Two-way analyses of covariance (ANCOVA) tested effects of FH and self-reported binge drinking on attention scores from the Barratt Impulsiveness Scale (BIS). In addition, mediation analyses tested whether BIS attention scores mediated the relationship between Conner-Davidson Resilience Scale scores and binge drinking. ANCOVA results indicated a significant FH-by-binge drinking interaction (p = 0.008) in which FH positive subjects who did not binge drink had the fewest attention problems, consistent with a marker of resilience. Furthermore, BIS attention scores significantly mediated the effect of Conner-Davidson Resilience Scale scores on binge drinking, with stronger effects in FH positive subjects (p < 0.001) than FH negative subjects (p = 0.49). The findings suggest that attention promotes resilience to binge drinking in individuals with familial risk for AUD. Interventions targeting attentional ability in this high-risk population, particularly FH positive individuals with attention deficits, may serve to reduce binge drinking and its consequences.Binge patterns of alcohol use among post-high school emerging adults are associated with both immediate negative consequences and increased risk of long-term drinking problems, particularly among individuals with a family history (FH) of alcohol use disorder (AUD). Therefore, the developmental time period of emerging adulthood, paired with the high-risk environment of college campuses, represents an important target for interventions. Attentional ability has recently emerged as a mediator of resilience to stress-related psychopathology and offers a potential neurocognitive target for interventions. We tested the hypothesis that attentional ability promotes resilience to binge drinking in a sample of 464 college students with ( Approximately 7% of adults in the United States meet criteria for an AUD, with the highest prevalence among individuals between late adolescence and young adulthood , 2. In fBinge drinking in particular represents a dominant pattern of drinking among college students, with 39% of these individuals aged 18–22 years) reporting at least one binge drinking episode in the past month 2 years r. Thus, aRecent studies have revealed a robust link between attentional ability and resilience against stress-related psychopathology, including AUD –14. ResiAmong those at greatest risk of developing AUD are individuals with a family history (FH) of AUD. Twin studies estimate that approximately half of the risk for AUD is heritable , 20. Thun = 148) consisted of a neuroimaging session as well as online self-report questionnaires. Study 2 (n = 316) was designed, largely in response to the COVID-19 pandemic, as an online alternative to the neuroimaging study in which participants completed the same set of self-report questionnaires but did not attend an in-person imaging session. Participants gave written (Study 1) or electronic (Study 2) informed consent in accordance with ethical standards of the UNC Office of Human Research Ethics.We recruited 464 first-year college students for one of two parallel studies. Study 1  for DSM-IV  and urine drug screen , respectively.Inclusion criteria for both studies was 18–19 years of age and in their first year in a 4-year undergraduate degree program. Given the strong effects of the college environment on alcohol consumption, and to reduce variability associated with this factor, college attendance at time of study enrollment was an inclusion criterion. The neuroimaging study, Study 1, had additional exclusion criteria: MRI contraindications , left-handedness, psychoactive drug use (including medications), neurological disorders, and psychiatric disorders with the exception of lifetime—but not current—mood or anxiety disorders. Psychiatric disorders were assessed r DSM-IV . We exclSubjects completed a computerized battery of self-report questionnaires administered with Research Electronic DATA Capture (REDCap) tools hosted at UNC , which iWe administered three items from the Alcohol Use Questionnaire (#10-#12) that were combined to create a “binge drinking score,” as described elsewhere .Timeline followback calendars  were admAUD among family members was assessed with the Family History Assessment Module (FHAM) . We creaThe CD-RISC is a measure of resilience that contains 10 questions relating to ability to cope with stressors and has been validated for use in college students with histories of stress and trauma . Scores a priori hypothesis centered around attention as a mediator of resilience and binge drinking, we used this subscale in our primary analyses. Secondary analyses explored relationships using other first-order and second-order subscales.Although the BIS was designed as a measure of impulsivity, the BIS factor structure contains a first-order factor that is comprised of items measuring attentional ability . QuestioDepressive symptoms were measured with the Beck Depression Inventory , and a tFor descriptive purposes, we calculated the means and standard errors of the means for the above self-report measures, separately by FH status and study. A chi-square test in SAS 9.4 PROC FREQ tested for differences in the distribution of the sexes by FH status and study. Two-way analyses of variance (ANOVAs) in SAS  PROC ANOVA were performed on BDI scores, CD-RISC scores, and BIS scores to test for main effects of FH status and study. Although we administered the Customary Drinking and Drug Use Record  to asseTo examine evidence for attention as a resilience factor among FHP subjects, we tested for statistical differences in attention between FHP binge drinkers and non-binge drinkers as well as between FHN binge drinkers and non-binge drinkers. Because there is not a specific binge drinking score that clearly delineates binge drinkers from non-binge drinkers due to the nature of the calculation , we desiWe conducted a two-way analysis of covariance  testing factors of FH, binge drinking, and their interaction, covarying for sex and study. Exploratory analyses tested other BIS subscales as dependent variables in similar ANCOVA models without correcting for the multiple tests.We assessed correlational relationships between CD-RISC and BDI scores, binge drinking scores, and BIS scores. Spearman rank-order partial correlations were conducted in SAS 9.4 separately by FH status, covarying for study. Statistical significance was determined by calculating 95% confidence intervals from 10,000 bootstrap iterations. We included biological sex as a covariate due to sex differences in binge drinking  as well as in stress-related psychopathology within attention systems . Due to Next, we sought to examine causal relationships between attention, resilience, and binge alcohol drinking. Specifically, we used mediation analyses to test whether BIS attention scores mediated the relationship between CD-RISC scores and binge drinking scores, and whether the indirect effect was moderated by FH.Missing questionnaire data was imputed with the mean value from other subjects from the same study, FH status, and sex. For all variables, missing data represented <4% of values. Mediation analyses were performed using the Multilevel Mediation and Moderation (M3) MATLAB Toolbox  in MATLAPrior to each mediation analysis, study variables were converted to rank-ordered values due to non-normal distributions. Next, we used linear regression models to estimate effects of sex and depression on the mediator (BIS attention) and the outcome variable (binge drinking score). These effects were subsequently subtracted from the mediator and outcome variables to adjust our mediation model for the effects of these nuisance variables. This adjustment was conducted separately for each study and FH group.After testing mediation models for the FHP and FHN groups, we additionally tested the null hypothesis of equal indirect paths for the two models, thereby testing whether the mediation effect was moderated by FH. To test this, we took the difference in the indirect path estimates between the FH groups and the variance estimates for those paths to compute a z-statistic of the difference between models for FHP and FHN . A signia priori hypothesis regarding attention, mediated resilience effects on binge drinking.Secondary exploratory analyses tested the remaining BIS factors as mediators using identical methods as above. The goal of these analyses was to explore whether other aspects of impulsivity, outside of our Demographic characteristics of subjects separated by FH status and study are presented in F = 7.17, p = 0.008]. Specifically, non-binge-drinking FHP subjects reported significantly lower attention problems than not only the FHP binge-drinkers, who reported the highest attention problems, but also FHN non-binge drinking subjects, consistent with a marker of resilience to binge drinking.Scores on the BIS first-order attention subscale by FH and binge drinking group are displayed in F = 5.85, p = 0.017], mirroring the primary finding  of BIS Attention scores was stronger for FHP than for FHN .Models of the mediating effects of BIS first-order attention scores on the relationship between CD-RISC and binge drinking are presented in Mediation effects for all BIS subscales are presented in In this study, we tested a hypothesis that enhanced attentional ability promotes resilience to binge alcohol drinking in at-risk emerging adults. The findings supported a role for higher trait attention in reducing binge drinking among first-year college students with familial risk for AUD. We further demonstrated that attention scores mediated the relationship between a measure of resilient coping  and binge drinking among first-year college students and that this relationship was stronger for FHP than FHN. The results suggest that even though attention may only be weakly correlated with alcohol use in the general population, it may actually play a key role in promoting resilience to binge drinking among FHP individuals.As expected, FHP subjects had higher binge drinking scores, consistent with previous