The health status of segregated Roma is poor. To understand why segregated Roma engage in health-endangering practices, we explored their nonadherence to clinical and public health recommendations.We examined one segregated Roma settlement of 260 inhabitants in Slovakia. To obtain qualitative data on local-level mechanisms supporting Roma nonadherence, we combined ethnography and systematic interviewing over 10 years. We then performed a qualitative content analysis based on sociological and public health theories.Our explanatory framework summarizes how the nonadherence of local Roma was supported by an interlocked system of seven mechanisms, controlled by and operating through both local Roma and non-Roma. These regard the Roma situation of poverty, segregation and substandard infrastructure; the Roma socialization into their situation; the Roma-perceived value of Roma alternative practices; the exclusionary non-Roma and self-exclusionary Roma ideologies; the discrimination, racism and dysfunctional support towards Roma by non-Roma; and drawbacks in adherence.Non-Roma ideologies, internalized by Roma into a racialized ethnic identity through socialization, and drawbacks in adherence might present powerful, yet neglected, mechanisms supporting segregated Roma nonadherence.The online version of this article (10.1007/s00038-018-1134-2) contains supplementary material, which is available to authorized users. The poor health status of segregated Roma represents the steepest and most persistent health inequalities in Central and Eastern Europe (CEE). Roma make up one of the largest ethnically outlined populations in Europe Crowe  with curWell exemplifying the situation elsewhere in CEE  do not allow questions on why many more Roma live at the lower end of the existing SEP gradients or how such positioning results in more adverse health-related practices to be answered , we selected a single segregated settlement with a growing population of approximately 260 people  on the outskirt of a village with a declining non-Roma population of about 530 . In 2004, approximately half of the Roma settlement’s inhabitants were children under age 15 years, and only 5 people were older than 60. In phase 2 (September 2004–October 2005), we obtained data on approximately 90 people belonging to one of the three then largest extended families in the settlement. In phase 3 (October 2005), we visited a sample of 10 of the settlement’s 48 households. The sample was representative according to the households’ social ranking , based on the combination of ascribed affluence and prestige, and kinship affiliations (to the three largest extended families). In these households, we interviewed 28 people, 22 of them adult women. Locally, men were considered less competent regarding health-related issues both by themselves and by women, and most of them also showed less interest in discussing health spontaneously. None of the people approached refused to participate in the interviews. Phase 4 follow-up observations and elicitations (November 2005–November 2014) were limited to approximately 15 Roma personally closest to the first author.The data consisted of field notes on direct observations and written and audio records of elicitations obtained during phases 2–4. We collected observations, spontaneous declarations and replies in elicitations regarding: why individual Roma did not adhere to selected clinical and public health recommendations—as data on reasoning for nonadherence; what experiences individual Roma considered important for their adoption of such pro-nonadherence reasoning—as data on the adoption of pro-nonadherence reasoning; and how and what local circumstances supported the recurrence of such contributing experiences and nonadherence practices—as data on local-level supporting mechanisms.To gain data specifically and exhaustively on contemporary clinical and public health recommendations, an encyclopaedic practitioner’s handbook covering both clinical and public health knowledge and recommendations was used throughout all phases of the study to guide observations and elicitations in terms of topics . In the last section, we describe how these mechanisms mutually supported each other.The Roma settlement was trans-generationally extremely poor, segregated both socially and physically from the local non-Roma village and had substandard infrastructure. This directly supported the adopting of pro-nonadherence reasoning by Roma youth, as it contributed to their frequent failures of adherence, and because some aspects of the setting were experienced by the youth as significantly positive. For instance, when trying to adhere to medication advice, young families experienced an inability to cover costs of medications due to low income, to understand clinical recommendations due to substandard education, to preserve documentation on their diseases due to a lack of personal storage space, etc. Yet, to illustrate their perceived positive experience of this setting, young people found that the segregated housing setup (yards shared by extended families outside the non-Roma village) enabled convenient child supervision .The setting directly supported nonadherence practices via a constant lack of means for adherence and a constant availability of means for local alternatives to adherence. Except for the highest ranked families, Roma lacked the income, information and infrastructure necessary to maintain “outside” (i.e. non-Roma) standards of personal healthcare . Meanwhile, the substandard infrastructure and spatial segregation enabled unhealthier ways of provision of, e.g. heating , water, electricity  and waste disposal (unsanctioned garbage piles).The dominant views in the settlement claimed the general or relative  inappropriateness for Roma of adherence to alleged outside standards. Such inappropriateness was typically framed in racialized and gendered ethnic terms quoting outdated racist expert concepts. This directly supported Roma youth in adopting pro-nonadherence reasoning by presenting appealing interpretations of standard local experiences with adherence failures, adherence and nonadherence. For example, youth interpreted some of the adherence failures they experienced as being due to their personal incapacities  as results and proofs of “natural Roma/Gypsy” collective bodily incapacity, quoting allegedly specific Roma biology .Based on experiences and dominant local interpretations of them, youth in the settlement gradually adopted practical reasoning that favoured local alternatives over outside standards. Adoption of pro-nonadherence reasoning formed an integral part of this contrastive mode of socialization: youth lacking appropriate means to adhere and being exposed to dominant local self-exclusionary views and misinformation gradually resigned and became adults who lacked the means and motivation needed to adhere. The socialization directly supported local nonadherence practices by generating adults prone to practice and further develop rather local alternatives to adherence regarding their health problems in general.Most adults in the settlements appraised, practiced and developed standards understood as more appropriate alternatives to alleged outside standards. The better appropriateness of such standards for Roma was typically framed in racialized and gendered ethnic terms in line with local self-exclusionary ideologies. Relatively riskier health behaviours and a less attentive approach to their own health formed an integral part of such alternative practices.This approach directly supported Roma youth in adopting pro-nonadherence reasoning by generating direct negative experiences with pro-adherence experiments and positive experiences with Roma alternatives to adherence. For example, youth witnessed their parents’ frequent failures to adhere to clinical recommendations. Simultaneously, they experienced some aspects of Roma alternatives to clinical recommendations as advantageous .Local non-Roma typically lacked information regarding most aspects of everyday life in the Roma settlement and expressed beliefs that Roma were naturally unable to maintain non-Roma standards. To support the latter, they quoted outdated expert concepts and personal experiences with deliberate Roma nonadherence practices. Such perspectives mostly supported Roma youth and early adolescents in adopting pro-nonadherence reasoning indirectly, by inspiring Roma self-exclusionary ideologies. Such views also indirectly supported Roma alternative practices via consequent non-Roma discrimination, racism and dysfunctional support for Roma (see below).Local non-Roma often acted towards the Roma in a discriminatory and racist manner. Moreover, even sincere local non-Roma attempt to provide support to Roma, typically drawn implicitly on racist or otherwise misinformed concepts, usually lacked practical functionality. Such approaches directly supported the adopting of pro-nonadherence reasoning by Roma youth by contributing to their experiences of related adherence failures. Examples of discrimination are that the Roma youth experienced longer waiting times as well as racist slurs from personnel. An example of dysfunctional support is that a public hygienic centre was installed in the settlement by the local municipality without consulting the local Roma. It then went ignored by the Roma community because it was impractical and ugly.The restrictive aspects of clinical and public health recommendations were mostly considered by the Roma as inherently conflicting with a “good life”, typically framed in racialized and gendered ethnic terms in line with the dominant local Roma self-exclusionary ideologies and misinformation. Such aspects directly supported Roma youth in adopting pro-nonadherence reasoning by labelling adherence as disadvantageous. For example, Roma youth found some clinically successful experiments with adherence (e.g. proper management of chronic diseases via dietary restrictions) to lead to too significant losses in terms of the quality of life that “real Roma” could and should prefer.The identified mechanisms formed an interlocked system, as schematically summarized in Fig. The Roma situation of poverty, segregation and substandard infrastructure directly supported Roma self-exclusionary ideologies and misinformation by generating a lack of experience with and information on outside standards. For example, the Roma were unaware that racist expert theories about Roma “natural incapacities” were outdated. They further lacked experience in how under different circumstances some adherence practices can become compatible with high-quality life according to their criteria. This setting also directly supported non-Roma anti-Roma ideologies and misinformation. For instance, due to segregation, non-Roma locals lacked experience and information on the efforts that Roma had to make regarding personal healthcare and the constraints that they faced.Roma socialization for their situation directly supported the Roma self-exclusionary ideology and misinformation by raising adults who contributed further to the trans-generational transfer of such perspectives. For example, adults would mock and ridicule youth experiments with adherence as “too non-Roma like”, “unnatural for Roma”, “too feminine”, etc.Roma alternative practices directly supported the Roma situation of poverty, segregation and substandard infrastructure, as they included the active maintenance of existing settings. For instance, adult Roma kept investing in and repairing the substandard local infrastructure. Roma alternative practices also directly supported the non-Roma in maintaining their anti-Roma ideologies and misinformation, as the non-Roma frequently observed deliberate Roma failures to adhere .Anti-Roma ideologies and misinformation among non-Roma directly inspired the self-exclusionary ideologies of Roma. For instance, in their own racialized explanations of Roma nonadherence, Roma would often quote the racist “expert” views of non-Roma. Such perspectives also directly supported non-Roma discrimination, racism and dysfunctional support, as they provided a seemingly reasonable rationale for such practices. For example, local non-Roma professionals would often quote misinformed knowledge  or racist assumptions  when justifying their own standard of not consulting the Roma themselves. In turn, this non-Roma discrimination, racism and dysfunctional support directly contributed to the Roma situation of poverty, segregation and substandard infrastructure .The drawbacks in adherence directly supported the Roma self-exclusionary ideology and misinformation by presenting arguments against adherence. For instance, Roma proponents of nonadherence to outside standards would often quote their personal negative experiences with restrictive aspects of adherence as their reasons for nonadherence .In our study, we explored local-level mechanisms supporting segregated Roma nonadherence to clinical and public health recommendations. We identified seven such mechanisms: the Roma situation of poverty, segregation and substandard infrastructure; Roma socialization into their situation; the perceived value of Roma alternative practices; exclusionary non-Roma and self-exclusionary Roma ideologies; discrimination, racism and dysfunctional support towards Roma by non-Roma; and drawbacks in adherence. We found that these mechanisms formed an interlocked system controlled by and operating through both local Roma and non-Roma.We found Roma nonadherence practices were being directly supported by non-Roma practices of discrimination, racism and dysfunctional support as well as by the Roma situation of long-term multi-dimensional segregation. This matches previous research well. Janevic et al.  distinguWe found that discrimination and segregation steadily generated frustrating experiences for Roma youth, which significantly contributed to the formation of adult Roma identities leaning towards deliberate and proud development of practices alternative to adherence. Previous research on the negative effects of discrimination and segregation on health-related practices has typically focused on processes working as direct everyday constraints to healthier behaviours, regarded as such also by members of the negatively affected minorities themselves Below is the link to the electronic supplementary material.


