The treatment of hypogonadism in men is of great interest to both patients and providers. There are a number of testosterone formulations currently available and several additional formulations under development. In addition, there are some lesser-used alternative therapies for the management of male hypogonadism, which may have advantages for certain patient groups. The future of hypogonadism therapy may lie in the development of selective androgen receptor modulators that allow the benefits of androgens whilst minimizing unwanted side effects. Given that testosterone concentrations decline with age3 and the increasing awareness of the signs and symptoms of hypogonadism, prescriptions for testosterone therapy have increased significantly in the last several years4.The Endocrine Society Clinical Practice Guideline defines male hypogonadism as “a clinical syndrome that results from failure of the testes to produce physiological levels of testosterone due to disruption of one or more levels of the hypothalamic-pituitary-testicular axis”In this review, we will briefly summarize the risks and benefits of testosterone replacement therapy. In addition, we will describe the existing options for testosterone therapy, including several newer formulations of testosterone under development. Lastly, we will discuss the data available on alternative therapies occasionally used for the treatment of male hypogonadism.1. The potential clinical benefits of testosterone therapy must be carefully weighed against potential risks. Potential adverse effects of testosterone replacement include erythrocytosis, increases in prostate-specific antigen (PSA) and worsening of prostate disorders (including benign prostatic hyperplasia [BPH]), dermatologic effects, including acne and skin irritation, and worsening of existing obstructive sleep apnea1. In addition, exogenous testosterone administration leads to the suppression of luteinizing hormone (LH), decreased intra-testicular testosterone concentrations, and reduced spermatogenesis5. Thus, testosterone replacement therapy is not appropriate for hypogonadal men desiring fertility.For men with symptomatic hypogonadism, there are a number of potential clinical benefits with testosterone replacement therapy, including improvements in libido, erectile function, muscle strength and body composition , mood, and cognition7.Notably, the US Food and Drug Administration (FDA) has recently added important warnings to testosterone products. The first is a warning added to all testosterone preparations highlighting a potential increased risk of cardiovascular disease  in patients taking testosterone, although additional studies are needed to guide clinicians in better understanding these potential risks, as the magnitude of these risks are unknown. However, until additional information becomes available, the current recommendation is that clinicians in practice should discuss these potential risks with all patients when starting or continuing testosterone replacement therapyIn October 2016, the FDA added additional warnings to the labeling of testosterone products to alert prescribers to the potential for abuse of testosterone and other anabolic androgenic steroids. The FDA statement outlined potential adverse effects of abuse of anabolic androgenic steroids, including myocardial infarction, heart failure, stroke, liver injury, male infertility, and mood changes including depression, aggression, and hostility. They also raised concerns that abuse of high doses of testosterone was reported to be associated with potential withdrawal symptoms including depression, irritability, fatigue, insomnia, and decreased libido. The potential for abuse of testosterone and other androgens should be considered in both adult and adolescent populations.There are a variety of testosterone preparations currently on the market in the US  and addi9. These are usually dosed every 1–2 weeks. In contrast, a newer long-acting testosterone ester, testosterone undecanoate (“Nebido” in Europe and “Aveed” in the US), can be dosed every 6–12 weeks. All of these formulations are administered as intramuscular injections. The majority of patients are able to administer injections independently at home with the help of a partner. Intramuscular testosterone formulations are highly effective in improving symptoms of hypogonadism. Additional benefits of long-acting injectable preparations include low cost of therapy (as compared to other preparations) and they more reliably achieve therapeutic serum concentrations of testosterone , thus reducing the need for routine monitoring of serum testosterone concentrations during therapy. With testosterone enanthate and testosterone cypionate, testosterone concentration and clinical effects peak 1–2 days after the injection and wane over the subsequent 2 weeks10. For some patients, the fluctuations in serum testosterone concentrations can lead to adverse impacts on mood, energy, and sexual function, which can be bothersome or disruptive. In these cases, alternate dosing using half the usual dose administered weekly (instead of full dose every 2 weeks) or use of an alternate testosterone preparation may be preferred.Two intermediate-acting injectable testosterone formulations are currently available in the US market: testosterone enanthate and testosterone cypionateIn contrast, testosterone undecanoate achieves relatively stable testosterone concentrations. Unfortunately, the relative large volume of testosterone undecanoate injections can be associated with the risk of pulmonary oil microembolism and anaphylaxis, albeit rarely. As a result, testosterone undecanoate is available only through a Risk Evaluation and Mitigation Strategy (REMS) program and must be administered by a trained, registered care provider in an office or hospital setting – it cannot be self-administered at home by the patient.11. In contrast to injectable testosterone preparations, absorption of transdermal testosterone gel can be quite variable. If a patient using a transdermal formulation of testosterone has no improvement in symptoms, it is reasonable to measure the serum testosterone concentration and adjust the dose as needed to achieve adequate circulating testosterone concentrations.Transdermal testosterone gels are widely available and popular among both patients and clinicians. There are multiple transdermal gel formulations currently available in the US including AndroGel, Testim, Fortesta, and Axiron . They arWhen the risk of skin-to-skin transfer of testosterone is of concern, the use of a transdermal patch may be appropriate. There is currently one transdermal testosterone patch preparation (Androderm) available in the US. Use of the patch has been limited by relatively high rates of skin irritation, with up to one-third of men who use the patch experiencing significant skin irritation. Similar to other transdermal testosterone preparations, monitoring of circulating serum testosterone concentration and appropriate dose adjustment are reasonable with transdermal patches, since testosterone absorption can be variable.12. Testopel is placed in the subcutaneous fat of the buttock, lower abdomen, or thigh every 3–6 months. Pellets are placed using sterile technique in an office or hospital setting and cannot be injected by the patient at home. Risks with subcutaneous testosterone pellets include infection, fibrosis, and pellet extrusion. Benefits include eliminating risk of skin-to-skin transfer, infrequent dosing, and relatively stable serum testosterone concentrations.A subcutaneous testosterone pellet (Testopel) is available for the treatment of hypogonadism14.Nasal and buccal testosterone preparations are also available for the treatment of hypogonadism and may be useful in limited clinical settings where other testosterone preparations are not effective or appropriate. Use of nasal and buccal preparations is limited because of the potential for nasal/sinus and gingival irritation, limited published data on use of the nasal preparation, and animal studies suggesting possible increases in central nervous system testosterone levels above that expected with other formulations15. However, high post-dose serum peaks and a relatively large degree of inter-individual variability in achieved drug concentrations are issues for these formulations. In response, the companies developing these newer formulations of testosterone undecanoate are developing dosing algorithms to ensure patients receive the appropriate dose to achieve therapeutic concentrations of testosterone. Other oral preparations, especially those alkylated at the 17-carbon position, such as methyltestosterone, are associated with hepatotoxicity and are not recommended for use.Oral testosterone undecanoate (Andriol) is available in many countries outside the US; however, serum testosterone concentrations achieved with this formulation can be low and administration must occur with a fat-containing meal. New self-emulsifying drug formulations of testosterone undecanoate are under development and may reach the market in the next 1–2 years16. While the scrotal gel and patches achieved equivalent serum androgen (testosterone and dihydrotestosterone [DHT]) concentrations, the transdermal gel actually achieved higher concentrations. The transdermal gel was also better tolerated than the patches whilst proving equivalent in safety outcomes such as hematocrit, serum PSA, and prostate volumes. Another formulation that is currently approved for use in Australia is an alcohol-free testosterone cream 17. This was studied in an open-label, randomized crossover study, comparing it with 1% testosterone gel in hypogonadal men with a treatment period of 30 days. Pharmacokinetic end points of both were comparable and there were no differences in serum hormone concentrations.Some newer testosterone formulations have recently come to the global market. These include both transdermal and injectable formulations. One of the transdermal formulations includes a hydro-alcoholic 2.5% testosterone gel (Testocur) that is approved for use in Germany. This drug was studied after application both transdermally and transscrotally, and compared with Androderm 2.5% patches applied transdermally in an open-label, parallel group, randomized controlled fashion in previously treated hypogonadal men for 24 weeksGiven the concerns surrounding the safety and benefits of testosterone therapy in men, other agents have also been used for the treatment of male hypogonadism. In particular, in younger men who are interested in fertility, testosterone replacement therapy is not recommended.18, and (b) it is also not aromatized and hence gynecomastia is not a concern. Studies of DHT gel have also shown (like testosterone replacement) improved sexual function and muscle mass, lower fat mass19, and favorable effects on lipid profiles20. The downside to using DHT gel, however, includes the higher cost and the theoretical harm of lack of aromatization to estradiol (E2), which could impact bone mineral density and libido. Additionally, it is uncertain if the supra-physiologic serum DHT concentrations that are achieved with DHT gel18 can have long-term unfavorable effects of their own.Testosterone is metabolized by 5α-reductase to DHT in the body. DHT has a stronger affinity than does testosterone for the androgen receptor in certain tissues such as the prostate, skin, and external genitalia. DHT gel is used for the treatment of hypogonadism in France and Belgium. The theoretical advantages of using DHT gel over testosterone in men would include mainly that (a) its use does not translate into increased intra-prostatic DHT concentrations and hence the risk of adverse prostate outcomes is lower21. In hypogonadal men, the level to which spermatogenesis is impaired depends on both the etiology of hypogonadism and the time of onset , since that affects the baseline testicular volume and the number and functionality of germ cells. Human chorionic gonadotropin (hCG) therapy (recombinant hCG) is traditionally used in hypogonadal men desiring fertility, since it shares a receptor with LH and produces similar effects. The dose is usually titrated to a serum testosterone concentration in the mid-normal range. After 6 months of therapy, sperm concentrations are assessed and if no response is noted, then FSH therapy, either human menopausal gonadotropin (hMG) or recombinant human FSH (rhFSH), is added. Response times can be as long as 1–2 years for the combination, and success is higher in men with testicular volumes >8 cc and later onset of hypogonadism22. Studies have also looked at the role of hCG therapy in the treatment of hypogonadism in men without fertility concerns, and it has been shown to improve hypogonadal