research . In addiMuch of the research on resilience implicates a role for dopamine signaling. For example, preclinical models of resilience have identified associations with stable firing of ventral tegmental area dopamine neurons projecting to the nucleus accumbens , increasThere are several possible behavioral mechanisms by which attention may promote resilience in at-risk individuals. First, attentional ability may attenuate alcohol misuse through its effects on alcohol-related attentional bias. Attentional bias, which describes an exaggerated attention to salient stimuli, is a predictor of craving and substance use outcomes. Attention problems have previously been associated with increased attentional bias among substance misusers, suggesting a close relationship between the construct of attention and this marker of addiction-related outcomes. Secondly, attention is closely related to mindfulness, which promotes resilience to stress. Indeed, mindful attention is associated with improved emotion regulation in both individuals with AUD  and thosAddiction is a complex and heterogeneous disorder , 57, andSecondary analyses  also revSeveral limitations of the study should be considered. This study was conducted only in first-year undergraduate students attending 4-year colleges and thus the results may not necessarily translate to adolescents, older populations, or 18–19-year-olds in other academic or non-academic environments. Because analyses did not control for other substance use, it is possible that reported relationships are not specific to alcohol use. Additionally, this study relied on self-report measures of substance use, attention, and resilience. The cross-sectional nature of this study is another limitation, and future studies are needed to determine whether the association of attentional ability with resilience and binge drinking represents a causal mechanism. It is also possible that many of the non-binge drinking subjects will develop AUD later in life. The utility of attentional ability as a predictor of future AUD remains to be determined. Additionally, a large proportion of our sample was female, and the study was not powered for testing sex differences, so it is possible that effects differ between males and females. Increased severity of clinical symptoms in the online sample (Study 2) was likely driven by the relaxed exclusion criteria, which was intended to provide improved real-world translation. However, differences in recruitment methods, geographical regions, and the pandemic may also have contributed to sample differences. Future studies are needed to identify the neural circuits that mediate the relationships between attentional ability, resilience, and binge drinking.This study revealed a novel link between attention and resilience to binge alcohol use among individuals at risk for AUD. Reducing hazardous alcohol use on college campuses remains an important goal of intervention research . The curThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board at the University of North Carolina at Chapel Hill. The patients/participants provided their written informed consent to participate in this study.AE was responsible for study design, data acquisition, statistical analyses, and drafting of the manuscript. JA was responsible for data acquisition and revisions. MY and FK was responsible for data acquisition and manuscript revisions. QL was responsible for calculations of timeline followback data and manuscript revisions. QL was responsible for calculations of timeline followback data and manuscript revisions. CB advised on study design and provided manuscript revisions. All authors contributed to the article and approved the submitted version.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.


Recent comprehensive genomic studies including single-cell RNA sequencing and characterization have revealed multiple processes by which protein-coding and noncoding RNA processing are dysregulated in many cancers. More specifically, the abnormal regulation of mRNA and precursor mRNA (pre-mRNA) processing, which includes the removal of introns by splicing, is frequently altered in tumors, producing multiple different isoforms and diversifying protein expression. These alterations in RNA processing result in numerous cancer-specific mRNAs and pathogenically spliced events that generate altered levels of normal proteins or proteins with new functions, leading to the activation of oncogenes or the inactivation of tumor suppressor genes. Abnormally spliced pre-mRNAs are also associated with resistance to cancer treatment, and certain cancers are highly sensitive to the pharmacological inhibition of splicing. The discovery of these alterations in RNA processing has not only provided new insights into cancer pathogenesis but identified novel therapeutic vulnerabilities and therapeutic opportunities in targeting these aberrations in various ways , and protein therapies) to modulate alternative RNA splicing or other RNA processing and modification mechanisms. Some of these strategies are currently progressing toward clinical development or are already in clinical trials. Additionally, tumor-specific neoantigens produced from these pathogenically spliced events and other abnormal RNA processes provide a potentially extensive source of tumor-specific therapeutic antigens (TAs) for targeted cancer immunotherapy. Moreover, a better understanding of the molecular mechanisms associated with aberrant RNA processes and the biological impact they play might provide insights into cancer initiation, progression, and metastasis. Our goal is to highlight key alternative RNA splicing and processing mechanisms and their roles in cancer pathophysiology as well as emerging therapeutic alternative splicing targets in cancer, particularly in gastrointestinal (GI) malignancies. Cancer is a complex and heterogeneous disease that evolves through successive genetic and epigenetic changes that support tumorigenesis . These gChanges in the genome that affect gene function often result from various genetic and genomic abnormalities including chromosomal translocations, insertions or deletions, amplifications, and single-nucleotide mutations or alterations in the epigenome as well as the dysregulation of specific suppressor miRs or oncomiRs; the upregulation or downregulation of global miRNA levels as a consequence of dysregulated miRNA biogenesis pathways also play a role in cancer pathogenesis ,3. In adMore recently, large-scale comprehensive genomic studies including single-cell RNA sequencing and characterization have revealed multiple processes by which protein-coding and noncoding RNA processing are dysregulated in many cancers. Among these, mutations that drive cancer by perturbing co-transcriptional and post-transcriptional regulation of gene expressions, such as alterations that affect each phase of RNA processing, including the transcription, splicing, transport, editing, and decay of protein-coding and noncoding RNAs, including microRNAs (miRNAs), have been implicated in the pathogenesis of many cancers.As a disease with incredible complexity in its biochemical and genetic landscape, it is unsurprising that recent scientific progress has highlighted the importance of understanding the aberrant nature of mRNA processing, more specifically, alternate RNA splicing, as an intermediary in gene expression in various types of cancers. Alternate RNA splicing was initially discovered in 1977 as a mechanism of protein diversity, allowing multiple variants of a single mRNA molecule to be produced by processing in eukaryotic cells ,5, and lHerein we aim to provide an overview of recent work and major themes regarding AS and its role as a disease mechanism and emerging therapeutic target in cancer, particularly in gastrointestinal (GI) malignancies. We then discuss the AS processing mechanisms that are being targeted by novel anticancer strategies, including small-molecule inhibitors and therapeutic oligonucleotides.Alternative splicing relies on the distinction between intronic and exonic sections of DNA within genes. The pre-processed mRNA transcript bears these same sections, which are recognized and spliced together by the spliceosome, a large complex of five small nuclear ribonucleoproteins (snRNPs) and proteins . SpecifiAnother considerable layer of complexity arises when considering the propensity for a common gene to be spliced in different ways in different cells or even within the same cell, with varying exon inclusions and splicing . While mThe first of these are cis-acting elements along the pre-mRNA, which represent regulatory sequences facilitating everything from protein interaction with the pre-mRNA to folding and the three-dimensional structure of the molecule . SSs theCertain sequences on the pre-mRNA additionally can serve as binding sites for trans-acting RNA-binding proteins (RBPs), allowing for a higher level of granularity in promoting or inhibiting certain splicing events . ModulatTwo major classes of trans-acting RBPs are serine/arginine-rich proteins  and heterogeneous nuclear ribonucleoproteins (hnRNPs) ,17. SR pTissue-specific RBP expression also plays an integral role in the regulation of alternative splicing. Direct interactive effects between RBPs as well as the interplay of cis-element type and positioning along with the pre-mRNA transcript, chemical regulation (such as through phosphorylation), and physical and structural realities within the cellular environment serve to create a unique regulatory environment in different cell types for alternative splicing . Such vaBecause human alternative splicing typically occurs alongside transcription, certain properties of the gene transcriptional environment can also regulate alternative splicing. This is partly determined by indirect effects, such as the impact of transcription rate on the three-dimensional folding of the pre-mRNA transcript. However, this same rate has also been shown to have an impact on SS recognition, with slower rates leading to increased splicing at weaker splice sites, for instance, and faster rates favoring splicing at strong splice sites instead . Such coA “recruitment model”, which encompasses the direct recruitment of RBPs and other factors to the splicing environment, is also involved in the regulation of alternative splicing by transcriptional dynamics. Direct interaction between RNAP II and splicing factors, for instance, has been proposed as one model of modulating the splicing environment . MoreoveEpigenetic factors on DNA have also been shown to influence regulating alternative splicing. While some of this is due to their influence on previously discussed methods—nucleosome positioning, for example, has an impact on the transcriptional rate and can cause RNAP II pausing —interactFinally, the spliceosome itself has been proposed to have a regulatory function on alternative splicing. Different points of control include spliceosome formation, the concentration of snRNP isoforms, and perhaps most interesting, kinetic proofreading .  