Skeletal metastases present a major challenge for clinicians, representing an advanced and typically incurable stage of cancer. Bone is also the most common location for metastatic breast carcinoma, with skeletal lesions identified in over 80% of patients with advanced breast cancer. Preclinical models have demonstrated the ability of mechanical stimulation to suppress tumour formation and promote skeletal preservation at bone sites with osteolytic lesions, generating modulatory interference of tumour-driven bone remodelling. Preclinical studies have also demonstrated anti-cancer effects through exercise by minimising tumour hypoxia, normalising tumour vasculature and increasing tumoural blood perfusion. This study proposes to explore the promising role of targeted exercise to suppress tumour growth while concomitantly delivering broader health benefits in patients with advanced breast cancer with osteolytic bone metastases.This single-blinded, two-armed, randomised and controlled pilot study aims to establish the safety, feasibility and efficacy of an individually tailored, modular multi-modal exercise programme incorporating spinal isometric training (targeted muscle contraction) in 40 women with advanced breast cancer and stable osteolytic spinal metastases. Participants will be randomly assigned to exercise or usual medical care. The intervention arm will receive a 3-month clinically supervised exercise programme, which if proven to be safe and efficacious will be offered to the control-arm patients following study completion. Primary endpoints  and secondary endpoints  will be measured at baseline and following the intervention.Exercise medicine may positively alter tumour biology through numerous mechanical and non-mechanical mechanisms. This randomised controlled pilot trial will explore the preliminary effects of targeted exercise on tumour morphology and circulating metastatic tumour biomarkers using an osteolytic skeletal metastases model in patients with breast cancer. The study is principally aimed at establishing feasibility and safety. If proven to be safe and feasible, results from this study could have important implications for the delivery of this exercise programme to patients with advanced cancer and sclerotic skeletal metastases or with skeletal lesions present in haematological cancers (such as osteolytic lesions in multiple myeloma), for which future research is recommended.anzctr.org.au, ACTRN-12616001368426. Registered on 4 October 2016.The online version of this article (10.1186/s13063-018-3091-8) contains supplementary material, which is available to authorized users. Bone metastases are generally incurable and clinically problematic, yet are present in over 80% of patients with advanced breast cancer , 2, reprChemotherapy, hormone therapy, radiotherapy and anti-resorptive medications are the primary therapeutic agents used in breast cancer palliation to delay disease progression, alleviate bone pain and associated symptoms, preserve skeletal integrity and extend survival –32. WhilBone is highly adaptive and osteogenically sensitive to its mechanical environment, principally through muscular contraction of neighbouring muscle, but also from impact and gravitational forces acting upon the skeleton during human movement and from external loads , 38, 39.Human clinical trials have yet to be implemented in this space, owing to a historical and misplaced belief that patients with advanced cancer and bone metastases should be excluded from exercise programmes and synonymous research due to increased risk of skeletal complications or other potential adverse events –54. FormGiven that bone metastases remain one of the leading causes of breast-cancer-related deaths worldwide, additional and novel interventions to target osteolytic lesions in skeletal tissue are highly clinically relevant. Expanding on our prior work, the aim of this study is to (1) assess the safety and feasibility of a supervised and individually tailored resistance, aerobic and flexibility exercise programme that includes targeted spinal isometric training in patients with advanced breast cancer and osteolytic bone metastases; (2) explore the preliminary efficacy of the exercise programme to slow tumour growth and tumour biomarker activity in target osteolytic spinal lesions and (3) examine the broader efficacy of the exercise programme to preserve muscle and bone mass, improve physical fitness, enhance physical function, reduce cancer-related fatigue and increase quality of life. It is the working hypothesis of this study that the exercise programme will be safe and feasible; will show signs of tumoural suppression and/or favourable alterations in tumour biomarkers; and will lead to positive physical and psychosocial outcomes for patients. If successful, the outcomes of this trial will be used to improve clinical knowledge pertaining to exercise prescriptions for patients with advanced cancer who have metastatic carcinomas and high disease burden, and will be used as a foundation for future phase II and phase III efficacy-focused human clinical trials to establish the anti-cancer effects of exercise. It is anticipated that this new information will aid in the establishment and/or renewal of clinical exercise guidelines for the management of cancer across the disease spectrum.This single-blinded , two-armed, randomised and controlled  explorative clinical trial will examine the feasibility, safety and preliminary efficacy of combining targeted spinal isometric training with modulatory, multi-modal exercise (M3EP-SIT) in women with advanced breast cancer and stable osteolytic spinal bone metastases. The exercise group (intervention arm) will receive an individually tailored and supervised 12-week exercise programme involving resistance, aerobic, flexibility and isometric exercises in addition to usual medical care. The control group will receive usual medical care only during this time and will be asked not to change their baseline levels of physical activity. However, following the trial, the control group will be offered the same exercise programme if proven to be safe and efficacious. This procedure has been shown to be an effective strategy to minimise study contamination, patient withdrawal or loss of patients to follow up in prior exercise oncology trials , 64–68.Patients will be recruited by invitation of their cancer specialist  who will provide clinically eligible patients with a study information sheet and refer these patients to an independent study coordinator. If patients are interested in participation and their eligibility is confirmed, they will receive an informed consent document to read and sign in the presence of a study investigator and clinical research coordinator before undertaking baseline measurements prior to randomisation Fig. .Fig. 1ScPatients will be randomly allocated in a ratio of 1:1 to the two study arms: exercise or usual care, stratified by age , hormone receptor (HR) status   and timen = 20; control, n = 20).A total of 40 women (20 subjects per arm) with breast cancer and stable osteolytic bone metastases in cervical, thoracic and/or lumbar vertebrae will be invited to participate. They will be included if they have not engaged in regular exercise in the past 3 months (defined as undertaking structured aerobic and/or resistance training two or more times per week). Due to the novelty of this explorative clinical trial, our sample size is based on previous preclinical animal studies , 70–72, Patients are permitted to receive radiotherapy for non-spinal bone metastases while enrolled in this trial. Patients require medical clearance prior to enrolment, therefore must achieve an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1, and must not have any acute illness, significant bone pain or cardiovascular or neurological disorders that could inhibit exercise participation as judged by their managing physician. All participants must provide written informed consent prior to participation. Patients will be excluded from this trial if they are receiving experimental treatments. The protocol has been approved by the Human Research Ethics Committee (HREC) of Edith Cowan University (ECU), Project ID 14266 NEWTON; St John of God Hospitals (SJOG), Project ID 969 and Sir Charles Gairdner and Osborne Park Health Group (SCGOPHG), Project ID 2016–118. This trial is also registered with the Australia and New Zealand Clinical Trails Register (ANZCTR), Trial ID ACTRN-1261600136842.Primary and secondary endpoints will be measured at baseline (week 0), post-intervention week 13) and through-out the 12-week on-trial period  and by recording post-session rating of perceived exertion  and post-session tolerance  after each exercise session. Programme adherence and compliance will be assessed using an exercise diary completed by the patient at all clinic-based and home-based exercise sessions to record volume of resistance training (weight lifted (kilogrammes), sets and repetitions), aerobic training (intensity (level), duration (minutes), speed (revolutions per minute), heart rate (maximum and average) and rating of perceived exertion), flexibility training (repetitions and hold time (duration)) and isometric training (repetitions and hold time (duration)) completed. These data will be compared to the prescribed and individualised exercise programme provided to each patient in order to establish programme adherence (completed versus missed sessions) and compliance ).Location of metastatic lesions will be initially identified through bone scans provided by the managing oncologist prior to referral to this study. Tumour morphology will be measured using axial T1-weighted magnetic resonance imaging (MRI)  in locations where osteolytic lesions have been identified in patients with bone metastases at either thoracic or lumbar spinal regions –78. All Primary scans of each affected vertebra will be performed in the transverse plane, capturing the vertebrae above and below to produce an image with three vertebrae in total . Following the acquisition of images, tumour morphology (volume (cubic millimetres) and intensity (watts per steradian (W/sr))) will be examined for each slice using ITK-Snap (V3.6.0) image analysis software  Metastatic tumour biomarkers, hypoxia-inducible factor 1-alpha (HIF-1α) and transformation growth-like factor beta (TGF-β) will be serologically examined to measure tumoural hypoxic activity and growth activity respectively; identified as synergistic drivers of metastatic tumour progression , 80–84. 