward-related processes necessary for maternal motivation and responsiveness. Thus, the mesolimbic DA system may constitute a therapeutic target for ameliorating reward-related deficits in PPD. Postpartum depression (PPD) is the most common psychiatric disorder following childbirth in women  system, which is critically involved in reward-related and motivated maternal behaviors in both humans and rodents , which increases the risk for PPD in humans  and Wistar-Kyoto (WKY) rats  materials from PD 2 to 9  compared to control dams at PD 9–10, but not at PD 20–21 (~1.5 weeks after cessation of LBN). This decrease in the number of active DA neurons is proposed to attenuate the ability of DA neurons to respond to reward-related stimuli in a behaviorally salient phasic manner Grace, . Our finvia optogenetic stimulation increases FST escape-related behaviors  in rats and rescues stress-induced depression-related behavioral phenotypes  overlap with those observed in rodent models of chronic stress relevant to depression  pathway , which precipitates an enduring negative affect state in the rat dam involving passive stress coping, social anhedonia, and DA hypofunction. The second one consists of creating an impoverished home cage environment, which stresses the dam, disrupts mother-infant interactions, dampens maternal motivation, increases passive stress coping, and blunts DA activity. In sum, pup removal and scarcity-adversity are emerging rodent models useful for studying adversity-induced changes in the maternal brain relevant to PPD while also providing support for the possibility that VTA DA neurons (and the mesolimbic DA system) may represent a therapeutic target for ameliorating reward-related deficits in PPD. The presented body of work provides ample opportunities for future directions examining neurobiological mechanisms contributing to PPD as well as potential treatments and/or interventions to ameliorate the negative impact of PPD on the mother-infant dyad, which may lead to enhanced mother and infant outcomes.Clinical and preclinical studies show that PPD is associated with dysfunction within the brain’s reward pathway- the mesolimbic DA system. In rodent models, these alterations occur across multiple levels and include structural and functional plasticity, as well as basal and pup-evoked changes in concentrations of DA metabolites. Mesolimbic DA system changes in PPD rodent models are summarized in The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.MR-C conceived the idea for the manuscript and wrote the manuscript. AAG revised and provided feedback for the manuscript. MR-C and AAG edited and approved the manuscript for publication. All authors contributed to the article and approved the submitted version.