to identify differently expressed alternative splicing events (DEAS), finding a pattern of abnormal alternative splicing events in genes related to protein kinase activity, PI3K-Akt signaling, and p53 signaling, as well as a link between alternative splicing events and survival . MechaniA different hnRNP, hnRNP K, has been implicated, along with SR RBPs SRSF1 and SRSF2 and hnRNP A1, in apoptotic dysregulation in pancreatic and liver cancers through the dysregulation of a host of target genes involved in both extrinsic and intrinsic apoptosis  as well as anti-apoptotic factors Bcl-x and Mcl-1. These RBPs are being currently explored for therapeutic targeting . OverexpAmong the discovery of similar disease mechanisms involving mutations of trans-factors such as SR proteins or upstream regulators of these factors, a study of alternative splicing in gastric cancers (GCs) recently led to the discovery of the importance of a class of circular noncoding RNAs (circRNAs). While these molecules have been known since as early as 1976, certain effects on alternative splicing promoting tumorigenesis have been described in recent literature. For one, the biogenesis of circRNAs is through the AS process, and therefore competes with normal AS . MoreoveDisease mechanisms in other GI system cancers bear overall similarity to those described previously in CRC, PCs, and GCs, with individual efforts underway to profile the AS landscape and establish predictive links between AS events and prognosis. One such effort with hepatocellular carcinoma (HCC) in 2020, for instance, has identified over 3000 candidate AS events associated with almost 400 splicing factors, ultimately producing a predictive model for prognosis and metastatic potential . The autNevertheless, the role of AS on carcinogenesis and GI malignancies particularly is not to be understated. Promising preclinical work showing the therapeutic power of targeting aberrantly regulated players within this pathway suggests an emerging treatment strategy on the patient-facing front.Given the fact that cancer cells can display widespread changes in RNA splicing compared to normal cells, modulating RNA splicing in some cancer types might provide therapeutic benefits. Currently, potential therapeutic options mainly include immunotherapeutic avenues that exploit the immunogenicity of alternatively spliced protein products, small-molecule-mediated spliceosome modulation, splice-switching oligonucleotide (SSO)-based splicing regulation, and some RNA-based therapeutic approaches.It is well-known that the antigenic presentation of endogenous cellular or exogenous viral protein-derived peptides on tumor cells by a major histocompatibility complex (MHC) can be recognized by T cells which may result in the rejection of tumor cells . ImportaSeveral natural products and their synthetic derivatives display antitumor activities by binding to components of the spliceosome involved in the removal of introns from mRNA precursors in eukaryotic cells . The scrAs a result of these developments, small molecules that target splicing factors have been developed for various cancers including GI malignancies ,68. SpliN-methyltransferase 5 (PRMT5) is the predominant type II PRMT which is critical in the assembly of crucial components of the spliceosome, snRNPs [The use of RNA splicing modulators in clinical trials appears as an attractive treatment option for establishing novel therapeutic cancer drugs. Towards this goal, several clinical trials, mostly targeting PRMT for various cancers including GI malignancies, are currently underway, but these are still in their early phases . Protein, snRNPs . There a, snRNPs . The fir, snRNPs . The dis, snRNPs . Moreove, snRNPs . PF-0693, snRNPs . Enrollm, snRNPs , and an , snRNPs , is acti, snRNPs . Mtap geBy using sulfonamides such as indisulam , tasisulam, and E7820 (aryl-sulfonamides) in both preclinical and clinical studies, activity against solid tumors, including GI malignancies, were previously shown in multiple studies ,96,97,98Oligonucleotide-based therapies can directly modulate pre-mRNA splicing through allowing selective induction and regulation of splice site specificity . Splice-Recently, the Food and Drug Administration (FDA) has approved the SSOs eteplirsen for the treatment of Duchenne muscular dystrophy  and nusiAlternative splicing of PKM contributes to the control of glucose metabolism by producing either the PKM1 isoform which contains exon 9 and leads to oxidative phosphorylation or the PKM2 isoform which contains exon 10 and leads to aerobic glycolysis; that is, the Warburg effect . It has BIM gene that is associated with resistance to imatinib cancer therapy in chronic myeloid leukemia [SSOs have also been applied to produce autoinhibitory HER2 protein isoforms by the modification of HER2 pre-mRNA alternative splicing in breast cancer cells . Likewisleukemia . AccumulModulating some other splicing targets, such as SmgGDS, MKNK2 in cancer cells was shown to inhibit tumor development in preclinical studies ,117. GivRecent large-scale genome, transcriptome, proteome, and epigenome profiling efforts and functional characterization of the candidate factors involved in RNA splicing have identified numerous abnormal RNA splicing events that have been implicated in tumorigenesis as oncogenic drivers and/or passengers in various cancers. Alternative splicing can produce multiple isoforms and pathologic variants with diverse functions for the same gene loci, and dysregulation of alternative splicing of mRNA has been implicated in the pathogenesis of different types of cancers. Because of this, the area of alternative splicing has become an attractive topic for cancer research to elucidate the regulatory mechanisms of alternative splicing and to further our understanding of tumorigenesis, which is also leading to new therapeutic strategies. As a result, therapies including small molecules that modulate splicing, SSOs, as well as novel RNA-based CRISPR-Cas13a editing technology and others that target abnormal splicing sites or events have also been explored as novel therapeutic strategies for various diseases, including cancer.The identification of neoantigens that elicit a specific immunogenic response is key for the development of effective cancer vaccines. However, many challenges remain before many of the cancer-specific candidate TAs can be translated into effective therapies. In addition, there remain a few challenges for targeting the abnormal splicing events and/or aberrant RNA species, which are the specificity and delivery efficiency which must be addressed before these strategies become clinically meaningful. Nevertheless, neoantigens derived from somatic mutations and alternative RNA splicing have been extensively characterized as a source of Tas, and they represent a novel immune therapeutic strategy that is still under investigation.The development of small-molecule drugs that target highly structured elements in aberrantly processed disease-causing mRNAs has been explored ,129. TheAlthough accumulating literature indicates that aberrant regulation of splicing is involved in tumorigenesis, the role of splicing in cancer pathogenesis, particularly in GI cancers, has not been fully elucidated. The targeting of splicing may provide novel attractive methods of treating cancer; however, the specificity and delivery efficiency are among the major challenges facing scientists. It should also be noted that mutations in genes related to splicing are rare in solid tumors, in contrast to in hematologic malignancies. Ongoing clinical studies are of great importance as they may provide new insights into splicing dysregulation in solid tumors and improve RNA-based anti-tumor therapy in the near future. Furthermore, although it is not the focus of this review article, the dysregulation of pre-mRNA processing, including alternative RNA splicing, provides a potentially extensive source of therapeutic antigens (TAs) for targeted immunotherapy. Post-transcriptional dysregulation contributes to the antigen profile of tumors, and this contribution has been leveraged for immunotherapy and led to the development of mRNA cancer vaccines which are attracting attention as SARS-CoV-2 mRNA-based vaccines have shown their feasibility, effectiveness, and scalability. Emerging preclinical and clinical data demonstrate that mRNA cancer vaccines are safe and efficient with the potential for rapid, inexpensive, and scalable manufacturing ,133,134.Despite the relative infancy of the field and inherent challenges involving specificity and delivery, therapeutic strategies targeting cancer-specific AS abnormalities are a promising, novel strategy for preclinical and clinical research, with potentially impactful clinical outcomes. As current research in the understanding of splicing abnormalities, addressing challenges involving specificity and delivery, and ongoing clinical trials progress, increasingly more specific and effective therapies with impactful clinical outcomes are likely to emerge.