2). Waist and hip circumferences are defined as the mid-point between the 10th rib and the iliac crest and the level of the greater trochanter, respectively, with the waist-to-hip ratio calculated. Femoral length will be measured from the greater trochanter to the knee-joint axis and tibial length will be measured from the knee-joint axis to the medial malleolus. Waist circumference, hip circumference, femoral length and tibial length will be measured to the nearest 0.1 cm using a constant-tension, retractable measuring tape . Stature, waist circumference and hip circumference will be measured in triplicate in each participant, with the average of each variable retained for analysis.Stature will be recorded to the nearest 0.1 cm using a wall-mounted stadiometer , with body mass recorded to the nearest 0.1 kg using an electronic scale , with body mass index (BMI) calculated as weight divided by height in metres squared  and regional  scans will be performed to examine bone area (BA), areal bone mineral content (aBMC), areal bone mineral density (aBMD) and lean mass using dual-energy x-ray absorptiometry . Whole-body and appendicular segmentations will be analysed in accordance with Hart and colleagues . RegionaAppendicular, non-lesion control sites will be scanned to quantify bone material, structure and strength using peripheral quantitative computed tomography . Specifically, trabecular, cortical, marrow and total volumetric density ; trabecular, cortical, marrow and total cross-sectional area ; cortical thickness (Ct.Th); stress-strain index (SSIPOL); absolute fracture load (FL.Ab) and relative fracture load (FL.Rel) of the left femur (4% and 33% slices) and left tibia  will be measured and analysed in accordance with Hart and colleagues , 88. MusWhole-body, segmental and central subcutaneous adipose tissue (fat mass), central visceral adipose tissue  and android-to-gynoid ratio will be measured using DXA. Whole-body and appendicular segmentations will be generated in accordance with Hart and Colleagues . Fat areMuscle strength, aerobic capacity and physical function will be assessed. Muscle strength will be measured using the one repetition maximum (1RM) test for the leg extension exercise. This exercise was chosen as it can be safely performed by all patients included in this study. The 400 m walk test and Timed Up and Go test will be used as measures for aerobic capacity and physical function, respectively. In addition, patients will also undergo a comprehensive balance test .Health-related quality of life outcomes for general health, pain, vitality, social functioning, emotional role and mental health will be measured using the Short Form 36  survey. In addition, the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire, Module 3 (QLQ-30) (cancer) and EORTC Breast Cancer, Module 23 (BR-23) surveys will also be provided to measure cancer-specific indices of quality of life. The FACIT Bone Pain (FACIT-BP) questionnaire will be used to examine bone pain, and the Brief Symptom Inventory (BSI-18) will be used to assess psychological distress for the anxiety, depression, somatisation and global distress severity domains. The Insomnia Severity Index (ISI) will be used to measure sleep quality disturbance, and the Godin Leisure-Time Exercise questionnaire will be applied to examine self-reported physical activity levels.Participants assigned to the exercise arm will be required to participate in a modular, multi-modal exercise programme M3EP), which includes spinal isometric training (SIT) for 12 weeks. The combined M3EP-SIT programme requires participants to attend three clinic-based exercise sessions each week spanning 60 min in duration (including warm up and cool down), supervised by an accredited exercise physiologist . Participants will also be asked to perform the SIT portion of the programme during two additional home-based exercise sessions each week spanning 15 min in duration. During combined M3EP-SIT sessions, spinal isometric training will be provided first, followed by the modular multi-modal exercise programme  through muscular contraction, thus isometric exercises have been designed to activate the full spinal column due to the commonality of lesions in cervical, thoracic and lumbar regions, the feasibility of which has been demonstrated . The SITt test and two-way (group × time) repeated measures analysis of variance (ANOVA)  to examine differences between groups over time. Any data that are not normally distributed will be log-transformed or non-parametric tests will be used. The Pearson chi-square test will be used to analyse categorical variables. An alpha level of p ≤ 0.05 will be applied to establish statistical significance. Effect sizes will also be calculated in accordance with Hopkins [d ≥ 0.2 is small; d ≥ 0.6 is moderate; d ≥ 1.2 is large; d ≥ 2.0 is very large. Incomplete data and missing values will be primarily managed using an intention-to-treat approach [Data will be analysed using SPSS . Normality of distribution of continuous variables will be determined by Shapiro-Wilk test and visual inspection of the data. Analyses will include standard descriptive characteristics, the  Hopkins : d ≥ 0.2approach  with mulapproach , 93 willDemonstrating the feasibility and safety of delivering targeted exercise  to skeletal sites with osteolytic lesions in patients with advanced cancer will lead to potential changes in clinical practice. Accordingly, if proven to be safe and feasible, the outcomes of this pilot study will form the basis of future phase II and III clinical trials to establish efficacy; will be published in high-impact peer-reviewed journals; will be presented at national and international conferences or research meetings and will be delivered to the community, consumer-led forums, local hospital departments and university seminars. Evidence from this pilot study may contribute to the renewal of current clinical exercise oncology guidelines for patients with cancer, specifically those in the advanced stages with a high disease burden, within national and international exercise and oncology associations.Last, the National Breast Cancer Foundation is a charitable organisation dedicated to improving patient outcomes for women and men with breast cancer. As the funder of this pilot study, the National Breast Cancer Foundation will assist with disseminating study outcomes through their extensive clinical, academic and consumer networks nationally. Similarly, the Cancer Council of Western Australia is the premier cancer charity in Western Australia, with wide-reaching connections to clinicians, academics, cancer survivors and their families, and will also assist in disseminating study outcomes through their state-wide networks.The Exercise Medicine Research Institute engages consumer representatives (patients with cancer and their families) throughout the conceptual design and development of its research programme to ensure all research questions directly address the needs of patients , including the engagement of prospective trial participants in a respectful, ethical and impactful way. During the development of this study protocol, authors NHH and RUN presented at national and state breast cancer meetings to patients and clinicians and sought feedback to confirm and optimise the study design. The National Breast Cancer Foundation (the funder of the study), and other cancer charities and associations  will assist in the dissemination of findings to their cancer support groups and the general public. Study participants will receive their individual results at the conclusion of their involvement and overall study results at the conclusion of the study.The research team of this study protocol includes a surgical oncologist (CS), radiation oncologists  and medical oncologists  who work with the target population on a daily basis, from which patient priorities, experiences and preferences gleaned from this engagement helped inform the development of the research questions and outcome measures. Last, the broader research team  have conducted research studies in exercise oncology involving a large number of patients over the course of the past 15 years, where participants have provided feedback to investigators to help design feasible, safe and effective exercise oncology clinical trials. This sizeable interaction across the clinical and community landscape contributed substantially to the design of this project.Complications arising from bone metastases present a major clinical issue for patients and clinicians alike , with boExercise medicine may positively alter tumour biology through numerous mechanical and non-mechanical mechanisms targeting local, neighbouring and systemic pathways in response to various modes and dosages of activity , 136. SpCompelling new insights from metastatic orthotopic animal models demonstrate the ability of mechanical stimulation  to interfere with tumour-driven remodelling in skeletal tissue containing human breast cancer cells , 41. ExeAccordingly, this study is our evaluation of the feasibility, safety and preliminary efficacy of a modular, multi-modal exercise programme, coupled with spinal isometric training, to provide a non-invasive, low-cost, innovative and scalable therapy in the management of advanced breast cancer. Examination of the modulatory potential of direct and targeted mechanical loading of osteolytic spinal bone metastases will also be conducted by quantifying tumour morphology and systemic activity of metastatic biomarkers , whilst also exploring whether targeted exercise can reduce bone pain, preserve neighbouring skeletal mass and structure (i.e. unaffected vertebrae above and below affected lesion sites) and reduce or avoid exacerbation of bone pain. Additionally, this study will also examine the multifaceted and broader effects of exercise participation by patients with advanced breast cancer on muscle and bone health (mass and strength), adiposity , physical fitness and function and psychosocial health .Outcomes of this study will inform future research into sclerotic, osteolytic or mixed lesions across solid and haematological malignancies (such as multiple myeloma), particularly in patients with cancer and extensive or widespread bone metastases and high disease burdens who would otherwise be contraindicated for exercise. Optimistically, the generalisability of this exercise programme across models seems achievable, given it is supervised, individualised and tailored to each patient’s unique condition, and thus auto-regulated accordingly , 51. TheAdditional file 1:Floor-based, spinal isometric exercise library for patients with prostate cancer and spinal bone metastases, to cater for varying physical capabilities and training progression rates. (PDF 554 kb)Additional file 2:Seated and standing, spinal isometric exercise library for patients with prostate cancer and spinal bone metastases, to cater for patients unable to perform floor-based exercises. (PDF 511 kb)Additional file 3:Photographic examples of prone (left) and supine (right) floor-based spinal isometric exercises, illustrating the start position and final hold positions of each labelled exercise to assist exercise physiologists and patients with cancer. The patient shown has signed a media release consent form. (PDF 923 kb)Additional file 4:SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents. (DOCX 51 kb)