symptoms23 and have favorable effects on body composition (increased fat-free mass and lower fat mass), lipid profile 24 and bone formation25. hCG therapy also seems to be less likely to cause the adverse effects that testosterone is associated with in terms of prostate health, hematocrit, sleep apnea, and gynecomastia; however, it entails more frequent (2–3 times a week) injections than does testosterone and can also cause testicular enlargement26.In a healthy male, pulsatile gonadotropin-releasing hormone (GnRH) secretion stimulates follicle-stimulating hormone (FSH) and LH secretion from the pituitary, which in turn act on the Sertoli and Leydig cells, respectively, and support spermatogenesis and intra-testicular testosterone production27 and consequently serum testosterone concentrations. For this reason, it works only in individuals with hypogonadotropic hypogonadism with an otherwise intact hypothalamic-pituitary-gonadal axis. In addition to improving serum testosterone levels, it has been shown to improve hypogonadal symptoms28 and improve bone mineral density while avoiding adverse effects on PSA and hematocrit and gynecomastia29 and may be more economical than testosterone therapy30. Though it seems a viable alternative to testosterone, it is not FDA approved for use in the treatment of hypogonadism. Potential drawbacks include an increased risk of thromboembolism as seen with other selective estrogen-receptor modulators, such as raloxifene, and a diminution of estrogen effects in the male, including effects on libido and bone mineral density.Clomiphene is a selective estrogen receptor modulator that has weak anti-estrogen action. It competes with estrogen for binding at the estrogen receptor and increases GnRH secretion, thereby increasing LH secretiontrans-isomer of clomiphene. It is being studied as a treatment for hypogonadism in men with intact pituitary who wish to retain spermatogenesis during treatment. Several studies support the contention that spermatogenesis is better preserved with this approach32, but limited data on fertility preservation are available. As a result, this medication has not yet been approved for clinical use but is an interesting compound for future study in men who wish to maintain sperm production during treatment for hypogonadism.Enclomiphene is the33, which in turn prevents feedback inhibition of GnRH and causes increased release, thereby raising serum testosterone concentrations as well as intra-testicular testosterone. Agents such as letrozole and anastrozole have been investigated for the treatment of male hypogonadism. These have uniformly shown an increase in serum testosterone concentrations35 and some have reported improvement in sexual desire34, lean mass, muscle strength, and physical function36. The other advantages of aromatase inhibitors over testosterone therapy are that the lower estrogen state does not increase prostate volume or lower urinary tract symptoms (LUTS)37 and it does not lower, or may even improve, sperm parameters38. These factors make them a possible alternative to testosterone in obese hypogonadal men with high E2 concentrations, older hypogonadal men with BPH, and younger hypogonadal and subfertile men. However, the effect of lowering E2 levels can cause adverse effects on bone mineral density40, while other studies have shown no such effects41. Also, recent studies have highlighted the importance of E2 in maintaining sexual desire42 and so lowering E2 concentrations in hypogonadal men may affect symptom improvement significantly.Aromatase converts testosterone to E2 in various tissues, particularly fat. Aromatase inhibitors prevent this and lower E243, but these are mostly pre-clinical or early-phase clinical studies of short duration. Rodent models have shown anabolic effects on muscle and bone with reduced impact on prostate growth as well as improvement in sexual behavior44. One promising 12-week, double-blinded, placebo-controlled phase 2 trial of GTx-024 (enobosarm) in 120 healthy men older than 60 years of age showed dose-dependent increases in total lean body mass and improvement in physical function and insulin resistance45. However, there is not enough evidence to recommend these as an alternative to testosterone for the treatment of hypogonadism as yet.Androgen therapies mostly have beneficial effects on skeletal muscle and bone; however, they tend to cause negative effects on erythrocytes (erythrocytosis), prostate (BPH), hair , and skin (acne). Therefore, an ideal therapeutic agent for the treatment of hypogonadism would have tissue-specific effects so that we can achieve the “good” without incurring the “bad”. This is the concept from which the development of selective androgen receptor modulators (SARMs) has stemmed. These agents act as tissue-specific androgen-receptor ligands, mainly acting at the level of skeletal tissue or bone. Studies have looked at their role in the treatment of chronic disease or cancer cachexia, frailty, sarcopenia, osteoporosis, hypogonadism, prostate cancer, and male contraception46. Such studies will likely require larger samples and better outcome measures, work that is somewhat hampered by the paucity of validated patient-reported outcome measures in the field.While alternatives to testosterone therapy have appeal, particularly for men wishing to avoid suppression of spermatogenesis by testosterone, there is greater uncertainly regarding their risks and benefits, as they have been less well studied. In addition, FDA approval for these therapies has been difficult to obtain, as the FDA has indicated that raising testosterone is not acceptable as a primary endpoint for non-testosterone therapies. Instead, the FDA requires data on improvement of the signs and symptoms of hypogonadismTreatment of male hypogonadism remains an area that requires in-depth discussion of the risks and benefits of therapy with the patient before proceeding. With the numerous testosterone formulations that exist and are being developed, patients have a variety of options to choose from, depending on their preferences. Additionally, there are a number of non-testosterone alternative therapies too that can be considered, particularly in men desiring fertility or wishing to avoid specific side effects of testosterone therapy. Still newer therapies, currently in the stages of early clinical trials (selective androgen receptor modulators), may indeed be the future of androgen replacement therapy and hint at the promise of more benefits than harm, which would simplify these patient discussions and decisions.BPH, benign prostatic hyperplasia; DHT, dihydrotestosterone; E2, estradiol; FDA, US Food and Drug Administration; FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; hCG, human chorionic gonadotropin; hMG, human menopausal gonadotropin; LH, luteinizing hormone; LUTS, lower urinary tract symptoms; PSA, prostate-specific antigen; REMS, Risk Evaluation and Mitigation Strategy; rhFSH, recombinant human follicle-stimulating hormone; SARMs, selective androgen receptor modulators.


Quality of life (QoL) questionnaires are desirable for clinical practice but can be time-consuming to administer and interpret, making their widespread adoption difficult.Our aim was to assess the performance of the World Health Organization Quality of Life (WHOQOL)-100 questionnaire as four item banks to facilitate adaptive testing using simulated computer adaptive tests (CATs) for physical, psychological, social, and environmental QoL.We used data from the UK WHOQOL-100 questionnaire (N=320) to calibrate item banks using item response theory, which included psychometric assessments of differential item functioning, local dependency, unidimensionality, and reliability. We simulated CATs to assess the number of items administered before prespecified levels of reliability was met.The item banks (40 items) all displayed good model fit (P>.01) and were unidimensional (fewer than 5% of t tests significant), reliable (Person Separation Index>.70), and free from differential item functioning  or local dependency . When matched for reliability, the item banks were between 45% and 75% shorter than paper-based WHOQOL measures. Across the four domains, a high standard of reliability  could be gained with a median of 9 items.Using CAT, simulated assessments were as reliable as paper-based forms of the WHOQOL with a fraction of the number of items. These properties suggest that these item banks are suitable for computerized adaptive assessment. These item banks have the potential for international development using existing alternative language versions of the WHOQOL items. Improving patient-centered care (PCC) is a key strategic priority for health care systems worldwide due to the increasing burden of non-communicable chronic disease and ageing populations . In the Increasing priority placed on PCC reflects a longstanding movement towards patient-centered metrics and away from sole reliance on disease-centered measures of severity, impact, and burden . Such paPatient-reported outcome measures (PROMs) are measurements of any aspect of a patient’s health status that come directly from the patient, usually through a paper-based questionnaire scale ,11. MeasClinical trials assessing PROM feedback report improvements in identification of clinical issues, emotional well-being, patient-centered discussions, and symptom recognition in pediatric, oncology, and respiratory settings -19. We aHowever, the overall level of evidence for the impact of using PROs in clinical practice is mixed ,14. In mDespite the potential benefits of PROM administration, their use is frequently dismissed in many medical settings including family practice , which mThe increased availability of modern computing technologies  provides an opportunity to computerize PROM administration, which has previously been primarily paper-based. In addition to practical advantages of not having to score and interpret paper-based questionnaires, administration using a computer adaptive testing (CAT) algorithm is a quicker and potentially more relevant and accurate method of assessing patient reported outcomes ,28. The , which are rigorously validated but unfortunately are currently limited to PROMIS-validated questionnaires only, which do not include subjective QoL )Previous studies that have applied WHOQOL scale data IRT models have employed different approaches. Studies using WHOQOL-100 data and the Rasch model have evaluated the suitability of an “index” solution, which assesses QoL as a single unidimensional, rather than multidimensional, construct. In these studies, the strict assumptions of the Rasch model led to the removal of a similar number of items, though they were not the same items that we removed from this study. Issues of DIF were also evident . Other IOne notable advantage of the methods employed in the current analysis of the larger initial item banks  led to acceptable measurement across all four domains of the WHOQOL measure and obtaining excellent measurement properties with each. It must be noted that the Social QoL domain displayed unidimensionality that was slightly above the recommended threshold  for strict unidimensionality.Multi-item questionnaires measuring health outcomes are still widely used in clinical trials  and epidThe cross-cultural development of the original WHOQOL instruments suggests good potential for the development of culturally sensitive item banks and CATs. Further analyses to the one presented here provided preliminary evidence on the use of the WHOQOL item banks for use in different cultures eg, ,70)..70]).From a technical perspective, there is clear potential to develop the IRT methods employed in this study further and to apply these data to a multidimensional item response theory (MIRT) model . An MIRTThis study naturally provides the foundations for future work to develop and evaluate a CAT system than can deliver these item banks to clinical populations and to assess the performance of the item banks under “live” testing conditions, rather than use simulations. The recent development of free-to-use and open source CAT platforms, such as Concerto  opens thWe have presented functional item banks that are capable of producing high-quality measurement across four domains of QoL using fewer items than equivalent paper-based measures. These item banks outperform the paper-based versions of the WHOQOL both in terms of reliability, length, and the flexibility in which they may be administered. The computer adaptive tests based on the WHOQOL would be suitable across a range of medical specialities, and hence particularly useful in primary care as an aid to understanding and quantifying the quality of life across diverse biopsychosocial domains.