Degenerative disorders of the Temporomandibular Joint (TMJ) are the second most common chronic musculoskeletal disorder . The degThe underlying mechanisms in age-related TMJ degeneration is largely unknown. Growing evidence suggests that retarding the fundamental aging process could simultaneously alleviate a range of age-related diseases and tissue dysfunction, which is now referred to as the Geroscience Hypothesis. Due to the high prevalence and uniquely complex nature of the TMJ in aging, the geroscience-guided approach, by targeting the whole aging process, might be beneficial for alleviating TMJ degeneration with aging. Among a number of basic aging mechanisms, cellular senescence has been indicated as a promising target . CellulaIndeed, in our recently published research, we observed that intermittent oral administration of Dasatinib (D) + Quercetin (Q) reduced senescent cells, preserved mandibular condylar cartilage thickness, improved subchondral bone volume and turnover, and reduced histopathological score in TMJs from both male and female aged mice, whereas D+Q had little effect on the TMJ in young mice . D+Q is In summary, senolytic drugs showed promising benefits on TMJ health in aging populations. The results of our studies might open avenues to develop pharmaceutical interventions targeting cellular senescence to improve the regeneration of the osteochondral tissues of the aged TMJs, and possibly other joints. It is necessary to further investigate the molecular and cellular mechanisms by which senescent cells lead to joint degeneration with aging. Notably, although D+Q has been shown to be relatively safe and well tolerated in older human subjects by a small clinical trial , and mul


Neutrophil Extracellular Traps (NETs) are neutrophil-derived extracellular scaffolds, which typically consist of fibrous decondensed chromatins decorated with histones and granule proteins. Initially discovered as a host defence mechanism of neutrophil against pathogens, they have also been implicated in the progression of sterile inflammation-associated diseases such as autoimmune disease, diabetes, and cancer. In this review, we highlight and discuss the more recent studies on the roles of NETs in cancer development, with a special focus on cancer metastasis. Moreover, we present the strategies for targeting NETs in pre-clinical models, but also the challenging questions that need to be answered in the field. Metastasis, although infrequent , remainsThe observations that neutrophils frequently accumulate in peripheral blood and resected metastatic cancer tissues of advanced cancer patients , 10 suggInterestingly, NETs was first discovered in 2004 as a host defence mechanism of bacteria trapping and killing . As the In this review, with a special focus on cancer metastasis, we discuss recent studies on cancer-associated NETs formation and their role in promoting metastasis. We also present the newly developed strategy in targeting NETs or interfering NETs-cancer cell interactions as a potential treatment option for advanced cancer therapy.Initially discovered in neutrophils though, the formation of extracellular traps do not exclusively confine to neutrophils. Indeed, many types of leukocytes –28, haveTwo main mechanisms of NETs formation have been described, depending on the death or live fate of neutrophils, and are termed as suicidal  or vitalAs the first discovered and classical mechanism of NETs formation, the NADPH oxidase-dependent suicidal NETs formation has been reported to occur primarily at 3 to 8 hours following the activation of neutrophils by various stimuli, such as phorbol 12-myristate 13-acetate (PMA), lipopolysaccharide (LPS) and interleukin-8 (IL-8) . Within Chromatin decondensation is a key step during NETs formation. The production of reactive oxygen species (ROS) mediated by NADPH Oxidase 2 (Nox2) have critical roles in NETosis as it triggers the downstream signalling cascade for chromatin decondensation. MPO and NE, two key enzymes stored in azurophilic granules of naïve neutrophils, are stimulated by ROS generation . ActivatIntriguingly, NETs formation has also been observed in patients with chronic granulomatous disease , an inheNon-lytic NETs formation, still poorly understood, on the other hand, is a faster neutrophil response without loss of nuclear or plasma membrane, and can be ROS-dependent or independent. Gram-positive bacteria such as Staphylococcus aureus, has been found to trigger viable NETs formation independent of oxidant, generating NETs DNA primarily of nuclear origin . SimilarNormally induced by pro-inflammatory factors during infection, NETs can also be stimulated by cancer cells and cancer-associated fibroblasts (CAF) in the absence of infection  , which NETs have been shown to participate in the dissemination of cancer cells, the initial steps of the metastatic cascade that arms neoplastic cells with the ability to invade the local microenvironment, survive in circulation and seed in secondary organs. Moreover, during the journey to distant organs, cancer cells encounter various obstacles including the endothelial barrier, immune surveillance, and metabolic/nutrient stress before a successful metastatic colonization . EmerginOne centrally important process arming the cancer cells with motility and invasiveness is the epithelial-mesenchymal transition (EMT). The ability of NETs to induce EMT is first described in vitro when the coincubation of normal endothelial cells with NETs isolated from human neutrophils stimulated with PMA leads to the loss of endothelial cell junction, the development of mesenchymal phenotype and aberrant activation of the Wnt/β-catenin signaling pathway . FollowiIntriguingly, Martins-Cardoso et al found that DNase treatment resulting in the destruction of NETs integrity exhibited minor impact on the invasive and migratory ability of breast cancer cells, suggesting a dispensable role of NETs integrity on EMT induction . ConsistNeoplastic cells derived from the primary site acquire the migration ability through EMT and may, sooner or later, invade into the circulation where they are termed as circulating tumor cells (CTCs) . Though After survival in the circulation and infiltration into the distant organs, newly disseminated tumor cells (DTCs) are immunologically and metabolically vulnerable to the challenging microenvironment in distant organs. The seed and soil hypothesis provides an explanation for organotropism in metastasis . Indeed,One of the key characteristics of pre-metastatic niche is inflammation. Evidence for a role of NETs in the establishment of an inflammatory milieu at secondary sites is emerging, which promotes seeding, survival, and proliferation of primary tumor cells to the metastatic sites. For example, a recent finding observed a positive correlation of NETs level with colorectal cancer metastasis. Further studies showed that neutrophil recruitment in response to primary tumor-derived factors results in the over-production of NETs in the liver, which is able to capture colorectal cancer cells (CRC) and subsequently induce the production of pro-inflammatory cytokines such as IL-8, IL-6 and TNF-α in trapped CRC . The inf+ T cells and NK cells, however, that function is commonly impaired in patients with advanced cancer. Recent study uncovered a NET-mediated physical barrier in immune evasion where NETs wrap and shield tumor cells from interactions with neighboring anti-tumor immune cells, thus impeding the activity of CD8+ T cells and NK cells against tumor [Local immune defence against infiltrating cancer cells are mainly executed by cytotoxic CD8 st tumor , 62.The pre-metastatic niche may enhance angiogenesis and vascular permeability to facilitate metastatic colonization. Though the direct evidence of NETs in angiogenesis and vascular permeability in the context of tumor is scarce, a functional link between NETs and angiogenesis has been implicated in tissue repair  as well et al unveiled a NETs-initiated reactivation of dormant tumor cells in multiple metastasis models. Mechanistically, this effect is not via the direct contact of NETs and tumor cells. Instead, remodelling of extracellular matrix (ECM) by NETs-associated NE and MMP9 are mainly responsible for the proliferation of DTC to form metastasis, whereby the cleavage of laminin generates a new epitope which could be sensed by the integrin present on dormant cancer cells. The integrin-mediated interaction of ECM and dormant cancer cells subsequently activates the downstream effectors such as focal adhesion kinase (FAK), mitogen-activated extracellular signal-regulated kinase (MEK) and extracellular signal regulated kinase (ERK), thus leading to the dormant cancer cells re-entering the cell cycle and reinitiation of aggressive metastatic outgrowth [Intriguingly, most DTCs that have managed to extravasate and disseminate to distant organs are destined to enter into a state of dormancy, sometimes for weeks, months, even years or decades, before forming metastasis . Dormancutgrowth .The ability of NETs to foster metastatic