Over 75% of individuals are exposed to a traumatic event, and a substantial minority goes on to experience mental health problems that can be chronic and pernicious in their lifetime. Early interventions show promise for preventing trauma following psychopathology; however, a face-to-face intervention can be costly, and there are many barriers to accessing this format of care.The aim of this study was to systematically review studies of internet-delivered early interventions for trauma-exposed individuals.A literature search was conducted in PsycINFO and PubMed for papers published between 1991 and 2017. Papers were included if the following criteria were met: (1) an internet-based intervention was described and applied to individuals exposed to a traumatic event; (2) the authors stated that the intervention was intended to be applied early following trauma exposure or as a preventive intervention; and (3) data on mental health symptoms at pre-and postintervention were described (regardless of whether these were primary outcomes). Methodological quality of included studies was assessed using the Downs and Black checklist.selected  or indicated . Selected interventions did not produce significant symptom improvement compared with treatment-as-usual or no intervention control groups. However, indicated interventions yielded significant improvements over other active control conditions on mental health outcomes.The interventions in the 7 studies identified were categorized as Consistent with the notion that many experience natural recovery following trauma, results imply that indicated early internet-delivered interventions hold the most promise in future prevention efforts. More studies that use rigorous methods and clearly defined outcomes are needed to evaluate the efficacy of early internet-delivered interventions. Moreover, basic research on risk and resilience factors following trauma exposure is necessary to inform indicated internet-delivered interventions. The typrecovery -4. Althorecovery . These irecovery . The purAlthough natural recovery is expected for most trauma-exposed individuals, trauma experts recommend that mental health professionals should not wait to provide care until problems are chronic and purport the value of early preventive interventions . The InsUniversal intervention delivered before trauma exposure has been argued to be infeasible and too costly. However, as compared with other mental health disorders that have a prodromal phase  or a waxing and waning course , disorders that have an onset subsequent to trauma exposure  have a clear onset, providing a unique window for selected or indicated prevention. Following a traumatic event, individuals may present to emergency rooms or be seen by health care providers, and these circumstances are opportune for the provision of intervention . In lighReviews of early interventions for trauma-exposed individuals demonstrate that efficacy varies across modalities. The literature consistently contraindicates psychological debriefing as an intervention following trauma ,11,13. IResearch suggests that internet-based interventions are feasible  and effiA search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement . The litTwo reviewers (NE and IS) screened identified abstracts and titles to identify full-text studies. Due to the nascency of internet-delivered interventions, and to review all available early posttrauma interventions, inclusion criteria were broad and not limited to controlled trials. Papers were included if the following criteria were met: (1) an internet-based intervention was described and applied to individuals exposed to a traumatic event; (2) the authors stated that the intervention was intended to be applied early following trauma exposure or as a preventive intervention; and (3) data on mental health symptoms at pre- and postintervention were described (regardless of whether these were primary outcomes). Internet-based interventions were defined as interventions delivered online via a computer or mobile phone platform. The terms internet-based and Web-based were used synonymously to describe such interventions. Papers that described stepped care interventions whereby 1 aspect of a broader intervention involved an internet-based intervention were included .Papers were excluded if (1) the intervention was delivered via the telephone or videoconferencing ; (2) an r=.88), inter-rater reliability (r=.75), and internal consistency (Kuder-Richardson formula 20=.89) of the checklist are good [A total of 2 raters  evaluated the methodological quality of each included empirical study  using the Downs and Black Checklist . This chare good . Higher After screening for relevance, full papers were examined. Data on the intervention, sampling, recruitment, methodology, and design were extracted from all included studies. Data on mental health outcomes at pre- and postintervention as well as longer-term follow-up, if available, were extracted . Any measures of mental health symptoms  were reviewed, given the range of psychological responses that individuals might experience after trauma. Results from intent-to-treat analyses and completer analyses were extracted. Interventions were coded as “selected” or “indicated.” Selected interventions were defined as interventions that were delivered to the entire sample, regardless of whether or not they endorsed mental health symptoms. Interventions were coded as indicated when delivered only to participants endorsing cut-off criteria of mental health symptoms.Database searches yielded a total of 2346 articles. Review of reference lists of relevant articles yielded an additional 15 papers. Abstracts and titles were screened for inclusion. A total of 7 articles were included in the review based on selection criteria see . The mosDescriptions of interventions are provided in zapped.Each of the 7 interventions described were based on cognitive and behavioral principles. Moreover, 3 interventions were completely self-guided and consisted only of self-help psychoeducational materials ,30,31. OOne intervention  was a stThe included studies are described in Across studies, participants were recruited from hospital emergency departments, intensive care units or surgical wards ,27,31,32Bounce Back Now intervention as compared with the assessment-only control group at 12-months postbaseline.With regard to outcomes, in controlled studies of selected interventions , the interventions were not better than control conditions in reducing mental health symptoms. Means of outcome measures for intervention and control groups are reported in The Bounce Back Now intervention is a combination of selected and indicated prevention wherein all participants had experienced trauma and were enrolled regardless of symptom presentation. However, within the intervention, modules were indicated based on participants’ symptomatology .My Disaster Recovery intervention endorsed significantly greater reduction in worry over time as compared with the groups receiving online information only and the intervention-as-usual group. No significant differences among intervention conditions were found for symptoms of depression, PTSD, perceived stress, or coping self-efficacy. Van Voorhees et al’s [at-risk for posttraumatic stress  and for baseline to 12 weeks (d=−0.68) for those at-risk, in favor of the intervention group. Small effect sizes were found for those not-at-risk between baseline to 6 weeks (d=−0.15) and for baseline to 12 weeks (d=−0.24).In the 3 studies in which interventions were indicated ,28,29, s et al’s  found si et al’s  conductem Scale; ) from thearly internet-delivered interventions for trauma-exposed individuals. The lack of research on internet-based interventions following traumatization is interesting, given the potential low cost and wide-reaching impact of such prevention efforts.The aim of this paper was to systematically review the literature on studies of internet-delivered early interventions for trauma-exposed individuals. Although previous reviews have identified numerous internet-delivered interventions for PTSD  and otheThe quality of the included studies ranged from fair to good. Studies were generally not adequately powered to detect differences. In addition, most studies did not employ gold standard clinician-administered assessments and lacked long-term follow-up data. The objectives of studies varied as mental health symptoms were not the primary outcome of interest in several studies ,32, and early interventions, given the time elapsed since trauma, and therefore, findings may not represent the value of early interventions or be generalizable to individuals recently exposed to trauma. In addition, given that the trajectory of change in posttraumatic distress is most robust in the first 3 months following trauma exposure [Despite the authors of these included studies describing the interventions as preventive or early interventions, the time since trauma varied widely across studies. For example, Van Voorhees et al’s  intervenAlthough limited conclusions can be drawn about the effects of the interventions because of the varied study quality and potential problems with timing of delivery in the included studies, a pattern emerged whereby interventions that were indicated (as compared with selected) tended to yield more promising results. In these studies, greater symptom improvement was found in intervention groups compared with controls. Interestingly, Kassam-Adams et al  providedAlthough data from this review and theory support that indicated interventions may be superior to selected early interventions, the potential for sampling bias across these types of interventions should be considered. For example, in over half of the included studies, the proportion of those who were approached to participate compared with the number who agreed was not reported, and no information was provided on how participating individuals might have differed from those who declined to participate. In indicated interventions, participants present with mental health symptoms. Individuals who self-select for a study and agree to participate may have more awareness of their symptoms and potentially more motivation for intervention, and this may contribute to better outcomes than studies of selected interventions. It is possible that stigma-related biases might render trauma-exposed individuals more likely to agree to participate in selected interventions where all individuals are given the intervention, regardless of whether they demonstrate natural recovery. Sampling bias must be considered when