The plant hormone ethylene is one of the central regulators of plant development and stress resistance. Optimal ethylene signaling is essential for plant fitness and is under strong selection pressure. Plants upregulate ethylene production in response to stress, and this hormone triggers defense mechanisms. Due to the pleiotropic effects of ethylene, adjusting stress responses to maximize resistance, while minimizing costs, is a central determinant of plant fitness. Ethylene signaling is influenced by the plant-associated microbiome. We therefore argue that the regulation, physiology, and evolution of the ethylene signaling can best be viewed as the interactive result of plant genotype and associated microbiota. In this article, we summarize the current knowledge on ethylene signaling and recapitulate the multiple ways microorganisms interfere with it. We present ethylene signaling as a model system for holobiont-level evolution of plant phenotype: this cascade is tractable, extremely well studied from both a plant and a microbial perspective, and regulates fundamental components of plant life history. We finally discuss the potential impacts of ethylene modulation microorganisms on plant ecology and evolution. We assert that ethylene signaling cannot be fully appreciated without considering microbiota as integral regulatory actors, and we more generally suggest that plant ecophysiology and evolution can only be fully understood in the light of plant-microbiome interactions. Plants are constantly facing a range of different environmental stressors linked for instance to temperature, water availability, presence of toxic minerals, or pathogens. Stress can be permanent, for instance, when a plant lives outside its ecological optimum, or acute during climatic extremes such as drought and flooding waves. Environmental stress has an important effect on plant fitness and elicits specific adaptations . Plants To optimize fitness, stress responses must be therefore carefully adjusted. This implies that plants need to perceive different stressors, process the signals, and trigger an optimal stress response, thereby maximizing resistance while minimizing costs and side effects. Signal integration in plants is generally achieved by alterations in hormonal balance. Hormones such as ethylene, auxin, or jasmonic acid interactively shape the relative investment of plants into growth, reproduction, and stress defense . HormoneIn this review, we approach ethylene, a central plant hormone regulating the balance between growth and stress tolerance, from a holobiont perspective. We first briefly, summarize the importance of ethylene for stress tolerance and other life history traits. We then go on to provide an overview of how plants and their associated microbiota jointly shape hormonal balances, thereby shifting plant response toward or away from adaptation to specific situations.Ethylene is a central plant hormone regulating several aspects of plant growth and development, throughout the whole plant life cycle, from germination to senescence . In addiACS and ACO form large multigene families in plants and different members can be regulated by different internal and external stimuli [An important step in ethylene production is the synthesis of its precursor ACC (1-aminocyclopropane-1 carboxylic acid) by ACC synthase (ACS) enzyme Alteration of ethylene level by microorganismsMicroorganisms may contribute to plant stress tolerance in an ethylene-independent way by providing protection mechanisms expressed outside of the host plant. For instance, plant-associated microbiota may reduce the intensity of stress experienced by the plant by detoxifying chemicals or providing protective substances against desiccation –48. FromRalstonia solanacearum, which, among other symptoms, induces banana premature ripening [Escherichia coli engineered to produce ACC oxidase [Microbes can potentially influence all regulatory steps of the ethylene pathway Fig. . The mosripening . Microbiripening , 51. Howripening  and the ripening , 55. Forripening . Phylogeripening , 56. Eth oxidase . Rhizosp oxidase , 59 and  oxidase , 60, two oxidase , 62.ACS genes [Microbioorganisms can also decrease ethylene levels, for instance, by producing ACC deaminase. This enzyme degrades ACC, ultimately leading to lower plant ethylene concentrations. ACC deaminase can be found in both commensal  and pathCS genes , 68. In CS genes , 70 and CS genes . For insCS genes . AlleviaACS genes, which can not only allow a wide range of responses, but may also lead to overreactions to stress without modulation by the associated microbiome.Co-evolution of plants with bacteria that increase or inhibit ethylene levels may have various consequences: co-evolution of plants with microbes increasing ethylene levels may cause the plant to reduce ethylene production in order to maintain homeostasis. This could result in a lower ability to produce ethylene, a higher sensitivity to stressors and a dependency on microbial ethylene production Fig. . In contIn addition to direct manipulation of ethylene levels, the microbiota is an integral component of stress perception and response. For instance, some microbial species can perceive environmental stressors relevant to the plant  as well Such intertwined signaling between plants and microbes might contribute to complete  or a parPlants live in close association with a wide range of microbes. Roots select and feed a specific microbiome . A wide Positive feedback loops: under stressful conditions, plants produce more ACC . This cogenetic variation in the microbiome is many orders of magnitude faster than in plants [Plant adaptation to fluctuating environments requires a rapid rewiring of stress response pathways such as ethylene signaling. However, this adaptation may be too slow in plants, requiring several generations to acquire and spread the needed mutations. Emergence of n plants . ModulatModulation of plant hormone levels via the microbiome may thus provide a new mechanism to match plant phenotype to environmental conditions.Ethylene-modulating microorganisms can be transmitted vertically, from one generation to the next generation, thus allowing co-evolution of microbes and the host as a cohesive unit of selection . VerticaAlterations of ethylene signaling may offer new functions and shift the niche of the holobiontAltering ethylene levels might allow plants to exploit new niche space, where other trait combinations are optimal. Co-evolution leading to ethylene overproduction Fig. c and insChange in plant-encoded ethylene signaling genesDuring co-evolution, some microorganisms are potentially part of holobiont-level ethylene-regulated traits Fig. , f. ThisUncoupling plant phenotype from mutations in the plant genomeMutations can alter plant evolution by affecting different pathways including the ethylene pathway. Mutations in the plant ethylene biosynthesis and signaling pathway  could cause new morphological traits or functions that promote plant fitness in a new environment, and therefore increase the chances for natural selection. Associated microbiota influence this selection by making the ancestral microbe-associated plants more successful in competition, thereby decreasing the advantage of mutations, as microbes might override the plant-bacteria co-evolution by altering different parts of the ethylene pathway.Based on existing scientific evidence, ethylene signaling most likely evolved within the context of long-term co-evolution processes between plants and their associated microbes. We propose that the joint regulation between microbes and plants can lead to several implications:The plant hormone ethylene mediates many aspects of plant life history. At the holobiont level, ethylene signaling is a regulatory cascade composed of both plant- and microbiota-associated traits, which together provide a dynamic and fine-tuned response to environmental conditions and stressors. The holobiont perspective in plant hormone regulation also has large evolutionary implications in which plants have become dependent on their microbiome for fully adaptive ethylene-mediated responses. From an agricultural perspective, the plant holobiont may facilitate appropriate or maladapted stress responses depending on the match or mismatch of plant and microbiome traits. Many aspects of plant health related to the microbiome and ethylene signaling may represent a useful model case to further our general understanding of plant holobiont ecology and evolution.