dissemination and immune evasion highlights the potential for NETs-targeted therapies to inhibit metastasis and boost efficacy of immunotherapy. Targeting tumor-associated neutrophils can be desirable, however, the risk of severe and even fatal infections found in patients caused by neutrophil depletion limits its clinical use . In thisTo study the effects of NETs deficiency on tumor metastasis, conventional and neutrophil-specific PAD4 knockout mice have been generated and exhibited defects in NETosis. While neutrophil infiltration was not affected by the NETs depletion, metastatic colonization was dramatically reduced, compared with NETs-competent mice , 71, 72.The context-specific pathway of NETs induction provides attractive target for interference of NETs formation under different malignancy, as exemplified by blocking IL-8 , CathepsDestruction of NETs structure at the primary or metastatic sites may represent another effective approach, which have the advantage of preserving antimicrobial functions of NETs in non-tumorous tissues. DNA, the backbone of the NETs structure, is therefore a feasible target for NETs degradation. Indeed, DNase I treatment is approved by FDA for the treatment of cystic fibrosis, partly attributed to the reduction of mucus viscosity caused by excessive NETs deposition during chronic inflammation . PreviouRecent progress have been made by crosslinking DNase I with nanoparticles to extend its half-life. As expected, treatment of DNase I-coated nanoparticles showed higher blood concentration, compared with free DNase I, but a continuous injection of the nanoparticles for two weeks is still required for the reduction of the lung metastatic burden . TherefoA growing body of evidence has suggested that NETs act more than a physical shield to cancer cells. Indeed the crosstalk of NETs and cancer cells promotes the invasiveness and migration ability through specific signalling. Therefore, some groups have focused on the interaction mediators present on NETs, cancer cells or both and explored the effects of inhibiting their interactions on metastasis. To date, the discovered mediator includes adhesion molecules such as integrin  and carcThe contribution of NETs to metastatic process has gained a growing appreciation and the approaches to targeting NETs deposition exhibited beneficial effects both in primary and metastatic tumors, which, however, has been challenged by a recent finding demonstrating an opposite effect of NETs to suppress tumor growth via the activation of immune response against tumor . This seSecond, if there exists some association of neutrophil phenotypes with NETs functions, it will give rise to another puzzling that how the divergent functions of NETs is executed since the DNA backbone and core proteins are found to be the main mediator of NETs biological roles, according to current research. The possible mechanism could be related to some non-core proteins within NETs which has been overlooked. Indeed, these non-core proteins can not only define the uniqueness of NETs in terms of neutrophil sources, stimuli as well as action sites, such as NETs deposited in vessels or tissues, but may also determines their functional specificity. Thus NETs proteomes would be very helpful for the comprehensive understanding of the proteomic profiles of NETs. Another perspective is attributed to a dose-dependent effect, as aberrant NETs deposition in chronic inflammation often leads to the detrimental role. Additionally, it has been found that NETs stability and integrity varies under different stimuli, which may also results in their functional differences.Finally, some limitations exists in the current study setting. For example, NETs are mostly isolated from neutrophils of healthy volunteers in response to PMA stimulation, which may not represent the NETs released in vivo under multitude stimuli in cancer patients. Besides, current studies on metastasis mainly rely on xenograft or orthotopicaly transplanted immune-compromised mouse models, which cannot recapitulate the complex relationship between the tumor and the microenvironment, therefore, immune-competent mouse model or humanized mouse model, if available, would be more desirable to study the effects of NETs on metastasis.


Uterine fibroids are common benign tumors that occur in up to 80% of women. Approximately half of the women affected experience considerable physical, psychological, and economic burdens and impact on quality of life due to symptoms such as heavy menstrual bleeding, pelvic pain, and infertility. Several medical and surgical options are available to treat uterine fibroids; however, healthcare providers may benefit from practical guidance in the development of individualized treatment plans based on a personalized approach. Medical treatments and minimally invasive procedures are generally preferred by most patients before considering more invasive, higher risk surgical interventions. In general, patient-centered, uterine-preserving procedures may be prioritized based on the patient’s goals and the clinical scenario. Occasionally, hysterectomy may be the preferred treatment option for some patients who require definitive treatment. This call-to-action highlights recent challenges to patient care, including radical shifts in physician–patient interactions due to the COVID-19 pandemic and recent changes to evidence-based, clinically approved therapies. This report also reviews contemporary recommendations for women’s health providers in the diagnosis and medical and surgical management of uterine fibroids. This call-to-action aims to empower healthcare providers to optimize the quality of care for women with uterine fibroids utilizing the best available evidence and best practices. Several key events took place during 2020 and the COVID-19 pandemic that have impacted how physicians diagnose and treat uterine fibroids. The use of virtual medical consultations as well as investigational and procedural delays has increased due to the COVID-19 pandemic ), and gonadotropin-releasing hormone (GnRH) agonists and antagonists. Combined estrogen/progestin oral contraceptives are commonly used as first-line therapy for the treatment of uterine fibroids; these agents reduce fibroid-associated symptoms such as HMB, but do not inhibit fibroid growth or reduce fibroid volume , 40–42. The LNG-IUS acts locally on the endometrium to decrease HMB (leading to amenorrhea or improvements in menorrhagia) and reduces HMB to a greater extent than do oral contraceptives , 42, 47.GnRH antagonists are the most recent addition to the options for the treatment of uterine fibroids . ElagoliResults from recent studies have also shown that the GnRH agonists leuprolide, goserelin, and triptorelin decrease fibroid volume, reduce HMB and fibroid-associated pain, and increase hemoglobin levels . A CochrGnRH agonists and antagonists have been associated with adverse effects such as hot flushes, decreased libido, and sleep disturbances; however, many of these effects can be successfully alleviated with hormonal add-back therapy , 42. LosSelective progesterone receptor modulators were initially considered promising treatment options and effectively reduced fibroid volume, treated symptoms, and delayed or eliminated surgical intervention . HoweverFor more than 100 years, surgical interventions (myomectomy or hysterectomy) have been the main options available to treat uterine fibroids Table ; howeverWhenever possible, patients should be made aware of less invasive and uterine-sparing procedures, which may minimize the risk to the patient. These include myomectomy via minimally invasive techniques when appropriate for fibroid removal and improvement of bulk symptoms or other less invasive techniques such as endometrial ablation or radiofrequency volumetric thermal ablation to control bleeding , 60. MyoOther less invasive non-surgical alternatives include uterine artery embolization to interrupt blood flow to the uterus and fibroids and MRI-guided, high-intensity-focused ultrasound to induce fibroid necrosis and regression Table  31]. Ul. Ul31]. When considering treatment plans for patients with uterine fibroids, important first steps include recognition, acknowledgment, and validation of symptoms; appropriate investigations (including imaging) to diagnose and classify specific fibroid subtypes; and consideration of individual patient needs (including effects on QOL or access to specific interventions) to guide management. This call-to-action highlights challenges and limitations associated with uterine fibroid management; discusses newer options, based on the best available evidence, currently available for the medical management of uterine fibroids; and serves as a guide for physicians to select the appropriate treatment based on individual patient characteristics and needs. Medical options and minimally invasive treatments are generally recommended as first steps for the treatment of uterine fibroids, with other surgical options available if symptoms persist or if the patient prefers surgery as first-line treatment.