comparing outcomes across selected and indicated interventions, and reported in future studies.Underscoring the importance of indicated over selected intervention, Feldner et al  hold thaAlthough the current data point to the potential benefits of indicated interventions, finding out whether users find them acceptable and sustainable and how far-reaching the interventions were is arguably as important as it is to ascertain whether the interventions are effective . Data provided on accessibility, sustainability, and reach differed across studies when reported, with the majority not demonstrating far reach, given that the design was a pilot study. For example, Kassam-Adams et al  found thFindings highlight several areas for future investigation. More research is needed before conclusions can be drawn about the efficacy and cost-benefit analysis of selected versus indicated prevention. The most common methodological weaknesses across the studies included variability in timing of the intervention , lack of adequate power to detect significant differences, and potential sampling bias. To address design weaknesses in the current literature, rigorous and adequately powered research with clearly defined objectives should be conducted on existing interventions that utilize gold standard, blinded-clinician assessment, control groups, and follow-up data. Blinded-clinician assessment reduces potential bias, and clearly defined objectives may increase internal validity of the study.Interventions should be delivered and tested in the intended acute phase after trauma. Accuracy in the timing of intervention delivery will ensure validity and generalizability of results. Due to the potential value of indicated over selected prevention, more research on posttrauma risk and resilience factors is necessary to determine for whom and how to target interventions. Participants should be recruited from diverse settings to determine the generalizability and efficacy of such interventions across survivors of different types of trauma. Moreover, to address potential sampling bias, recruiting participants from settings that draw trauma survivors for reasons other than mental health purposes  could be employed. By recruiting individuals who do not necessarily present for mental health posttrauma care, samples may include individuals who do not self-select based on predetermined symptoms of trauma. Future research should also identify barriers to accessing internet-delivered interventions.In addition to lack of rigor across studies, the literature is limited in that none of the studies evaluated early internet-delivered intervention in survivors of interpersonal trauma  specifically. Interpersonal trauma may be especially important to target, given its prevalence  and thatDespite calls for interpersonal-based early posttrauma interventions  and findIn addition, although there was an approximately equal distribution of interventions included in this review that were targeted at adults, compared with children and adolescents, only 7 studies were reviewed. Researchers should continue to develop and study early posttraumatic interventions targeted at different age groups, given the prevalence of trauma across the life span . There windicated early internet-delivered interventions in reducing mental health symptoms among trauma-exposed individuals experiencing elevated mental health symptoms. However, more high-quality, adequately powered studies are necessary before concrete conclusions can be drawn about the efficacy of such interventions.To conclude, data suggest the potential efficacy of


Lemmel syndrome is a rare and misdiagnosed cause of acute abdominal pain due to a juxtapapillary duodenal diverticulum causing mechanical obstruction of the common bile duct. Frequently, patients suffering from Lemmel syndrome have a history of recurrent access to the emergency room for acute abdominal pain referable to a biliopancreatic obstruction, in the absence of lithiasis nuclei or solid lesions at radiological examinations. Ultrasonography (US) may be helpful in evaluation of upstream dilatation of extra-/intra-hepatic biliary duct, but computed tomography (CT) is the reference imaging modality for the diagnosis of periampullary duodenal diverticula compressing the intrapancreatic portion of the common bile duct. Recognition of this entity is crucial for targeted, timely therapy avoiding mismanagement and therapeutic delay. The aim of this paper is to report CT imaging findings and our experience in two patients affected by Lemmel syndrome. PAD incidence increases with age, observed in around 10–20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), with no gender predilection. PAD is acquired extraluminal outpouching of the duodenal wall through “locusminoris resistance” located within 2–3 cm to ampulla of Vater. Even if usually asymptomatic, PAD can cause acute abdominal pain due to an extrinsic obstruction of common bile duct or pancreatic duct, miming a biliopancreatic colic. While acute abdomen resulting from common intra-abdominal pathology has been extensively covered in the medical literature as well as the role of cross-sectional imaging in depicting acute or subacute abdominal conditions, the role of imaging in the diagnosis of symptomatic duodenal diverticula is an underreported entity, mainly due to the absence of specific pathognomonic symptoms and signs.Lemmel syndrome, first described by Lemmel in 1934,Lemmel’s syndrome could be challenging to diagnose, but recognize this condition is crucial to avoid wrong treatment. The first step in diagnosis is the identification of PAD . For this reason, PAD is better characterized after oral and/or intravenous contrast material administration: oral contrast  could be helpful in evaluation of diverticulum size before and after administration, as diverticulum could double in maximum diameter after oral contrast and could reveal underlying extrinsic compression on biliary duct [PAD may appear as rounded collection of gas material situated along the medial wall of the junction of the second and third portions of the duodenum on unenhanced CT, sometimes filled with fluid and misdiagnosed as a pancreatic abscess, pancreatic pseudocyst, or as a metastatic lymph node.ary duct . IntraveA 79-year-old male with acute abdominal pain after having presented several self-limiting episodes of abdominal pain in the right hypochondrium and epigastrium, underwent US examination in the emergency department, with no significative findings. He was discharged 6 h later. After 2 days, he was readmitted to the emergency department for increased epigastric pain happened about an hour after lunch. As slight increase in total bilirubin was found in blood test, unenhanced CT scan of the abdomen was required. It demonstrated the presence of a PAD associated with common bile duct dilatation . No otheA 70-year-old female presenting with nausea, vomiting, weight loss, and slight jaundice was evaluated for acute cholecystitis. Laboratory values revealed that hemoglobin was normal, but bilirubin metabolites and inflammatory markers, including CRP, were elevated. US demonstrated dilated common bile duct with no signs referable to lithiasis. A contrast-enhanced CT scan was required to study in deep pancreatic head region.CT retrospectively revealed the presence of a 17-mm PAD  and confWe reported two cases of PAD related to Lemmel syndrome. Lemmel syndrome is an unrecognized cause of jaundice and/or common bile duct dilatation because more frequent and important causes (choledocholithiasis or pancreaticobiliary and periampullary tumors) are first depicted. Imaging is essential to correctly identify and diagnose Lemmel syndrome, as awareness of this condition may prevent mismanagement. CT scan is the reference imaging modality because majority of patients present to emergency department with acute abdominal pain. US could reveal biliary duct dilatation, but the inherent limited ability to examine bowel pathology results in non-depiction of the duodenal diverticula. PAD could be evaluated through CT, MRI, or ERCP, which could be also therapeutic.,5-7There are few data reported in literature about imaging related to Lemmel syndrome, mainly case reports evaluated with ERCP.et al. in their study on small bowel diverticular disease described three cases of symptomatic duodenal diverticula focusing on the clinical findings without imaging correlation. Abdominal cross-sectional imaging has been reported to be a useful diagnostic tool in defining duodenal pathology and overcoming the aforementioned difficulties of clinical and ultrasound examinations.Kouraklis et al. reported 10 patients, all presenting with acute abdomen and diagnosed with duodenal diverticula, documented with MDCT in eight cases, in which they focused on the importance of both axial and coronal plane in demonstrating the presence of the diverticula.A study of Perdikakis et al. presented a case of Lemmel’s syndrome with a large PAD causing obstructive jaundice and mimicking periampullary tumor: in this case, an endoscopic ultrasound was performed, revealing a 2 cm diameter duodenal diverticulum with a small flange that increased in size (more than 50%) on instillation of water and resulted in obvious compression of both the biliary tract and main pancreatic duct, confirming the diagnosis of Lemmel’s syndrome. We also demonstrated that after oral contrast administration, PAD could significative increase in size, causing dilatation of common bile duct, even if oral hyperdense contrast media could hinder small CBD stones.Rouet PAD is best demonstrated using a side-viewing endoscope, but it remains an invasive imaging modality which could reveal that the distal portion of the common bile duct is laterally compressed by the PAD.Patients who do not undergo ERCP or endoscopic examination may benefit from the ability of MR and magnetic resonance cholangiopancreatography (MRCP) to detect PAD, enabling determination of the etiology of clinical symptoms and guidance for appropriate management.,10 Conservative management consists of nasogastric decompression and wide spectrum antibiotic coverage in cases of perforation. Therefore, duodenal diverticula are usually untreated unless complications occur. If conservative treatment options fail, surgical transduodenal diverticulectomy is usually performed.Although duodenal diverticula can be found in up to 22% of the population, only 1–2% of these patients become symptomatic.Although duodenal diverticula constitute a rare cause of acute abdomen, careful imaging analysis can aid to the identification of this uncommon factor of abdominal symptomatology. Contrast-enhanced CT is the imaging of choice for a rapid, non-invasive, and specific evaluation of PAD associated with Lemmel syndrome. Oral contrast could help in confirming size-related symptoms.