Polyostotic sclerosing histiocytosis, also known as Erdheim-Chester disease (ECD), is a rare form of non-Langerhans histiocytosis. ECD has wide clinical spectrums which mainly affect skeletal, neurological, dermatological, retroperitoneal, cardiac, and pulmonary manifestations. Here we describe a case of ECD in a 45-year-old female who presented initially with bilateral knee pain and homonymous superior quadrantanopia progressed to ophthalmoplegia and complete visual loss of the left eye over a period of one year. Plain X-ray of both knees showed bilateral patchy sclerosis of the distal femur and upper parts of the tibiae. Initial brain magnetic resonance imaging (MRI) showed bilateral enhancing masses in the temporal lobes anterior to the temporal horns, thickening of the pituitary stalk, partially empty sella, and involvement of the left cavernous sinus one year later. Our case is a peculiar case of ECD initially presented with unilateral homonymous superior quadrantanopia due to involvement of the visual apparatus in the mesial temporal lobe which progressed to unilateral ophthalmoplegia and total visual loss secondary to involvement of the cavernous sinus. Thus, the diagnosis of ECD should be kept in mind in the presence of bilateral bone sclerotic lesions. Polyostotic sclerosing histiocytosis, also known as Erdheim-Chester disease (ECD), is a rare form of non-Langerhans histiocytosis. ECD was first described in 1930 as a rare type of Langerhans histiocytosis which is characterized by foamy macrophage accumulation, fibrosis, chronic inflammation, and multiorgan failure [A 45-year-old female referred to our tertiary care hospital complaining of bilateral knee pain associated with swelling, intermittent generalized body pain that affected her daily activity, progressive painless visual loss in the left eye, and mild headache for one year. She was treated in another hospital symptomatically for bone pain with no improvement. Her past medical history was irrelevant except for vitamin D deficiency.On initial examination, she was afebrile, both knees were tender at joint line, with swelling over the anteromedial aspect of upper part of tibia with erythematous overlying skin. Patellar tap and ballottement tests as well as crepitus test were negative. Visual field testing revealed left homonymous superior quadrantanopia with normal visual acuity. Detailed slit lamp examination was insignificant and showed no involvement of retina. Complete blood count was normal at the time of presentation. Creatinine, urea, and electrolytes were within normal limits. High alkaline phosphatase and normal lactate dehydrogenase were present. Plain X-ray of both knees showed multiple sclerotic patches of the distal femur and upper parts of both tibiae  while biLeft tibial biopsy was performed to rule out malignancy and showed marrow infiltration with sheets of foamy histiocytes with the presence of sclerosed trabeculae. The immunohistochemistry showed CD-1a negative histiocytes; however, molecular pathology showed negative BRAF mutation. The clinical, radiological, and immunohistochemical characteristics were consistent with ECD. The patient was started on standard interferon alpha 135 mg per week for a duration of 3 weeks and methylprednisolone with improvement of her symptoms after 1 week.One year later, the patient presented with double vision and left ophthalmoplegia. On examination, she was found to have unequal pupils and papilledema. Brain MRI showed new enhancing lesion in the vicinity of the left cavernous sinus , with paECD is a rare myeloid neoplasm of multisystem involvement which can be potentially life-threatening –5. Its eSkeletal lesions are typically bilateral and symmetric, involving mainly lower limb bones. These lesions are usually found to be localized in the diaphysis-metaphysis junction and sparing the epiphysis and the axial skeleton –10. BoneCNS involvement is seen in about 40–50% of cases and responsible for 29% of all deaths due to the disease . The mosApproximately, 60% of patients will have simultaneous involvement of at least two CNS anatomical sites . The invOur case is a peculiar case of ECD involving the mesial temporal lobe which is a rare intracranial site as a cause of visual symptoms in ECD. Thus, ECD should be considered in the differential diagnosis of parenchymal intracranial lesions in the presence of bilateral skeletal sclerotic lesions.


This review discusses the need for computational modeling in myelodysplastic syndromes (MDS) and early test results.As our evolving understanding of MDS reveals a molecularly complicated disease, the need for sophisticated computer analytics is required to keep track of the number and complex interplay among the molecular abnormalities. Computational modeling and digital drug simulations using whole exome sequencing data input have produced early results showing high accuracy in predicting treatment response to standard of care drugs. Furthermore, the computational MDS models serve as clinically relevant MDS cell lines for pre-clinical assays of investigational agents.MDS is an ideal disease for computational modeling and digital drug simulations. Current research is focused on establishing the prediction value of computational modeling. Future research will test the clinical advantage of computer-informed therapy in MDS. Myelodysplastic syndromes (MDS) comprise a variety of clonal hematopoietic neoplasms with each showing dysplastic hematopoiesis, observed by light microscopy that cause at least one peripheral blood cytopenia and a risk for progression to acute myeloid leukemia (AML) –3. MDS tWith advent of DNA sequencing, we now understand that most MDS cases harbor one or more of over 70 driver gene mutations in a subclonal architecture . FurtherThe necessity to understand MDS is impelled by a limited number of therapeutic options . In the Thus, MDS is biologically complex and challenging to treat. Bridging MDS disease characteristics to clinical decision-making requires much greater sophistication than our wholesale treatment practices of the twentieth century.odo-leucoses and then a refractory cytopenia distinguished from vitamin and mineral deficiencies .••.29••].Each patient’s map also enables a quantitative means of measuring the disease physiology in a composite MDS cell growth score consisting of MDS cell apoptosis, cell proliferation, and cell viability. Next, the patient’s MDS profile can be digitally screened to predict response to drugs of interest. If the drug targets and downstream mediators for the drug are present and unperturbed by genomic mutations in the MDS profile, the cell growth score will normalize in a dose-dependent manner, suggesting a response to that particular agent. If the drug in the model does not have its targets or necessary downstream mediators, then the MDS cell growth score is unchanged and the MDS is predicted as non-responsive to the drug. Combinations of drugs are also tested in any permutation. Once the model is created and validated over the course of 5–7 days, the drug simulations can be executed on the order of minutes. PubMed references are provided as documentation linking the genomic abnormalities with predicted drug sensitivity or resistance.To test this computational method in MDS, we accessed three retrospective MDS datasets ••. The fClinicalTrials.gov NCT02435550). The trial establishes the prediction values of the computational method and is generating IDE-enabling data for a future clinical trial randomizing HMA-refractory MDS patients to SOC versus computer-informed treatment. Preliminary data show high prediction accuracy in MDS and AML patients receiving SOC [Based on these results, we subsequently initiated a prospective clinical trial designed to test the feasibility of computer-informed treatment in the management of MDS patients , Gene Expression Omnibus (GEO), cBioPortal, The Cancer Genomics Hub, canEvolve, and others have collected genomic information from a myriad cancer patients, although the lack of comprehensive clinical annotation and therapy response in most of these datasets is a major limitation .Celgene’s Connect MDS/AML Disease Registry aims to fill this data gap by capturing patient demographic data, diagnostic laboratory and bone marrow pathology data, genomic mutations, prognostic risk variables, treatments, and clinical outcome data for 1500 newly diagnosed lower-risk MDS, higher-risk MDS, ICUS, and AML patients . This riAdditionally, several groups have allowed access to their annotated clinical and/or genomic data, providing opportunities for novel computational analyses that will lead to important discoveries in MDS , 9, 35.Ongoing clinical trials, such as those coordinated by the CIBMTR, are comparing outcomes with allogeneic HCT versus HMA therapy or best supportive care. Genomically annotated clinical records from these CIBMTR trials will be essential in assessing the potency of allogeneic HCT to overcome poor-risk MDS genetics.Going forward, a concerted effort by an honest broker, such as a professional society, is needed to coalesce and harmonize the assortment of MDS datasets worldwide. This MDS database would engage engineers and scientists outside the traditional MDS research community and enable detection of a greater number MDS variables that associate with prognosis and treatment response.ex vivo assays and patient-derived xenograft (PDX) modeling, can rapidly test a limitless number of drugs and drug combinations, which catalyzes drug development for MDS.A major need in the treatment of MDS patients is to identify those with poor prognosis features who will benefit from therapy. The advent of NGS has made clear the importance of molecular profiling, as certain genomic aberrations significantly associate with drug response, survival, and allogeneic HCT outcomes. As the full complexity of MDS biology unveils, prognostic and predictive modeling will need to utilize sophisticated techniques aided by computational biology systems. By incorporating the totality of the MDS mutanome, computational methods have shown early accuracy in predicting drug response in patients with MDS. Use of a computational system may improve a clinician’s effectiveness in treating MDS, avoid toxicity when there is no prospect of benefit, weigh treatment options in the absence of guidelines, and find alternatives to treatment when none exist. Finally, computational modeling, unlike