Doxorubicin (DOX) is a kind of representative anthracyclines. It has greatly prolonged lifespan of cancer patients. However, a long course of DOX chemotherapy could induce various forms of deaths of cardiomyocytes, such as apoptosis, pyroptosis and ferroptosis, contributing to varieties of cardiac complications called cardiotoxicity. It has become a major concern considering the large number of cancer patients' worldwide and increased survival rates after chemotherapy. Exosomes, a subgroup of extracellular vesicles (EVs), are secreted by nearly all cells and consist of lipid bilayers, nucleic acids and proteins. They can serve as mediators between intercellular communication via the transfer of bioactive molecules from secretory to recipient cells, modulating multiple pathophysiological processes. It has been proven that exosomes in body fluids can serve as biomarkers for doxorubicin-induced cardiotoxicity (DIC). Moreover, exosomes have attracted considerable attention because of their capacity as carriers of certain proteins, genetic materials (miRNA and lncRNA), and chemotherapeutic drugs to decrease the dosage of DOX and alleviate cardiotoxicity. This review briefly describes the characteristics of exosomes and highlights their clinical application potential as diagnostic biomarkers and drug delivery vehicles for DIC, thus providing a strategy for addressing it based on exosomes. Globally, malignancies are a dominant cause of death and chemotherapy is an effective strategy. There are varieties of chemotherapeutic drugs, mainly including anthracycline, alkylating agent, antimetabolie antineoplastic agents, and antitumor antibiotics. Doxorubicin is a kind of typical anthracyclines, which belongs to the antitumor antibiotics. However, a long course of DOX chemotherapy exerts dose-dependent side effects on cardiomyocytes due to their vulnerability and low regenerative abilities The emergence of cardiotoxicities, such as arrhythmia, myelosuppression, cardiomyopathy, and congestive heart failure (CHF) limits clinical use of DOX Although accumulating studies have explored the means for DIC In this review, we point out the possibility of exosomes as biomarkers and delivery vehicles for diagnosis and therapy for DIC. We hope that with deepening cognition to exosomes' potential in DIC, they can come into clinical practice in the near future.Secreted by membrane vesicles, extracellular vesicles (EVs) are highly heterogeneous and traditionally divided into three categories based on size: apoptosomes, microvesicles, and exosomes. Exosomes, derived from the endosomal membrane through endocytosis, range from 30 to 150 nm The exosomes are formed by a phospholipid bilayer and bioactive cargos such as nucleic acids, including mRNAs, microRNAs (miRNAs) Due to the non-selective effects of DOX on cells, cardiotoxicity is unavoidable. Clinicians usually monitor cardiotoxicity by atypical symptoms  and typical symptoms . They also utilize techniques, such as echocardiography, multigated acquisition scanning (MUGA) Cardiac troponins are routinely regarded as sensitive biomarkers for diagnosing acute myocardial infarction (AMI) Studies have confirmed that miRNAs in circulation could be markers for DIC In a trial, EV-derived miRNAs in serum were found to express differently after single-DOX chemotherapy in dogs model of sarcoma compared with the initial. In detail, exosomal miR-107 and miR-146a were greatly downregulated, while exosomal miR-502 was upregulated. The changes in the pattern of exosomal miRNAs were more persistent compared to cTnI in serum Studies have confirmed that exosomes contain many proteins related to cancers. And they could serve as biomarkers for pancreatic cancer The superior characteristics of non-immunogenicity and high-capacity make exosomes ideal vehicles for chemotherapeutic drugs and genetic regulators. In this section, we introduce cells that produce exosomes and discuss the bioactive contents delivered by them to alleviate cardiotoxicity. Summaries are shown in Table in vivo. Increasing evidence has shown that exogenous cell transplantation play therapeutic function through paracrine of EVs, since it is reversed by exosome inhibitor, GW4869 Cell transplantation has been explored to exert repair functions through injection, but its application is limited for low survival rate and immunogenicity As is mentioned before, pyroptosis is a kind of cardiomyocyte death induced by DOX. This death is characterized by the release of vast pro-inflammatory factors and participates in the development of infectious diseases, neurological disorders and cardiovascular diseases (CVD). NLRP3, which has been validated its function in endothelial dysfunction Hypoxia, exosomeHypoxia showed superiority in protecting cardiomyocytes from senescence induced by DOX Mesenchymal stem cells (MSCs) mainly derive from bone marrow and adipose tissues and have the potential of proliferating and differentiating into multiple cell types. Researchers have used mesenchymal stem cells (MSCs) as common, efficient, and productive sources of exosomes, for they possess the capacity to promote osteogenesis in vitro and in vivoExosomes derived from CPCs have been proven to be cardioprotective for myocardial infarction (MI) and ischemia/reperfusion (I/R) in vitro, this cancer-homing behavior similar to the Trojan horse enables such exosomes to be better therapeutic agent to treat cancer and enhance the therapeutic drug retention Cltc, in exosomes and successfully blocked the uptake of exosomes from MPS, facilitating exosomes to distribute more efficiently Usually, experts explore the possibility of making exosomes target tumors more selectively, actually, tumor itself is a source of exosomes. Previous studies have confirmed the “homing behavior” of stem cells. This behavior could guide stem cells to reach the impaired cells or organs and repair them. If tumor cells have similar behavior, exosomes derived from tumor cells may kill themselves locally without distant movement. Recently, Li and co-workers discovered that tumor-derived exosomes preferentially fuse with parent cancer cells Dendritic cells (DCs) are the professional antigen presenting cells. They secrete EVs to play a significant role in CVDs Lamp2b, they could deliver cargo of DOX to tumor selectively and inhibit their growth without obvious cardiotoxicity, which is of great potential for clinical application Natural exosomes are regarded as less immunogenic and toxic, they are not always therapeutic. For example, immature dendritic cells (imDCs) can produce exosomes, but they could not target tumor selectively, when they were engineered to express a special exosomal membrane protein called As is mentioned above, the non-targeted damage has limited the use of DOX in cancer patients. Hence, it is necessary to find a strategy to make the drug more tumor-specific. Increasing studies have proven that exosomes can be constructed to deliver DOX to treat cancers and they showed better loading capability and splendid efficacy compared to the traditional form of DOX MicroRNAs, 19~22 nucleotides, can inhibit mRNA translation or promote degradation, thus negatively regulating expression of genes Since DOX induces cardiomyocytes death and cardiac atrophy, promoting the proliferation of cardiomyocyte is an approach to reversing damage Her 2) are all negative. Its prognosis is poor in breast cancer and deserves attention. Gong and coworkers identified that a kind of exosomes could express disintegrin and metalloproteinase 15 on the membrane (A15-Exos), which can deliver DOX and miR-159 modified by cholesterol to TNBC cells at the time, exerting synergetic therapy of anti-cancer through silencing TCF-7 without adverse effects mTOR pathway Triple-negative breast cancer (TNBC) refers the Results of immunohistochemical examination of estrogen receptor, progesterone receptor and proto-oncogene , length exceeding 200 nt, are a subset of non-coding RNAs and modulate transcription and expression of genes from short- and distant range. Increasing evidence points out that lncRNAs are involved in cardiomyocyte proliferation, cardiac repairing and senescence MALAT1 in exosomeHypoxia. In detail, MALAT1 sponged microRNA-92a-3p, and the binding of them activated ATG4a, improving mitochondrial metabolism and thus partially playing a cardioprotective role in DOX-induced cardiac lesions Recently, lncRNA H19 contained in exosomes were found to regulate DOX resistance of breast cancer. The treatment of exosomal H19 from DOX-resistant breast cells sensitive cells increased chemoresistance, while this phenomenon could be reversed by downregulating H19. This implied that exosomal lncRNAs could affect DOX resistance and act as a therapeutic target Proteins are the inherent structure of exosomes. And certain proteins of exosomes can mediate communication between exosome-secreting and recipient cells. They may have an effect on the development and treatment of DIC.Recently, Tania et al. attested that EVs membranes contain a special protein called gap junction protein Connexin 43 (CX43), a variety of channel of exosome. It could facilitate the contents of EVs to enter into recipient cells CVDs and cancers are the top two fatal diseases worldwide. Traditionally, they are viewed as independent diseases. With the wide application of chemotherapy and the emergence of heart symptoms, accumulating attention was attracted on how to mitigate heart reverse effects, cardiotoxicity, without weakening the potency of drugs, contributing to the birth of a novel discipline-CardiOncology. Exosome, a kind of liquid biopsy, mitigate DIC via two pathways: serving as diagnostic biomarkers for early detection and therapeutic vehicles for drugs or regulatory molecules (nucleic acids and proteins), which not only regulate various forms of cardiomyocyte deaths induced by DOX and alleviate cardiac injuries directly, but also modulate chemo-resistance of cancer cells, thus decreasing the cardiotoxicity indirectly Figure . miRNAs There are still some problems. First, means of enriching exosomes require further improvements. Second, more tools need to be developed to facilitate exosomes to target tumor more selectively besides CRISPR/Cas9 system Collectively, due to their advantageous features discussed in this review, exosomes will be preeminent in the aspects of diagnosis and therapy for DIC in the near future with the development of proteomics, genomics, and high-throughput sequencing technology. Combining the superior characteristics of exosomes and nanoparticles designed for capturing biomarkers or delivering mRNA and siRNA