The microenvironment encompasses all components of a tumor other than the cancer cells themselves. It is highly heterogenous, comprising a cellular component that includes immune cells, fibroblasts, adipocytes, and endothelial cells, and a non-cellular component, which is a meshwork of polymeric proteins and accessory molecules, termed the extracellular matrix (ECM). The ECM provides both a biochemical and biomechanical context within which cancer cells exist. Cancer progression is dependent on the ability of cancer cells to traverse the ECM barrier, access the circulation and establish distal metastases. Communication between cancer cells and the microenvironment is therefore an important aspect of tumor progression. Significant progress has been made in identifying the molecular mechanisms that enable cancer cells to subvert the immune component of the microenvironment to facilitate tumor growth and spread. While much less is known about how the tumor cells adapt to changes in the ECM nor indeed how they influence ECM structure and composition, the importance of the ECM to cancer progression is now well established. Plasticity refers to the ability of cancer cells to modify their physiological characteristics, permitting them to survive hostile microenvironments and resist therapy. Examples include the acquisition of stemness characteristics and the epithelial-mesenchymal and mesenchymal-epithelial transitions. There is emerging evidence that the biochemical and biomechanical properties of the ECM influence cancer cell plasticity and vice versa. Outstanding challenges for the field remain the identification of the cellular mechanisms by which cancer cells establish tumor-promoting ECM characteristics and delineating the key molecular mechanisms underlying ECM-induced cancer cell plasticity. Here we summarize the current state of understanding about the relationships between cancer cells and the main stromal cell types of the microenvironment that determine ECM characteristics, and the key molecular pathways that govern this three-way interaction to regulate cancer cell plasticity. We postulate that a comprehensive understanding of this dynamic system will be required to fully exploit opportunities for targeting the ECM regulators of cancer cell plasticity. Metastasis is the primary cause of cancer-related mortality  and resuNormal interactions between the parenchyma and the stroma are characterized by (1) A two-way communication by molecular messengers that are secreted into the microenvironment, 2) biochemical and biophysical cues exerted by the ECM, and (3) direct cell-cell contact permitting reciprocal signaling between the two cell types. These interactions direct tissue homeostasis and the establishment of niches bearing distinct microenvironmental characteristics that facilitate the maintenance of specialized cell types including stem cells. Under abnormal conditions in which the parenchymal cells acquire tumor-causing genetic lesions, the microenvironment—its cellular and ECM components—is remodeled under the influence of the growing tumor as well as the organism, resulting in aberrant tissue homeostasis and disruption of the specialized niches. These microenvironment changes strongly influence the progression of the disease , and enhanced survival—all key adaptations that are required for traversing the basement membrane, promoting abnormal interactions between cancer cells and the extracellular matrix (ECM), intravasation and survival within the circulation. Conversely, MET is associated with integration into epithelia at sites of distal metastasis. EMT has long been associated with acquisition and maintenance of cancer stem cells (CSCs) .The CSC hypothesis takes its origins from the observations made in the hematopoietic system, where a pluripotent progenitor gives rise to all hierarchical lineages of the system by a stepwise process of differentiation . AnalogoCancer plasticity is driven by reciprocal interactions between a cancer cell and its microenvironment, which permits this cell to, on the one hand, calibrate its response to the altered environment and on the other, actively remodel the microenvironment to facilitate its survival and proliferation. In this review, we will discuss how the ECM influences cancer cell plasticity and conversely how cancer cells directly or indirectly influence changes in ECM structure and composition.The extracellular matrix is a scaffold of fibrillar proteins, accessory proteins and molecules that provides structural and biochemical support for cells. The predominant component of the ECM is fibrillar collagen, the structure and mechanical properties of which strongly influence cellular phenotype . Based oThe normal ECM is highly remodeled after it has been initially set down and exhibits tissue-specific composition and organization. In pathological conditions such as desmoplasia, the appearance of linear ECM fibers correlates with poor patient outcomes. Linear fibers have been observed to provide tracks that migratory cancer cells can use to their advantage , to enhaCell-ECM interactions in both normal and pathologic conditions are principally mediated via integrins, which constitute a large family of cell-surface receptors. Integrins also regulate cytoskeleton organization and activate intracellular signaling pathways, conveying both mechanical and chemical signaling . BesidesNormal tissue homeostasis is strongly influenced by the ECM and a key example of this is the process of wound healing. One of the steps for the re-establishment of normal tissue homeostasis following wounding is the migration of fibroblasts into the wound space in order to break down the thrombus and regenerate the ECM . The mecFibroblasts, a cell type of spindle-like morphology and mesenchymal lineage, constitute the major cell type of the normal tissue stroma. Stroma-resident fibroblasts that are not actively engaged in ECM production or turnover are termed “resting” or “quiescent.” Resting fibroblasts are mostly observed within fibrillar ECM and have the potential to be “activated.” Activated fibroblasts are morphologically and metabolically different to their resting counterparts, and activation can be caused by acute or chronic inflammatory responses such as wound healing or fibrosis. Pro-inflammatory factors such as TGF-β, IL-6, platelet-derived growth factor (PDGF), hypoxia, and reactive oxygen species (ROS) can activate quiescent fibroblasts. Once activated, fibroblasts synthesize and deposit ECM components, release chemokines and cytokines into the stroma and generate tissue-level tensile forces via their actomyosin cytoskeletons, all key requirements for tissue remodeling. Activated fibroblasts are therefore essential for epithelial cell differentiation, control of immune responses and the maintenance of tissue homeostasis , 27.A long-standing concept tumor as “wounds that do not heal”  hinges oActivated fibroblasts in the tumor microenvironment are termed cancer-associated fibroblasts (CAFs). CAFs are among the main cellular contributors to cancer-associated changes in ECM architecture and may arise from normal fibroblasts. CAFs are thought to be recruited via growth factors secreted by tumor and immune cells , and subsequent proliferation and expansion of these cells may be auto-regulated by paracrine/autocrine mechanisms governed by other CAF populations . There iCAFs are among the few stromal cell types that have been conclusively shown to promote an EMT program in cancer cells. Using stromal fibroblasts isolated from breast cancer patients in co-culturing experiments with a panel of breast cancer cell lines, CAFs were demonstrated to promote cancer cell EMT via TGF-β secretion and induction of the TGF-β/SMAD signaling pathway in the cancer cells . AnotherRecent evidence suggests that ECM remodeling components secreted by CAFs play a role in the maintenance of the cancer stem cell niche , 35. Forin vitro , chemokines , and growth factors  produced at the invasive margin stimulate monocyte recruitment, differentiation and survival –54. We hTAMs play important roles in cancer cell proliferation , invasioex vivo mouse colorectal tumor tissues has revealed that TAMs are capable of initiating deposition, cross-linking, and linearization of collagen fibers during tumor development, particularly at the invasive front  cells in co-culture with macrophages. Accordingly, in human PDAC tissue samples, EMT correlated with the presence of infiltrating neutrophils . In a zeigration . SeveralEmerging evidence suggests that neutrophil-mediated ECM remodeling augments tumor invasiveness. Co-culture experiments of oral squamous cell carcinoma (OSCC) cell lines with neutrophils revealed that neutrophils increase the formation of invadopodia and collagenous matrix degradation by cancer cells. This process was induced via IL-8-mediated recruitment of neutrophils and subsequent release of TNF-α by neutrophils into the surrounding microenvironment . Consistin vitro evidence that they may. One study has demonstrated the ability of NETs to trap cancer cells under static and dynamic conditions, raising speculation that NETs produced during inflammation could assist in the colonization of secondary tissues by circulating cancer cells (Another intriguing field that has recently emerged is the study of neutrophil extracellular traps (NETs) and their contribution to tumor progression. NETs are three-dimensional networks of extruded DNA packed with cytosolic and granule proteins. NETs were first described as contributors to the innate immune response, with an ability to trap extracellular pathogens. It has since been shown that inflammatory responses can trigger NET formation (or NETosis). Comprehensive reviews on the roles of NETs in tumorigenesis have been recently published , 91. Forer cells . Anotherer cells . FurtherAdipocytes are the lipid-storing cells of adipose tissues (AT) that regulate energy storage and metabolism within the body. Adipocytes secrete hormones and