The present review aims at compiling the findings of particularly interesting studies that use cancer cell line models for assessment of antioxidant and oxidative stress modulation properties of plant-derived bioactive compounds.Medicinal and aromatic plants (MAPs) are known and have been long in use for a variety of health and cosmetics applications. Potential pharmacological usages that take advantage of bioactive plant-derived compounds' antimicrobial, antifungal, anti-inflammatory, and antioxidant properties are being developed and many new ones explored. Some phytochemicals could trigger ROS-mediated cytotoxicity and apoptosis in cancer cells. A lot of effort has been put into investigating novel active constituents for cancer therapeutics. While other plant-derived compounds might enhance antioxidant defenses by either radical scavenging or stimulation of intracellular antioxidant enzymes, the generation of reactive oxygen species (ROS) leading to oxidative stress is one of the strategies that may show effective in damaging cancer cells. The biochemical pathways involved in plant-derived bioactive compounds' properties are complex, and  Nevertheless, interactions with other cell types are not usually considered in cell culture assays, so that the in vivo environment might not be fully mimicked. As a consequence, experimental design should be done carefully, with appropriate controls included in every assay [Cell culture techniques allow investigators to look ry assay .in vitro assessment of medicinal and aromatic plants (MAPs) regarding their antioxidant and oxidative stress-modulating properties in cancer cell lines is presented.There are several strategies for oxidative stress modulation such as ionizing radiation  and platMedicinal and aromatic plants (MAPs) are vegetal materials that have pharmacological properties and also have aromatic and gastronomic uses . The useIt is estimated that more than 80% of the world's medicinal plants grow in Asia and America , 10. MAPα inhibition and in vitro decrease of nitric oxide generation [Another application of herbal products takes advantage of their high flavonoid content that confers them free radical scavenging properties that may, in turn, reduce cellular oxidative damage and ultimately help in the maintenance of intracellular antioxidant defenses . In addineration . Naturalneration .Since the discovery of the vinca alkaloids in the 1950s and their further application in cancer therapy, the interest in MAPs has increased . The cheA number of plant-based anticancer drugs are currently under clinical studies  see Tab. Amin etIn eukaryotic cells, the most important redox process is aerobic respiration, which is mediated by mitochondrial electron transfer. This leads to the generation, in turn, of most of the endogenous intracellular reactive species (RS). For a proposed classification of RS that are produced within cells, see Generation of RS might be (1) exogenous, from sources such as UV radiation, toxic chemicals, cigarettes, drugs, pollutants, alcohol, physiological changes , and exercise or (2) endogenous, from intracellular sources including peroxisomes, mitochondrial metabolism, and the NADPH oxidase complex and myeloperoxidases, which play a fundamental role in maintaining a balanced cellular metabolism .Oxidative stress (OS) is defined as an imbalance in ROS levels and cellular antioxidant endogenous mechanisms. Although ROS are involved in innate immunity and inflammatory signaling through pathogen elimination , ROS preHigh ROS concentrations have a major negative impact in biomolecules  , with hiIntracellular ROS reduction is regulated by antioxidant enzymes such as glutathione peroxidases (GPx), catalases (CAT), and superoxide dismutases (SOD). However, in some cases, antioxidant defense mechanisms may be not enough to maintain a redox balance and might become easily saturated, causing permanent genome impairment and toxicity .In cancerous cell lines, high levels of ROS are necessary to maintain a fast proliferation rate. Szatrowski and Nathan have reported that some cancer types such as melanoma, neuroblastoma, colon carcinoma, and ovarian carcinoma generate large quantities of hydrogen peroxide . Furtherin vitro effects of plant extracts on cancer cell lines, has increased substantially over the last 10 years, as shown in The number of publications, in a PubMed search for in vitro cell functions. The use of immortalized cell lines facilitates in vitro research, but normal cell lines need to be included as experimental controls [Cell culture techniques provide a relatively easy and affordable way into eukaryotic experimentation. Cell culture is a very useful tool for the study of pathologic/normal mechanisms in cell biology and is considered essential when screening for potential new drugs for complex diseases, such as cancer. The use of a primary culture from certified vendors and proper culture media with adequate supplements and growth factors are crucial to secure consistent and stable controls .Cell line models have been widely used in OS research and also in the study of new candidate molecules for the treatment of OS-related diseases. For instance, procarbazine, an azo derivative, has been part of cancer treatment schemes since its discovery 50 years ago. Procarbazine's mechanism of action as anticancer drug involves oxidation of the molecule and production of intracellular hydrogen peroxide .Regulation of ROS is fundamental for homeostasis and normal functioning of cells. Several studies have addressed this complex series of phenomena. For instance, in a study by Schlenker et al., OS was evaluated using a bile duct epithelial cell (BDE) model to determine the earliest effects of RS in cell injury. The study authors found that OS causes a significant decrease in cell volume and affects multiple cell functions such as ion permeability, activation of ion channels, and apoptosis . Glorieuin vitro screening of MAP-derived antioxidants has been on the rise in the last years. In the next section, we will look at several promising applications of MAPs based on data from in vitro cancer studies.As shown in The methodology used in all the studies presented in this review has been summarized in A study by Yedjou and Tchounwou evaluated the effect of garlic extract in an HL-60 model (human leukemia cells). This extract was found cytotoxic (via apoptosis) and an inductor of oxidative stress on tested cells. An interesting finding of the above study is the potential of malondialdehyde (MDA) as a biomarker of oxidative stress associated with caspase activation and DNA fragmentation. Mechanistic data regarding the observed cell responses to garlic extract is, however, still lacking .in vitro effect of apigenin, a natural polyphenolic compound rich in flavones, on cell lines HT-29  and HCT-15  models, the authors [In a study on the  authors  showed tThe anticancer properties of this herbal mixture used in traditional medicine have been assessed on several cancer cell lines  . In the Chemotherapeutics are usually toxic for both noncancer and cancer cells. Appropriate combinations of available drugs are crucial to effectively kill cancer cells, reduce side effects and improve survival rates. A study by Tyszka-Czochara et al.  evaluateInula helianthus aquatic on HT-29 and HCT 116 colorectal cancer cell lines was studied in a recent work by Li et al. [The effect of this sesquiterpene lactone naturally produced by i et al. . The autIwasaki et al. in a recently published work  studied Curcuma longa L. that has shown many pharmacological activities, such as modulation of the nuclear NF-κB signaling pathway. Hong et al. [Curcumin is a bioactive compound isolated from g et al.  showed tg et al. .The role of natural antioxidants in oxidative stress-related diseases has been studied for several years. MAPs can act as protective agents against OS and thus their potential for use in such diseases might be worth exploring.Fucus spiralis on H₂O₂-treated MCF-7 cells (breast adenocarcinoma) [A study of five antioxidant fractions from seaweed rcinoma)  showed aCannabis sativa, on a hydrogen peroxide ROS-induced murine RAW 264.7 macrophage model. This study identified the selective receptor antagonists needed to elucidate CBG's known antioxidant properties at the mechanistic level. The authors found that activation of CB2 receptors is involved in CBG effects, with receptor inhibition leading to lower oxidation as a cytoprotective effect. CBG was found to downregulate several oxidative markers through inhibition of phosphorylation and modulation of MAPK. In addition, CBG exerted antioxidant activity by inducing superoxide dismutase-1 (SOD-1) overexpression, which causes an imbalance in proapoptotic factors to avoid cell death.In another recent study, Giacoppo et al.  evaluate(60)Co γ-radiation DNA damage in exposed lymphocytes. Furthermore, these natural polyphenols could inhibit lipid peroxidation and activate antioxidant enzymes.Plant compounds such as flavonoids, polysaccharides, and phytohormones could function as radioprotectors, meaning they can protect adjacent normal cells from the harmful effects of radiation therapy. It has been proposed that the above compounds might also offer protection against ionizing occupational and environmental radiation exposure . In a reConversely, plant products could act as radiosensitizers by enhancing the effect of ionizing radiation therapy against radioresistant cells. A study conducted by Wang et al.  showed tin vitro oxidative stress cell model. Hydrogen peroxide is a chemical that is frequently used for oxidative stress induction in cultured cells; however, concentrations and exposure times vary extensible and may require standardization to assure reproducibility and data comparability [Lastly, it is important to mention that many studies currently in place evaluate the protective effect of novel antioxidant plant compounds against oxidative stress. Due to the complexity of biological systems, an interesting approach in antioxidant molecules testing might be the construction of an rability –58.in vitro cell models is critical for a comprehensive understanding of the biological properties of plant-derived compounds in cancer research. According to the European Union Reference Laboratory for Alternatives to Animal Testing (EURL-ECVAM), there are several in vitro cell models accepted for drug development applications. In the case of oxidative stress, studies on cell models help to integrate multiple metabolic routes and identify novel plant-based drugs or therapeutic targets. For instance, human-induced pluripotent stem cells (hiPSC) might be a valuable model for neurotoxicity studies with the use of the oxidative stress biomarker Nrf2 [in vitro toxicology testing platforms.The use of ker Nrf2 . Such a Evaluation of potential natural drugs for modulation of oxidative stress in cancer might, in our opinion, be addressed efficiently and rigorously using cell line models. The NCI60 human tumor cell line anticancer drug screen panel had been used for testing of natural crude extracts collections since 1989. The panel requires previous individual cell line screening, which has led, for example, to the discovery of bortezomib, the first therapeutic proteasome inhibitor for the treatment of multiple myeloma [Additionally, it is important to consider that a wide range of subtypes of cancer cell lines is currently available through certified vendors and collections. Colorectal cancer cell lines, for instance, show different genomic patterns and mRNA expression profiles  and may in vivo experiments with animal models might be optimized based on in vitro data. Information from in vitro and in vivo studies will, in turn, facilitate and improve further clinical trials [In conclusion, carefully planned experiments on cell culture models allow a throughout assessment of the molecular pathways involved in the mechanism of action of a bioactive compound. The use of these models for evaluation of ROS production and oxidative stress modulation properties of plant-derived biocompounds is well documented and growing. Consequently, l trials .in vivo environment. Three-dimensional (3-D) cultures closely emulate tumor formation processes by synthetic tumor microenvironment mimics (STEMs). Models of human lung epithelial cells, pulmonary vascular endothelial cells, and human bone marrow-derived mesenchymal stem cells have been used for induction of ROS production and evaluation of upregulated efflux transporters [Cell culturing aims at mimicking sporters . Finally