Dysregulation of joint tissue homeostasis induces articular degenerative changes and musculoskeletal diseases such as osteoarthritis. This pathology represents the first cause of motor disability in individuals over 60 years of age, impacting their quality of life and the costs of health systems. Nowadays, pharmacological treatments for cartilage disease have failed to achieve full tissue regeneration, resulting in a functional loss of the joint; therefore, joint arthroplasty is the gold standard procedure to cure this pathology in severe cases of Osteoarthritis. A different treatment is the use of anti-inflammatory drugs which mitigate pain and inflammation in some degree, but without significant inhibition of disease progression. In this sense, new therapeutic alternatives based on natural compounds have been proposed to delay osteoarthritis progression, particularly those agents that regulate articular homeostasis. Preclinical studies have shown a therapeutic application of honey and its bioactive compounds, ranging from treating wounds, coughs, skin infections, and are also used as a biological stimulant by exerting antioxidant and anti-inflammatory properties. In this article, we reviewed the current medicinal applications of honey with particular emphasis on its use regulating articular homeostasis by inhibiting inflammation and oxidative stress. Osteoarthritis (OA) is a disabling condition characterized by joint degeneration; it is related to different etiological factors such as aging, genetics, metabolic and biomechanical stress. In this context, inflammation and oxidative stress play a pivotal role in the progressive deterioration of joint tissues including articular cartilage (AC), subchondral bone, synovial membrane and meniscus that maintain the functionality of joints until an exacerbated homeostatic dysfunction occurs . DespiteThe management of OA includes weight control and specific physical exercises as interventional strategies to support the pharmacological therapy . The firin vitro , free radicals including reactive oxygen species (ROS) and reactive nitrogen species (RNS) .Under normal conditions, chondrocytes exert anabolic functions that maintain a low-turnover replacement of specific ECM components including collagens, proteoglycans and non-collagen proteins . The ratThe changes previously mentioned cause a state of sustained catabolism which perpetuate progressive destruction of cartilage and deteriorates joint tissues. Since the number of chondrocytes and their viability are substantially affected in OA, the synthesis of ECM components decreases. The impaired integrity of AC attenuates articular homeostasis, adversely affecting the function of other joint tissues such as synovium, meniscus, and subchondral bone . MoreoveThe imbalance between anabolism and catabolism generated during OA progression can be slightly counteracted by the expression of the transforming growth factor-beta (TFG-β) which modifies the synthesis-replacement imbalance of proteoglycans in ECM . Howevers an exuberant inflammation level associated with the OA severity , of disintegrin and metalloproteinase (ADAM), as well as the gene expression of disintegrin and metalloproteinase with thrombospondin motif (ADAMTS) in chondrocytes and synoviocytes, accelerating the development of OA due to a mayor degradation of ACAN and collagen fibrils in cartilage . Moreovevia two different mechanisms. Firstly, ROS can exert direct hydrolysis of matrix components; secondly, it promotes the expression of MMPs that generates hypertrophic cartilage matrix -induced knee OA model in rats . It was demonstrated that chrysin increased the expression of COL2A1, while cell apoptosis, MMP-13 and IL-6 were inhibited   .via signaling inhibition of c-FOS/AP-1 and JAK/STAT . Nevertheless, some flavonoids as apigenin and quercetin can act as inhibitors of CD38 attenuating the release of NO and mitochondrial superoxide generation drocytes .in vitro IL-1β-injured human chondrocytes also supports the biological role of chrysin inhibiting oxidative stress. Zheng et al. observed that chrysin significantly inhibits IL-1β-induced NO and PGE2 production on human chondrocytes that were pretreated and subsequently stimulated with the pro-inflammatory agent. Additionally, this flavonoid down-regulated the expression of COX-2 and iNOS  and tissue inhibitor of metalloproteinases-1 (TIMP-1), promoting a downregulation of MMP-13 in synovial tissue  production when it was used for treating human articular chondrocytes previously stimulated with IL-1β .et al. identified baicalin as a potential candidate for OA treatment, as it prevented cartilage destruction and synovitis relief in OA in vivo models  axis, which enhances ECM synthesis on human OA chondrocytes (It is well known that maintenance of autophagy is essential for preserving cartilage integrity. In this sense, a novel study documented that baicalin exerts an anti-apoptotic role through the up-regulation of Bcl-2 expression and through autophagy activation drocytes . Similardrocytes .Considering the several health benefits and general well-being that have been associated with honey and its components, the emerging use of these products as a complementary strategy to regulate molecular mechanism underlying articular homeostasis is leading to further investigation in tissue engineering application for cartilage repair.in vitro human mesenchymal stem cell chondrogenesis via increasing the expression of COL2A1 as well as the synthesis of GAGs and proteoglycans; additionally, no cytotoxic effect has been observed (in vivo studies of honey-contained hydrogels activity have shown significant results inhibiting infections and non-severe immunological reactions (The cartilage ability to self-regeneration is low, even when it is substituted with tissue-engineered constructs. However, many promising strategies are still attempting the promotion of AC repair and regeneration. In this regard, recent studies have focused on the development of honey-biomaterial based scaffolds such as hydrogels in order to prompt cartilage repair, due to the honey intrinsic antibacterial properties and its unique viscosity enhance the mechanical features of hydrogels . The innobserved . To dateeactions , which rClostridium botulinum spores have been previously identified in honey samples (The increased interest in honey for medical use is leading to a strict regulation of its quality and safety. Honey can also contain toxic compounds including pesticides , heavy m samples . In this samples . It has  samples .Melipona spp., Trigona spp., Tetragonisca spp., and Scaptotrigona spp have exhibited therapeutic properties for treating inflammation (Although Manuka MGH is widely investigated as a novel non-pharmacological therapeutic strategy worldwide, other honey types are emerging with similar biological activity. In early reports, honey from stingless bees including ammation , wound hammation  and oxidammation . Furtherammation . TherefoSince ancestral times, the therapeutic effects of honey have been described and widely observed in ameliorating the clinical course of wounds, coughs, skin infections and inflammation. Nowadays, the effectiveness of honey on counteracting articular damage to improve the quality of life of individuals with OA is being explored. We know that the bioactive compounds of honey exert chondroprotective activity by counteracting the homeostatic dysregulation of the joint. Therefore, its use as a therapeutic tool in the management of OA is widely supported, as it can shift major OA-related signaling pathways. This adjuvant non-pharmacological strategy might relieve pain, regulate joint homeostasis and repair AC, slowing down the OA progression; thus, reducing physical limitations, disabilities, mental stress and the socioeconomic burden commonly seen in individuals with this chronic disease.in vitro and in vivo reports showing the molecular pathways underlying the biological effect of honey-derived flavonoids. Articular homeostasis is quite complex, and its total restoration by a single molecule after either a biomechanical, inflammatory, or oxidative stress stimulus can be complex. Nevertheless, maximal therapeutic potential can be achieved by the combination of these molecules. However, suitable dosage and outcome represent a challenging issue. In this context, further preclinical studies are required to validate the honey emerging applications as a rational therapeutic strategy for OA, considering that most current reports have shown the effect of biologically active flavonoids on articular homeostasis regulation on in vitro research. Finally, it is highly relevant to develop clinical trials to verify the safety and efficacy of honey-derived bioactive compounds to better understand their activity at the cellular and molecular level for future therapeutic approaches.There is a clear evidence that natural products represent an excellent source of bioactive molecules with potential medical applications. We introduced seven natural compounds derived from honey as possible candidates for treating OA due to their chondroprotective activity. However, there is a limited number of