other molecules, collectively termed adipokines, which exert paracrine and endocrine regulatory roles in obesity, adipose tissue fibrosis, inflammation, tumorigenesis, and cancer metabolism –96. Manyex vivo using primary breast cancer samples  or undifferentiated adipocyte precursors within adipose tissue stroma , 98. A s samples . Co-cult samples .in vitro cell motility of both pre-malignant and malignant breast cancer cell lines  which include CD8+ cytotoxic T lymphocytes (CTLs), CD4+ T helper lymphocytes (Th), CD4+ regulatory T lymphocytes (Treg), γδT cells, and B-cells. Tumor-suppressing roles of T helper and cytotoxic T cells have been widely studied , 114. HoTregs, on the other hand, are thought to exert an immunosuppressive influence within the tumor microenvironment and are able to induce apoptosis of NK cells via direct cell-to-cell contact as well as through TGF-β secretion , but undActivated B-cells contribute to pre-malignant inflammatory responses and to enhance tumor growth in the HPV-16-driven multistage epidermal carcinogenesis model . In castex vivo purified peripheral lymphocytes respond to chemokine and cytokine stimulation by increased MMP-9 production  in human tumor cells . LOX-medInterestingly, hypoxia also affects the ability of tumor cells to produce collagen-modifying enzymes [reviewed in ]. HypoxiAnother class of ECM-modifying enzymes produced by cancer cells are matrix metalloproteinases. It has been observed that hypoxia-induced upregulation of MMP2 and MMP9 in breast and colon cancer cells contributed to tumor cell invasion , 141 andIn another example, enforced activation of Rho kinase signaling in pancreatic ductal adenocarcinomas (PDAC) in mice caused increased production of Mmp10 and Mmp13, which were released in micro-vesicles. This enabled efficient collagen degradation within close vicinity of the cancer cells and as a result enhanced PDAC cell proliferation and collective invasion . These oin vitro and for actomyosin-based contractility  paired with actin-remodeling proteins (such as cortactin and gelsolin). These structures are able to incorporate integrin-mediated signaling and recruit Rho GTPases, myosins, Src kinases, and dynamin . Focal aactility .in vitro studies have shown that invadopodia formation is important for basement membrane penetration, conclusive in vivo evidence is lacking regarding the physiological roles of invadopodia.Focal adhesions are known to integrate multiple signaling inputs and transduce them across the cell . HoweverIn this section and summarized in Table The microenvironment is precisely regulated by several molecular players that have evolved to return this system to its steady state in the shortest possible time following perturbation, while also permitting it to adapt quickly to changed circumstances such as injury or disease. This ability to quickly adapt to circumstances and resilience under injury can be co-opted by disease states such as cancer and accounts for a significant component of the plasticity exhibited by cancer cells. Changes in the mechanical and biochemical properties of the ECM have been linked to cancer cell plasticity that promotes increased invasiveness and metastatic potential . FurtherTumor and stromal cells employ several signaling pathways that regulate the biochemical and biomechanical interactions between the parenchyma and the microenvironment to establish, remodel and maintain the ECM. Whereas normal epithelial cells produce only small amounts of ECM, fibroblasts, tumor cells, and certain immune cells like macrophages have the capacity to produce vast quantities of the proteins that form this meshwork scaffold and are largely responsible for its production and maintenance. Nevertheless, they do not perform this task independently, but are regulated by biochemical and biomechanical cues from the parenchyma.Established molecular pathways that regulate ECM properties include TGF-β, CTGF, and Wnt signaling axes and the mediators of the YAP signaling system, which are discussed here.TGF-β family members are multifunctional cytokines with roles in wound healing, tissue repair, and cancer, and regulate a signaling cascade largely involved in the transcriptional regulation of genes that control EMT and stemness . ActivatThe numerous TGF-β superfamily of ligands  comprise two major subfamilies based on structure and function. These are the TGF-β/Activin/Nodal subfamily and the bone morphogenetic protein/growth and differentiation factor/Müllerian inhibiting substance subfamily (BMP/GDF/MIS) . While eTGF-β is secreted by many cell types, including those abundant within the tumor microenvironment such as activated macrophages , endotheTGF-β signaling controls the transcription of a suite of genes, including those encoding ECM proteins such as collagen, and ECM remodeling enzymes such as lysyl oxidase , 173, viGiven the high level of reciprocal crosstalk between TGF-β, the ECM and cellular plasticity as detailed above, this signaling pathway is well-established as a key target in cancer therapy. However, the pleiotropic and context-dependent functions of the pathway have hampered the development of tractable agents that reliably target TGF-β-regulated tumor cell plasticity.CTGF. Fibronectin in turn determines the biosynthesis and fibrillogenesis of collagen 1, the main component of the cancer ECM.The Connective Tissue Growth Factor  is a member of the CCN family of non-structural ECM proteins and is therefore most appropriately termed a matricellular protein. It can interact with a large array of signaling molecules, including bone morphogenetic proteins (BMP), TGF-β, VEGF, IGF, and Wnt ligands as well as directly bind trans-membrane receptors such as integrins, Notch receptors, TGF-β receptors, and lipoprotein receptor-related proteins (LRPs) to elicit the corresponding signaling cascades , 176. InCTGF has been shown to regulate the MET of head and neck cancer cells  and drug2+ pathway, by interacting with cell surface bound Frizzled receptors. Critical to Wnt signaling are low density lipoprotein (LDL) receptor-related proteins, which act as co-receptors of the Wnt signal , the planar cell polarity pathway  and the Wnt/Cat signal . Transdut signal , which at signal –184.GSK3B exists in a large multi-protein complex containing Axin, β-catenin, and the adenomatous polyposis coli (APC) protein –188. In In vivo evidence for the role of Wnt signaling in regulating EMT and metastasis has been provided in breast cancer (The role of Wnt/β-catenin signaling in EMT has been well known for some time. Wnt signaling was first demonstrated to stabilize and thereby control the turnover of the EMT regulator Snail1  and incrt cancer  and panct cancer . It is at cancer .The Wnt signaling pathway has also been demonstrated as a regulator of stemness, both in stem cell maintenance and renewal, for example in the intestine , as wellFunctional interactions between the Wnt signaling pathway and the extracellular matrix are being uncovered, most prominently in normal development of bone, where it is emerging that mechanotransduction signaling initiated by ECM stiffness regulates Wnt secretion . These oThe 22-member RHO family of small GTPases are named for their homology to the Ras proto-oncogenes. Of these, the best characterized are RHOA, RAC1, and CDC42, which have distinct roles in regulating actin polymerization and turnover, and myosin contractility . These sA key role for RHO-ROCK signaling has been delineated in the tissue and tumor microenvironments, to complement its well-established function in cell migration and adhesion . The patThe still rather enigmatic Salvador/Warts/Hippo pathway is a highly conserved signaling pathway and acts as a controller of organ size in animals by regulating the balance between cell proliferation and death . The patThese and other signaling molecules that regulate ECM structure and function to influence cancer cell plasticity both directly and indirectly are summarized in Table As we have discussed above, cancer cell plasticity permits tumors to adopt shifting identities that allow them to adapt to changing environments, modify their microenvironment to suit their needs and evade the immune system. In this effort, cancers can co-opt and deftly commandeer many of the body's own normal homeostatic processes such as wound healing, immune surveillance and maintenance of the stem cell niche. While this poses a significant challenge to cancer therapy, it also provides us with an opportunity to target the aberrant microenvironment that has been built around the tumor. A key vulnerability of tumors exhibiting plasticity is their need to subvert the activities of genetically normal stromal cells for their own purposes by biochemical and biomechanical means. This provides us with an opportunity to block signals traveling between cancers and their stroma pharmacologically, using antibody therapy or by modifying the mechanical environment of the tumors; or indeed a combination of all three. Coupled with precision therapies tailored to the tumor genotype, a multi-pronged approach targeting the tumor as well as its microenvironment has the potential to revolutionize cancer therapy.As a note of caution however, it is important to appreciate that plasticity may also provide tumors with the means to evade such combination therapies. It is therefore imperative that the core set of principles driving cancer cell plasticity be soundly researched and fully appreciated. Given the plethora of autochthonous animal models of human cancers and more recently the patient-derived xenograft models being propagated in immunologically humanized animals, we believe the tools are being rapidly assembled to make this a reality.VP wrote the review and edited the manuscript. MK wrote the review and edited the manuscript. SP wrote the review and edited the manuscript. MS conceived of the review, planned the outline, wrote the review and edited the manuscript.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.