Donor-specific induced pluripotent stem cells (iPSCs) offer opportunities for personalized cell replacement therapeutic approaches due to their unlimited self-renewal potential and ability to differentiate into different somatic cells. A significant progress has been made toward generating iPSC lines that are free of integrating viral vectors, development of xeno-free culture conditions, and differentiation of pluripotent stem cells (PSCs) into functional somatic cell lineages. Since donor-specific iPSC lines are genetically identical to the individual, they are expected to be immunologically matched and these iPSC lines and their cellular derivatives are not expected to be immunologically rejected. However, studies in mouse models, utilizing rejection of teratomas as a model, have claimed that syngenic iPSC lines, especially the iPSC lines derived with integrating viral vectors, could be inherently immunogenic. This manuscript reviews current understanding of inherent immunogenicity of PSC lines, especially that of the human iPSC lines and their cellular derivatives, and strategies to overcome it. Isolation of human embryonic stem cells (hESCs) from early stage embryos  and repr−/− and CD8−/− mice could form teratomas , but 20 × 106 allogenic mESC can form teratomas in all the transplanted animals  (The issue of inherent immunogenicity of human pluripotent stem cell (hPSC) lines was first examined with hESC lines, and they were shown to express low levels of MHC class I molecules but no MHC class II molecules . Drukker process . To testman PBMC  and showman PBMC . Howeveres (CTL) .−/− mice and immune-competent CD1 mice and did not find any sign of immune-reactivity at the transplantation site, evident by lack of granulocytes infiltration in Prk−/− mice and abrogation of granulocyte and lymphocyte infiltration in immune competent mice upon endotoxin administration along with hESC, suggesting that the hESCs exhibit immunosuppressive properties in vivo  ruling out an active immune response against the grafts /chimeric antigen receptor (CAR) engineered antitumor T cells that have produced remarkable clinical outcomes in cancer patients –58. Howevia tumor antigen-specific TCR and CAR engineering approaches, and these T cells have been shown to exhibit antigen-specific effector function (in vitro as well as in vivo (A significant progress has been made toward generating effector T cells, APC, NK cells, and other blood lineages from the hESC and iPSC lines –65. Funcfunction –70. Dono in vivo , 71. Whi in vivo  and the Since the isolation of first hESC lines and especially the derivation of donor-specific iPSC lines, regenerative medicine field has progressed at an exponential pace. Methods have been developed to generate donor-specific iPSC lines that are free of integrating viral vectors from different somatic cell lineages, including terminally differentiated primary immune cells, and different types of functional somatic cells have been derived, some of which have even advanced to the clinical trials stage. However, several challenges, such as the inherent immunogenicity of iPSC lines, have also been identified that need to be addressed. Since iPSC lines derived from different somatic cells and with different iPSC derivation methods can harbor different genetic and epigenetic signatures, it is necessary to fully characterize the mechanism of development and maintenance of pluripotency to generate iPSC lines with stable genomic architecture. This is important given that incomplete reprogramming could generate a neoantigen repertoire that could translate into enhanced immunogenicity of iPSC lines. Furthermore, while inherent immunogenicity of iPSC lines is not desired, iPSC-derived immune cells need to be fully functional. Therefore, according to the somatic cell lineage of choice, appropriate models need to be developed to characterize their molecular, cellular, as well as functional profiles. Addressing these issues is critical for developing safe and effective CRT.AC conceived and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer, FR, and handling editor declared their shared affiliation, and the handling editor states that the process nevertheless met the standards of a fair and objective review.


Currently, a marked number of clinical trials on cancer treatment have revealed the success of immunomodulatory therapies based on immune checkpoint inhibitors that activate tumor-specific T cells. However, the therapeutic efficacy of cancer immunotherapies is only restricted to a small fraction of patients. A deeper understanding of key mechanisms generating an immunosuppressive tumor microenvironment (TME) remains a major challenge for more effective antitumor immunity. There is a growing evidence that the TME supports inappropriate metabolic reprogramming that dampens T cell function, and therefore impacts the antitumor immune response and tumor progression. Notably, the immunosuppressive TME is characterized by a lack of crucial carbon sources critical for T cell function and increased inhibitory signals. Here, we summarize the basics of intrinsic and extrinsic metabolic remodeling and metabolic checkpoints underlying the competition between cancer and infiltrating immune cells for nutrients and metabolites. Intriguingly, the upregulation of tumor programmed death-L1 and cytotoxic T lymphocyte-associated antigen 4 alters the metabolic programme of T cells and drives their exhaustion. In this context, targeting both tumor and T cell metabolism can beneficially enhance or temper immunity in an inhospitable microenvironment and markedly improve the success of immunotherapies. Over the past decades, huge efforts have focused on refinement of conventional cancer therapeutic strategies of chemotherapy, radiation, surgery, or targeted therapies. Although all these advances have displayed clear improvement of clinical outcomes for many types of cancers –3, theirTumor-infiltrating lymphocytes (TIL) reflect tumor biology and prognostic significance. However, they are challenged with a hostile microenvironment that dampens their function and produces antitumor effects . NeverthCollectively, the cancer cell energetics dictates the metabolic landscape of the TME. Abnormal metabolic activities of cancer cells lead to intratumoral heterogeneity and immunosuppression that could be responsible for the failure of immunotherapy , 25. The+ T cells can differentiate into T helper (Th) subsets or into regulatory T cells Treg, while CD8+ T cells differentiate into effector cytotoxic T lymphocytes (CTLs). Importantly, each T cell functional subset utilizes a distinct metabolic program  cells, macrophages, dendritic cells, fibroblasts, and adipocytes. Regarding its genetic and metabolic diversity, this intricate network of cells contributes to the intratumoral heterogeneity. Tumors exhibit a metabolic shift and shape the TME in such a way to support cancer proliferation and metastasis , 60. YetIt is well known that tumor cells like effector T cells (Teff), exhibit intensive aerobic glycolysis that improve their metabolic fitness and provide cell-extrinsic advantage, resulting in competition for vital metabolites such as glucose and amino acids. Therefore, tumor-infiltrating T cells are exposed to nutrient depletion in TME and become dysfunctional , 63. NutMoreover, it has been recognized that in addition to consumption of key nutrients, tumors produce large amounts of waste products: lactate, arginine and tryptophan by-products, and phosphoenolpyruvate, that impair T cell metabolism and function and confer worse prognosis for patients , 68.Lactate accumulation due to the use of aerobic glycolysis by cancer cells has been described in TME, accompanied by consequent low pH and acidification of the milieu. In mouse models, lactate levels negatively correlate with markers of T cell activation in melanoma . The tumProliferative cancer cells create a state of tryptophan deprivation in the TME because of their increased demand for tryptophan . IndoleaImmune checkpoint regulators are critical to coordinate effective and efficient immune response, to maintain self-tolerance and to prevent the onset of autoimmunity . NeverthTumors can evade immune surveillance through defective immune-checkpoint signaling pathways , 85. It Although the effectiveness of the immune checkpoint blockade in enhancing antitumor immunity by reducing the number and/or the suppressive activity of Tregs and by restoring the activity of Teff has been reported, little is known about mechanisms underlying T-cell activation. Recent evidence suggest that both checkpoint ligation and inhibition may directly modify metabolism of T cells and cancer cells and alter their metabolic feature. Emerging data have shown that PD-1 binding to its ligands impairs the metabolic phenotype of TIL, by inhibiting glycolysis and upregulating fatty acid oxidation (FAO) , 96. CTLInterestingly, the immune checkpoint blockade appears to differentially impact the metabolic profile in TME by favoring T cell activation and in contrast inhibiting cancer cells. Blocking PD-1 and PD-L1 may reduce glycolysis level in cancer cells by inhibiting mTOR pathway . ConsequIn conclusion, clear evidences demonstrated that tumor cell metabolism deeply affects TME differentiation and functions. By modulating tumor cell metabolism, one can control nutrient availability for T cells, thus promoting either their antitumor or immunosuppressive functions.In tumors, T cell activation and proliferation could be impaired by metabolic disruption, therefore cell metabolism becomes an attractive target to restore anti tumor immunity and to develop anticancer therapy . Howeverin vitro . AZD3965 is targeting MCT-1/MCT-2. Yet, the inhibitory effect has also been observed in T cells -OH], showed reduced glutamine uptake and cell growth in lung and prostate cancers (Glutamine is considered as a critical amino acid for cancer cell metabolism as well as for rapidly dividing T cells. To overcome the high glutamine consumption rates of cancer cells, several therapeutic agents targeting glutamine metabolism have been explored in preclinical studies . Three c cancers , 170. YeCancer immunotherapy provides successful and powerful opportunity in cancer treatment. However, it is important to get comprehensive understanding of mechanisms leading to reduced antitumor immunity under hostile TME. Importantly, TILs have to surpass not only immune checkpoints but also a wide range of metabolic checkpoints that fate their energetic behavior defects and dampen their function. In fact, cancer cells upregulate nutrients uptake and waste metabolites production to generate an immunosuppressive TME that allows their evasion and growth, and that dictates immune cell fate Figure A. IncreaAll authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.