Parkinsonian symptoms are common adverse effects of antipsychotics. Older adults are particularly vulnerable to drug-induced parkinsonism. Nonetheless, parkinsonian symptoms in seniors treated with antipsychotics cannot be straightforwardly attributed to antipsychotic medication. A comprehensive diagnostic workup is necessary in many cases in order to shed light on the cause of such symptoms in this patient population.Eight cases of hospitalized depressed older adults with parkinsonian symptoms, who were treated for at least one year with antipsychotics, are reported. Based on neurological consultation, structural brain imaging and Ioflupane (I-123) dopamine transporter (DAT) single photon emission computerized tomography (SPECT), Parkinson’s disease was diagnosed in one case, idiopathic tremor in another, vascular parkinsonism in another one, while in another individual parkinsonian symptoms persisted at 12-month post-discharge follow-up even though his/her symptoms were classified as drug-induced on discharge. In four patients, parkinsonian symptoms were definitely drug-induced and no movement disturbances were reported at follow-up.Differences in the cause and outcome of parkinsonian symptoms in seniors treated with antipsychotics merit systematic and in-depth study considering the therapeutic and prognostic implications of an accurate detection of the cause of such symptoms. Familiarizing clinical psychiatrists with these differences could pave the way towards approaching seniors with severe, atypical and/or persistent parkinsonian symptoms in a more individualized diagnostic and therapeutic manner, and towards more cautious prescribing of antipsychotics in this age group. Antipsychotic augmentation is not a rare strategy in the pharmacological treatment of depression in older adults. Τhe prevalence of clinically relevant depressive symptoms in seniors is higher than 15%, while the prevalence of major depression exceeds 5% . AntipsySeniors are particularly vulnerable to side effects of antipsychotic agents, such as parkinsonian symptoms. Both typical antipsychotics, which mainly block D2 receptors, and to a lesser degree atypical ones, blocking both D2 and serotonin 5-HT2A receptors, can lead to parkinsonian symptoms , 11. TheHere, we report on eight hospitalized depressed older adults with parkinsonian symptoms who were treated for at least 12 months prior to their hospital admission with antipsychotics. The presented case series highlights the different causes and 12-month post-discharge follow-up outcomes of such symptoms, despite the initial assessment on admission that they were drug-induced.The case series consists of five women and three men older than 59 years who were admitted between 2012 and 2017 to the old age psychiatry division of the Eginition Hospital in Athens because of severe depressive symptoms and consecutively agreed to undergo brain SPECT with 123I-FP-CIT . The brief, focused neurological examination on admission revealed parkinsonian symptoms, which had been developed during exposure to antipsychotic treatment   and the Patients were diagnosed with antipsychotic- induced parkinsonism according to the International Statistical Classification of Diseases and Related Health Problems version 10 (ICD-10) diagnostic criteria . SeveritBrain MRI 3 T) was performed during the hospitalization period. It included T1 weighted sequences on coronal, sagittal and axial planes (or isotropic T1 images), T2 weighted sequences, T2 Fluid Attenuation Inversion Recovery (FLAIR) images and Diffusion Weighted Imaging (DWI). All MRI scans were evaluated by an experienced neuroradiologist (PT). White matter lesions and vascular disease were evaluated using the Fazekas scale on T2-FLAIR sequences . This sc T was peDue to the severity and persistence of parkinsonian symptoms, despite cessation of antipsychotic medication in four cases or switching to other antipsychotic agents in the rest of cases, the assessment of the basal ganglia’s presynaptic dopamine function was recommended. Patients agreed and underwent DaTSCAN. DaTSCAN scintigraphy acquisition and processing methodology as well as the analysis method of the striatal uptake ratios of DaTSCAN images have been previously depicted in detail , 30. VisBased on clinical data, GDS- and MMSE results and imaging findings and in accordance with ICD-10 diagnostic criteria mental disorder- and neurological diagnoses were established . DepressFor the 12-month post-discharge follow-up outcome assessment, a caregiver-based telephone interview format was employed. The interview was based on questions about movement disturbances and mental disorder- and neurological diagnoses. The individuals diagnosed on discharge with Parkinson’s disease, idiopathic tremor and vascular parkinsonism, respectively, still suffered from movement disturbances, as expected. In a patient who had been diagnosed on discharge with drug-induced parkinsonism, persistent movement disturbances were reported, despite the discontinuation of antipsychotic agents during hospitalization. In all other patients no parkinsonian symptoms were reported, in line with the discharge diagnosis of drug- induced parkinsonism. The two patients who received on discharge the diagnosis of mild cognitive impairment due to Alzheimer’s disease progressed to dementia and faced at follow-up difficulties with both complex and basic activities of daily living.The development of parkinsonian symptoms while being on antipsychotic medication does not straightforwardly substantiate the presence of drug-induced parkinsonism, especially in seniors. The presented case series, which in contrast to the heterogeneity of study samples of most past reports –37, focuTreatment with antipsychotics can induce parkinsonian symptoms, uncover subclinical degenerative and/or vascular striatal brain pathologies, or lead to the exacerbation of previously mildly manifest parkinsonian symptoms . Drug-inIn older adults treated with antipsychotics, the puzzle of the genesis and clinical manifestation of parkinsonian symptoms are further perplexed by the heavy burden of coexisting brain pathologies  , 40. TheDeciphering the cause of parkinsonian symptoms in seniors treated with antipsychotics is crucial for designing the proper, individualized therapeutic plan. Prescribing antiparkinsonian drugs without an established diagnosis of Parkinson’s disease or even of a Parkinson-plus syndrome, which albeit responds in most cases poorly to current therapies compared to Parkinson’s disease , is not Despite the phenotypic homogeneity and the thorough and rigorous diagnostic workup of the considered patients, the presented case series has a number of limitations. Even though all patients suffered from severe depressive symptoms on admission, four were diagnosed at discharge with recurrent depressive disorder and four with organic mood disorder, while in one case the diagnosis of bipolar disorder had been established prior hospital admission. Moreover, the age of onset of the first mood disorder episode as well as performance on MMSE varied across the cases. Only four cases can be classified as suffering from late-onset depression. In four cases MMSE scores pointed to clinically significant abnormalities in cognitive function . Taking In conclusion, detecting the cause of parkinsonian symptoms in seniors who are exposed to antipsychotics and subsequently taking appropriate action is a challenging task. Indeed, parkinsonian symptoms cannot be straightforwardly classified as drug-induced in older adults treated with antipsychotics. Age-related neurodegenerative and vascular brain changes may underlie parkinsonism and shape a terrain of unreliable clinical characteristics, ambiguous exam findings and in many cases hardly justifiable therapeutic choices. Comprehensive diagnostic workup is in cases with atypical, severe and/or persistent parkinsonian symptoms the only feasible strategy for developing proper treatment plans. The field of deciphering the cause of parkinsonian symptoms in seniors treated with antipsychotics merits a systematic and thorough study of possible clinical, imaging and outcome endophenotypes of such symptoms, so that in the future personalized and efficient therapeutic strategies can be designed. Familiarizing clinical psychiatrists with effective ways to cope with inconsistent and/or ambiguous imaging and clinical data and make good diagnostic and therapeutic decisions is another step towards this direction.