Essential to development, primary cilia are microtubule-based cellular organelles that protrude from the surface of cells. Acting as cellular antenna, primary cilia play central roles in transducing or regulating several signaling pathways, including Sonic hedgehog (Shh) and Wnt signaling. Defects in primary cilia contribute to a group of syndromic disorders known as “ciliopathies” and can adversely affect development of the brain and other essential organs, including the kidneys, eyes, and liver. The molecular mechanisms of how defective primary cilia contribute to neurological defects, however, remain poorly understood. In this mini review, we summarize recent advances in understanding of the interactions between primary cilia and signaling pathways essential to cellular homeostasis and brain development. Primary cilia are microtubule-based cellular organelles that aid in sensing and transducing environmental signals during development : primaryLeading to defective primary cilia, mutations in genes necessary for ciliogenesis and ciliary structure and function are known to cause a group of human genetic disorders described as “ciliopathies.” To date, 187 mutated genes in 35 known ciliopathies and 241 ciliopathy-associated genes essential to ciliary structure and function that could potentially be causative for ciliopathies have been documented . These cSonic hedgehog signal transduction is accomplished through binding of Shh to the transmembrane receptor Patched (Ptch). In the absence of Shh, Ptch inhibits the ciliary localization of Smoothened (Smo), a membrane G protein-coupled receptor (GPCR)-like protein. When present, Shh binds to Ptch to alleviate the suppression of Smo, which, in turn, translocates to the primary cilium to repress Suppressor of Fused (SUFU) . This inKinesin family member 3A (Kif3a), which is important for ciliogenesis, show reduced Gli1 expression, thereby leading to defects in hippocampal neurogenesis and formation of neural stem cells , which is localized with basal bodies along ciliary axonemes and appears to play a role in ciliogenesis in association with intraflagellar transport proteins (IFTs) (Stumpy mutant mice (driven by Nestin-Cre) have been found to show abrogated Shh signaling and Gli processing in the hippocampus  . Conditipocampus .MTOR elicits abnormal activation of canonical Wnt signaling and inactivation of non-canonical Wnt signaling, resulting in defective neuronal migration due to disrupted neuronal polarization   . Neverthreatment . In focapatients . Given tAutophagy is a cellular degradative process by which a cell gains nutrients to maintain homeostasis . Two indHuntingtin, which is mutated in HD, is known to regulate autophagy, it also participates in trafficking pericentriolar material 1 (PCM1) to the centrosome. When Huntingtin is mutated, aberrant accumulation of PCM1 occurs, which, in turn, causes dysregulated ciliogenesis , which show severe disorganization of the telencephalon, have been found to exhibit an ambiguous dorsal-ventral forebrain boundary and dorsal telencephalic-diencephalic boundary, concomitant with increased levels of full-length Gli3  have also been shown to display defects in dorsal–ventral patterning and rostral–caudal patterning. Researchers have reported that Ttc21b-null mice exhibit normal anterograde transport that permits entry of Shh signaling components into cilium but partially defective retrograde transport. Overactivation of GLI2 and GLI3A in these mice could accounts for activation of Shh signaling and abnormal patterning, suggesting a periciliary role for retrograde IFT in GLI3 processing and GLI2 activity  that possess very short axonemes with no visible microtubules in their cilia have also been found to exhibit a global brain-patterning defect along the dorsal–ventral and rostral–caudal axes , which display defective cilia, surprisingly exhibit dramatic inversion of the apicobasal polarity of the radial glial scaffold, which, in turn, changes the location of the progenitor zone to the outer part of the cortex. This defect is also observed when Arl13b is removed just before the formation of radial glia from neuroepithelial cells using Foxg1-driven Cre. However, Arl13b removal after establishment of the radial glial scaffold using Nestin- or GFAP-driven Cre has not been found to generate this intriguing phenotype, suggesting that the role of Arl13b in polarization is temporally restricted to the period during which the radial glial scaffold develops  of Kif3a, Ift88, and Ttc21b in a series of specific spatiotemporal domains. Intriguingly, the observed neurological defects, including forebrain expansion, cortical malformations, impaired olfactory bulb development, and ventriculomegaly, were significantly different across four different Cre transgenic alleles , indicating that the roles of cilia in cortical development are discretely spatiotemporal. For example, the deletion of Ift88 at earlier stages of development, driven by Foxg1-Cre, was found to increase brain size; however, when deleted at later stages, driven by Emx1-Cre, there were no significant differences in brain size  in the developing cortex, which resulted in defective neuronal differentiation and migration; this was accompanied by delays in neural stem cell cycle progression and failures in interkinetic nuclear migration  and NPCs in the dorsal pallium  and subventricular zone (SVZ) was decreased, and Gli1 expression was abolished  progenitors domain, and the number of mDA neurons was severly reduced  as a neurological deficit. Although there are not enough studies to explain the mechanism underlying ID as a result of defects in primary cilia, several studies have shown that depletion of primary cilia leads to hippocampal-dependent learning and memory deficits . Hippoca pallium . Meanwhicontrols . In Kif3bolished  These de reduced . ConsideIn this review, we briefly summarized the interaction between primary cilia and several signaling pathways, including Shh, Wnt, MTOR, and autophagy, all of which are essential to cellular homeostasis. Given that neurological disorders are typical symptoms of ciliopathies, the importance of primary cilia during brain development cannot be emphasized enough. At present, however, we are unable to fully understand the underlying mechanisms by which defective neuronal cilia contribute the pathogenesis of neurological defects in ciliopathies. Future studies of neuronal cilia in relation to signaling pathways may provide better understanding of the functions of neuronal cilia and may help to develop novel treatments for ciliopathies by targeting neuronal cilia-mediated signaling pathways. Compared with considerable studies on neuronal cilia, there is a lack of research on the role of primary cilia in glial cells, another major component of the brain. Glial cells, such astrocytes and oligodendrocytes, also possess a single primary cilium . RecentlTo help achieve a better understanding of human ciliopathies resulting from mutations in ciliary genes, CRISPR/Cas9 genome editing of identified mutations in human ciliopathies or 3D culture of brain organoids derived from pluripotent stem cells from ciliopathy patients can be used to generate more pathophysiologically relevant models for ciliopathy, thereby overcoming the gap between animal models and human subjects. Also, increasing studies on interactions between primary cilia and other signaling pathways may uncover a previously unknown role for cilia in the pathogenesis of human neurological diseases that are not considered classical ciliopathies, such as FMCD, brain cancer (medulloblastoma and GBM), and neurodegenerative diseases (Alzheimer’s disease and HD) . Future SP, HJ, and JL conceived the idea and wrote the manuscript.JL is a co-founder of SoVarGen, Inc. that develops new diagnostics and therapeutics for brain disorders. The remaining 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.


Polyampholytes are a class of polymers made up of positively and negatively charged monomer subunits. Polyampholytes offer a unique tunable set of properties driven by the interactions between the charged monomer subunits. Some tunable properties of polyampholytes include mechanical properties, nonfouling characteristics, swelling due to changes in pH or salt concentration, and drug delivery capability. These characteristics lend themselves to multiple biomedical applications, and this review paper will summarize applications of polyampholyte polymers demonstrated over the last five years in tissue engineering, cryopreservation and drug delivery. A significant amount of research is being done with polyampholyte polymers in the biomedical community. Polyampholytes are polymeric systems comprised of both positively and negatively charged monomer subunits. Through the selection of monomers, one can build a polyampholyte with desired properties, tuned to specific biomedical applications. Our previous work evaluated much of the relevant literature prior to 2013  (PMAPTACMAAc) copolymers with various concentrations of monomers and loaded indomethacin (IND) [N-isoproplyacrylamide), and the release was affected by temperature, pH, and crosslinker density [A variety of specific drug species have also been used to test drug delivery from assorted polyampholyte mediums. Mishra et al. used poly 3-[(methacryoylamino)propyl trimethylammonium chloride-in (IND) . IND is  density . This le density . These nInvestigators have also begun incorporating polyampholytes into multicomponent systems to enhance performance or offer additional benefits. For example, Wang et al. examined a polyampholyte hydrogel release system based on pyromellitic diester diacid chloride (PDDC) combined with combinations of diethylenetriamine (DETA) and triazine . This poN,N′-diallyl-N,N′-dimethyl-almaleamic carboxylate)  was integrated into a lamellar liquid crystalline system of sodium dodecyl sulfate, decanol, and water, it was found that release from the new structure could be tuned by varying the pH or temperature. This suggests it has promise as a new structural material for drug delivery systems [Others has also incorporated polyampholyte polymers into their drug delivery vehicles to add pH responsive release characteristics. For example, Schulze et al. saw potential in lamellar liquid crystalline systems, but the structure did not react to environmental stimuli such as pH. When the polyampholyte poly (CM-PVIm), into an existing system. CM-PVIm was used to coat poly(ethylenimine)/DNA (PEI/DNA) complexes, to reduce nonspecific protein adsorption to this delivery platform. The results demonstrated this coating did not significantly reduce gene transfection or cell viability. Therefore, the authors concluded that CM-PVIm is an effective coating for improved circulation of gene therapy agents .Another application of adding polyampholytes to drug delivery vehicles is based on their strong water holding capacity. Polyampholyte acrylic latexes were incorporated into drug tablet coatings to minimize the amount of water removed from the drugs during the tablet drying step . During Throughout this review, many exciting advancements applying polyampholyte hydrogels to biomedical applications were highlighted. However, despite this progress and the clearly demonstrated capabilities of polyampholytes, these materials have not yet been investigated in the in vivo environment in depth. This is the critical next step in the continued development of these materials, and our group is pursuing these efforts in the application of polyampholyte hydrogels for bone tissue engineering. Additionally, while the tunability and responsive properties of polyampholytes have been widely demonstrated, the ease of tuning polyampholyte materials for targeted applications of these capabilities must also be further pursued.