Background: Huntington disease (HD) is an inherited neuropsychiatric condition with progressive neurodegenerative changes, mainly affecting the striatum. Pathological processes within the striatum are likely to lead to alterations in dopamine and glutamate activity in frontostriatal circuitry, resulting in characteristic motor, behavioural and cognitive symptoms. Methods: We conducted a systematic literature search in order to identify and review randomised, double-blinded, placebo-controlled trials of anti-dopaminergic and anti-glutamatergic therapy in HD.Results: Ten studies satisfied our selection criteria. These studies investigated a range of agents which act to antagonise dopamine  or glutamate  transmission.Discussion: Although most agents showed efficacy in terms of amelioration of chorea, the available evidence did not allow us to identify a universally effective treatment. One difficulty associated with analysing the available evidence was a high prevalence of side effects, which prevented the full therapeutic potential of the medications from being adequately investigated. A further limitation is that many studies evaluated treatment effectiveness only in relation to patients' motor symptoms, even though behavioural and cognitive changes may negatively impact patients' quality of life. There is a clear need for further higher-level evidence addressing the effects of dopaminergic and glutamatergic agents on global functioning in HD.


As radiotherapy advances, inadequate deliveries decrease and salvage radical prostatectomy, when necessary, tends to be less challenging with improving oncological and functional results. It treats cancer foci in regions such as apex or periurethral tissue, often spared in ablative approaches to minimize side effects; adds the clear goal of an undetectable PSA; and the opportunity for pelvic lymph-node dissection to potentially treat loco regional micrometastasis.Up to 50% of men may develop recurrence after definitive radiation for prostate cancer, and about one-third of these men will have a biopsy-proven local radiorecurrence, which occurs due to either inadequate delivery of the prescribed radiation dose or inherent biologic resistance of prostate cancer clones to radiation. Standard of care for these patients has been classically observation followed by androgen deprivation (ADT), which adds substantial morbidity and doesn't offer the possibility of cure.In selected patients, radical prostatectomy, brachytherapy, cryotherapy, and high-intensity focused ultrasound (HiFU) offer reasonable cancer control outcomes without the need for salvage ADT, which is reserved for situations of clear evidence of systemic disease, with the goal of delaying progression and reducing morbidity and mortality .There are currently no uniform definitions of cancer control and toxicity in the post-radiorecurrence setting, no randomized trials comparing any of local salvage therapies to ob-servation or ADT, and no analysis of the impact of pelvic lymph node dissection. At first glance, one might envisage a central role for the potentially less aggressive local approach offered by ablation strategies as opposed to salvage radical prostatectomy (SRP), mainly because if one has not opted for surgery as the first line treatment, the reasons against surgery will exponentially grow in the salvage setting.However, in pooled head to head data, even based on the more permissive recurrence definitions of ablative therapies, ablative approaches do not necessarily supplant SRP in terms of oncological results and have also not always exhibited the expected dramatic decrease in morbidity when compared to SRP , 3.As radiotherapy advances and improves over time, inadequate deliveries decrease and when necessary, SRP tends to be less challenging, as evidenced by improvement in surgical morbidity and oncologic outcomes in later series, especially in high volume centers where Clavien grade 3 or higher complications are uncommon and successfully treated in most cases . Also, sA benefit of SRP is that it adds the clear goal of an undetectable PSA and the opportunity for pelvic lymph-node dissection (LND) to potentially treat loco regional micrometastasis and delay further progression, although cancer-specific survival data is still needed . Also, tLow-risk disease patients show higher chances of cancer control, but also carry a higher risk of overtreatment in the radiorecurrent setting. Identifying better markers of metastatic disease is critical to determining which patients are salvage treatment candidates and current rapidly-improving imaging tools impacting the accuracy to distinguish local from locoregional and distant recurrence play a central role.Initial low-risk disease, long PSADT, low pre salvage PSA, and a lower Gleason score at the time of recurrence indicate a better likelihood of response to local treatment and both improved patient selection and exclusion of metastatic disease are fundamental, independent of therapeutic choice. While recently introduced whole-body MRI, PET with radiolabelled PSMA, bombesin or uPAR and PET/MRI might improve staging accuracy, no standard protocol has been shown to completely rule out the possibility of subclinical metastases .To minimize overtreatment, patients should have: 1 - life expectancy long enough to benefit from intervention; 2 - a disease that is aggressive enough to warrant salvage therapy; 3 - but not so aggressive that there is a high chance that the patient has disseminated disease beyond the capacity of locoregional treatment for curative intent.Pending high-quality randomized studies, the patient should be involved in an individualized decision-making process where all treatment options pros and cons should be discussed in a multi-disciplinary team and independent of salvage local treatment choice, patient should be highly motivated and aware of significant morbidity and risk of future multimodal treatment.


Acquisition and transmission by an insect vector is central to the infection cycle of the majority of plant pathogenic viruses. Plant viruses can interact with their insect host in a variety of ways including both non-persistent and circulative transmission; in some cases, the latter involves virus replication in cells of the insect host. Replicating viruses can also elicit both innate and specific defense responses in the insect host. A consistent feature is that the interaction of the virus with its insect host/vector requires specific molecular interactions between virus and host, commonly via proteins. Understanding the interactions between plant viruses and their insect host can underpin approaches to protect plants from infection by interfering with virus uptake and transmission. Here, we provide a perspective focused on identifying novel approaches and research directions to facilitate control of plant viruses by better understanding and targeting virus–insect molecular interactions. We also draw parallels with molecular interactions in insect vectors of animal viruses, and consider technical advances for their control that may be more broadly applicable to plant virus vectors. The majority of plant viruses that cause disease in agricultural crops rely on biotic vectors for transmission and survival . The larMyzus persicae .,28.2,28]oviridae . After ioviridae ,31,32,33oviridae ,34,35,36oviridae . Criticaoviridae . Interesoviridae . PinheirGeminiviridae) circulative transmission in their whitefly vector were recently reviewed . ,4. 2,4].ncticeps  involvesncticeps ,47. Thisncticeps ,49. RDV ncticeps . RDV Pnscificity . The reourcifera ,53. Thisurcifera ,55. SRBSFrankliniella occidentalis, even though in insect cell lines tubules can be generated from the non-structural movement protein NSm [Tomato spotted wilt virus (TSWV) and other tospoviruses also generate tubules for viral movement in plants . Howevertein NSm . The routein NSm . Infectitein NSm ,59. Numetein NSm ,61,62. Atein NSm . Gc prottein NSm ,65. Desptein NSm ,67.Nilaparvata lugens involves invasion of the principal and accessory salivary glands but does not involve entry into neural tissues or ovarioles [Laodelphax striatellus [L. striatellus and involves Vg interaction with RSV major nucleocapsid protein pc3 [Tenuiviruses are transmitted by planthoppers and leafhoppers and their vector dissemination route includes diverse organs ,69. Diffiatellus ,71. Inteiatellus  and theyiatellus . Tenuivitein pc3 . Rhabdoviridae, monopartite cyto- and nucleorhabdoviruses with known vectors are transmitted in a persistent, circulative-propagative manner by aphids, planthoppers or leafhoppers [Peregrinus maidis appears to breach the transmission barriers in P. maidis by spreading from the midgut to the anterior diverticulum and esophagus, a region that spans the compound ganglia and salivary glands, and then invades neuronal tissues including brain, compound ganglion and compound eye cells to gain access to the salivary glands [In the fhoppers ,75,76. Mfhoppers . Plant ry glands . Plant ry glands ,75, but Insect vectors play a crucial role in determining the plant host range of a virus. Competency for virus transmission is determined by genetic components and specific molecular interactions of virus and vector, and potentially host plant components taken up during feeding. Better knowledge of these interactions and mechanisms of transmission will be essential for developing more effective control measures in future. Currently available strategies to interfere with virus transmission by vectors include host genetic resistance to virus and/or insect, insecticides and integrated pest management . CriticaAn excellent recent review discusses potential avenues to disrupt or interfere with insect transmission of plant viruses . The maiEmerging evidence suggests that non-circulative, “stylet-borne” virus transmission involves more than passive adhesion to the sucking-feeding mouthparts, and instead results from specific molecular interactions between virus, plant and vector. The concept of “transmission activation” has been proposed, based on the immediate intracellular response of CaMV to the presence of the aphid vector on the plant . Aphid pRhabdoviridae), tospoviruses (family Bunyaviridae), tenuiviruses and reoviruses (family Reoviridae), viruses encounter multiple barriers to acquisition, replication, intercellular movement, cell escape and host plant inoculation [During the infection process of persistent, propagative viruses such as rhabdoviruses  leading to the inhibition of internal virus spread . Anti-viGraminella nigrifrons, the leafhopper vector of the nucleorhabdovirus MFSV, were shown to be differentially expressed when insects fed on virus-infected leaves [P. maidis that transmits MMV shows innate immunity and RNAi pathway genes upregulated [Replicating plant viruses have been shown to activate the immune response of their insect vectors. This was first demonstrated for TSWV through up-regulation of thrips transcripts for antimicrobial peptides, pathogen recognition and innate immune system activation . Immune d leaves ,88. The egulated . Persistegulated . A betteThe salivary gland of transmission-competent sucking vector insects deserves special attention. Saliva plays a crucial role in insect feeding behavior and virus transmission . In thriFrankliniella occidentalis thrips [Plant viruses can modify insect vector behavior directly, and indirectly by manipulating plant hosts, leading to enhanced transmission efficiency and spread . Directls thrips . The nons thrips ,95. The s thrips . FurtherVirus-induced biochemical and physiological changes in the host-plant have been shown to influence vector insect host preference . Virus-iWhile the processes involved in transmission of viruses directly from plant to plant or animal to animal vary substantially, viruses of both plants and vertebrates that are vectored by insects have many parallels in their interactions with their insect host. Insects that vector viruses are mainly hemipteran sap-feeders for plants and mainly dipteran blood-feeders (primarily mosquitoes) for vertebrates. In both cases the virus is acquired during feeding on the non-insect host and then is transferred to a naïve non-insect host again via feeding. The interaction with the insect host for vertebrate viruses is considered either biological (the virus replicates in the vector) or mechanical (not involving replication) . As discFlaviviridae, Togaviridae and Bunyaviridae) with Aedes and Culex species mosquitoes transmitting the majority of these [A major focus of insect vector transmitted vertebrate viruses is the mosquito-borne viruses that cause significant human disease. These include viruses from three RNA virus families  . UnderstMosquito-borne viruses generally cycle between infection of the vertebrate and insect hosts. Many mosquito vectors require a vertebrate blood meal to reproduce. Following mosquito acquisition of virus via feeding on an infected vertebrate host, the virus enters and replicates in the cells of the gut epithelium, spreads via the hemocoel to other tissues and organs, culminating in transport to and infection of the salivary glands. The virus then escapes the salivary glands and is transmitted in the saliva when the infected insect feeds on a new vertebrate host (reviewed in ). FollowDrosophila model system has been used to identify many of these antiviral immune pathways [Drosophila viruses can be highly pathogenic to their host. Persistent infection of Drosophila can be established following integration of DNA copies of fragments of an RNA virus genome, created by reverse transcription by a retrotransposon reverse transcriptase. These integrated sequences then act as the templates for initiation of the RNAi response against the virus [Efficient virus transmission is a balance between virus infection and insect host health. While mosquito-borne viruses are commonly pathogenic to their vertebrate host, biological infection of the insect host has few major pathogenic impacts on the insect host, allowing efficient transmission of the virus by the insect vector . The virpathways ,121, buthe virus . Thus unThe mosquito microbiome also plays a role in the outcome of virus infection. The mosquito gut microbiome is diverse and can influence mosquito vector competence Wolbachia and Spiroplasma, are commonly identified in the mosquito microbiota. While Spiroplasma can be pathogenic in mosquitoes, their role in mosquito competence to vector viruses remains to be determined [Wolbachia pipientis has antiviral effects in both naturally infected and experimentally infected insects. Wolbachia is an endosymbiotic bacteria commonly found in cells of the reproductive tissues, salivary glands, Malpighian tubules, head and muscle [Wolbachia is maternally inherited and is well known for its ability to invade invertebrate populations via modification of the reproductive system of the host insect [Drosophila, flies naturally infected with Wolbachia can be protected from RNA virus infection , artifimission  [Culex mosquitoes with Culex flavivirus reduced susceptibility to West Nile virus (WNV) infection [The advent of the ‘omics’ age has identified a plethora of sequences of important arboviruses within vector mosquitoes. In a number of cases these virus sequences have been matched to infectious viruses, which have been shown to have a host range restricted to insects, and are termed insect specific viruses (ISVs) . ISVs arviruses) . ISVs haviruses) ). There nfection  and in vnfection ,151. TheIn addition to the bacterial and viral microbiota, mosquitoes are commonly associated with yeast and fungi (reviewed in ). ComparWolbachia . Seiewed in ,144) andiewed in ). This fustralia ,155. Howustralia . Other microbes of mosquitoes have the potential as platforms for control of arboviruses. Recently, bacteria have been utilized as a vehicle to generate and deliver double-stranded RNA (dsRNA) to mosquitoes to manipulate gene expression, and adaptation of this approach to manipulate arbovirus infection is an interesting  para-transgenic approach ,158. OthAnopheles stephensi [Recently the exciting CRISPR/Cas9 genome editing system has been adapted to introduce refractory genes into the Asian malaria vector tephensi . An impotephensi , which wtephensi . In theotephensi . Vector tephensi .Wolbachia has antiviral effects on virus transmission in mosquitoes [Wolbachia is a common endosymbiont of insects and is predicted to be present in over 40% of arthropod species [Wolbachia has not been identified in the vast majority of aphid species, Wolbachia is known to be present in at least some plant feeding insect vectors including the whitefly [Wolbachia was recently shown to play a role in the supply of essential nutrients to the banana aphid [Wolbachia in the mosquito are strongest following experimental transfer of the bacteria into a new host [Wolbachia into plant virus vectors may interfere with virus replication or transmission is yet to be examined. Other parts of the vector insect microbiome may also have an effect and one might imagine use of inhibitory microbes to block plant virus transmission. Insect-associated bacteria could also potentially be used to deliver dsRNA to knockdown vector genes that are essential for insect survival or that code for virus receptors. It may also be possible to use engineered insect or plant viruses to deliver insect genome editing tools based on programmable RNA-guided nucleases such as zinc-finger nucleases or CRISPR/Cas9. Interestingly, although potential virus receptors for bunyavirus early interactions with host cells were demonstrated in vertebrates, none appear to have been identified in their arthropod vectors [Application of molecular technologies to the investigation of virus–vector interactions can be expected to provide deeper insights in the future. Some of these may be transposed from advances in the understanding of virus-mosquito interactions, although there are both parallels and differences between plant and animal/human systems. The bacterial endosymbiont squitoes ,144 but  species . Althougwhitefly ,164,165.na aphid . Antibionew host , the pos vectors . On the  vectors ,168 and  vectors ; clearlyThe use of green fluorescent protein tagged viruses will aid visualization of virus uptake, tissue tropism, intercellular movement in the vector, and transmission. This will require the use of reverse genetics systems to generate infectious virus clones that are available for many DNA and positive-sense RNA viruses, but are lacking for negative-sense RNA viruses such as TSWV. Only recently has the first reverse genetics system been developed for a plant rhabdovirus, which may serve as a model to develop such tools for other negative-sense RNA viruses . MutatioImmunofluorescence confocal laser scanning microscopy has been used to identify a neurotropic route for MMV in its planthopper vector  and coulhttp://www.aphidbase.com), including the genomes of the pea aphid (Acyrthosiphon pisum) and green peach aphid (M. persicae). Draft genomes for the western flower thrips  and brown planthopper (N. lugens) are also now available and others are in progress through the i5K project (http://arthropodgenomes.org/wiki/i5K). Transcriptome analysis of transmission-competent vectors using RNA sequencing and quantitative RT-PCR has been used to identify insect defense response genes and pinpoint expression in relevant tissues like insect gut, salivary gland and nervous cell tissues [RNAi is increasingly used for functional genomic studies of vector insects including leafhoppers, aphids and thrips, and to knock down insect proteins that interact with virus proteins . These a tissues ,87,89.F. occidentalis are available, and differentially expressed (DE) genes in response to TSWV infection including antiviral defense are being annotated [A foundational toolbox of sequence-based resources has been developed to elucidate thrips gene function and understand thrips-plant interactions and tospovirus transmission  that maynnotated . Global nnotated . Primarynnotated . The binding and functional properties of virus acquisition determinants could be exploited in translational research approaches for improved disease control . This coProtein–protein interactions between plant viruses and their insect vectors are an essential molecular interface that determines acquisition from infected host plants and transmission to new hosts. The apparent specificity of these interactions in both non-persistent and persistent plant virus transmission opens avenues for interference and control of the vector populations as well as virus transmission. While several viral interacting proteins are known, insect vector receptor-like molecules are only beginning to be identified. Increasing application of ‘omics’ technologies has the potential to contribute significantly to the identification and validation of virus-interacting proteins in the vector, as well as, a better understanding of innate immune responses to viral infection. Much knowledge can be gained from the application of emerging technologies including reverse genetics systems applied in insects and insect cells, high resolution imaging techniques, functional genomics and gene editing. Direct and indirect effects on vector behavior in relation to the infected plant host is another important research area impacting on virus acquisition and dissemination that once better understood, may lend itself to adoption of novel control strategies.