Some previous studies have suggested a high prevalence of pulmonary embolism (PE) during exacerbations of chronic obstructive pulmonary disease (ECOPD). The SLICE trial aims to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE  in patients hospitalized because of ECOPD.SLICE is a phase III, prospective, international, multicenter, randomized, open‐label, and parallel‐group trial. A total of 746 patients hospitalized because of ECOPD will be randomized in a 1:1 fashion to receive either an active strategy for the diagnosis and anticoagulant treatment of PE or usual care . The primary outcome is a composite of all‐cause death, non‐fatal (recurrent) venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Secondary outcomes are (a) death from any cause within 90 days after enrollment, (b) non‐fatal (recurrent) VTE within 90 days after enrollment, (c) readmission within 90 days after enrollment, and (d) length of hospital stay.Enrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 patients was 71 years , and 26% were female.This multicenter trial will determine the value of detecting PEs in patients with ECOPD. This has implications for COPD patient morbidity and mortality.Trial registration number: NCT02238639. Consecutive adult patients with ECOPD who require hospital admission are eligible for the study. The inclusion and exclusion criteria of the SLICE trial are listed in Table SLICE is an investigator‐initiated, phase III, prospective, international, multicenter, randomized 1:1), open‐label with blind end‐point evaluation (PROBE), parallel‐group trial , and management allocation is concealed from all investigators.In a patient with ECOPD who requires hospital admission, randomization should occur in the first 24 hours after admission. The trial uses a computer‐generated randomization scheme. Randomization is stratified by center and, within the centers, performed in blocks of 4 and 6 to ensure balanced distribution of the management groups. Randomization is performed centrally through the Internet  is performed. CTPA results are categorized as positive for PE if an intraluminal filling defect is seen in (sub)segmental or more proximal branches, and are considered negative if no filling defect is observed. Scans are considered technically inadequate only if main or lobar pulmonary vessels are not visualized. Although not mandatory, the protocol suggests the use of complete lower limb compression ultrasonography (CCUS) to detect concomitant deep vein thrombosis (DVT) for patients with isolated subsegmental PE.If the diagnosis of PE is confirmed, patients receive anticoagulant treatment according to guideline recommendations: parenteral anticoagulation  overlapped and followed by vitamin K antagonists; or parenteral anticoagulation followed by dabigatran or edoxaban; or monotherapy with apixaban or rivaroxaban.2.3.2Patients in the control group undergo standard  clinical management,2.4The primary efficacy outcome is the composite of death from any cause, non‐fatal (recurrent) symptomatic venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Confirmation of (recurrent) symptomatic PE requires symptoms of PE and a new or an extension of a previous intraluminal‐filling defect in (sub)segmental or more proximal branches on PE‐protocol chest CTPA. Confirmation of (recurrent) symptomatic DVT requires symptoms of DVT and the following criteria: (a) In the absence of previous DVT investigations at baseline, a non‐compressible venous segment on ultrasonography, (b) if there were previous DVT investigations at baseline, abnormal lower limb CCUS where compression had been normal; or, if previously non‐compressible, a substantial increase (≥4 mm) in diameter of the thrombus during full compression.Secondary efficacy outcomes include: (a) death from any cause within 90 days after enrollment, (b) non‐fatal (recurrent) symptomatic VTE within 90 days after enrollment, (c) readmission for ECOPD within 90 days after enrollment, and (d) length of hospital stay.The principal safety outcome is major bleeding within 90 days after enrollment, defined according to the guidelines of the International Society of Thrombosis and Hemostasis,A central independent adjudication committee whose members are unaware of management allocation adjudicates all suspected study outcomes during the study period.2.5The study requires the following scheduled visits: enrollment, 1 week, 1 month, and 3 months after randomization. Additional visits are performed if new symptoms and/or signs of VTE or major bleeding occur during the study period or anytime it is deemed necessary by the investigator. Clinical examination, laboratory and diagnostic imaging are performed if the patient develops symptoms or signs suggestive of (recurrent) VTE.2.6Previous studies have shown short‐term rates of death, thromboembolic events, or readmission of approximately 40% at day 90 among patients who required hospital admission because of ECOPD.2.72 statistics or Fisher's exact test. Continuous variables will be summarized as the means ± SD or median and compared using Student's t test  and Mann‐Whitney U test . Survival curves with time‐to‐event data will be generated by the Kaplan‐Meier method and compared using the log‐rank test. Comparisons between the two groups will be performed using the Cox proportional hazard model. A P‐value <0.05 will be considered statistically significant. All analyses will be performed with the use of the statistical programme SPSS V.24.0.All analyses will be performed on the intention‐to‐treat population, defined as all patients randomized, regardless of the management actually received. A per‐protocol analysis, excluding protocol violations, will be performed as a sensitivity analysis. The distribution of continuous variables will be assessed by the Kolmogorov‐Smirnov test. Categorical variables are expressed as frequencies or percentages and compared by χSubgroup analyses will include: age (<75 vs ≥75 years), sex , COPD severity , hospital volume (<300 beds vs ≥300 beds), and season of the year .Two sensitivity analyses are planned for the primary outcome. The first is an analysis of primary‐outcome events after excluding those patients in the intervention group with a diagnosis of isolated sub‐segmental PE. The second is an analysis of outcomes after excluding patients with a history of cancer.2.8The SLICE is an independent, investigator‐initiated trial with an academic sponsor . The Steering Committee .2.11An independent DSMB periodically reviews the study outcomes with all information available concerning management allocation. The DSMB is composed of three expert clinicians with experience in the conduction and monitoring of clinical trials.2.12The study is performed in accordance with the provisions of the Declaration of Helsinki and local regulations. Protocol and amendments have to be approved by the Institutional Review Board or Ethic Committee at each study center. The protocol and informed consent have been approved by the Institutional Review Board of Ramon y Cajal Hospital, and accepted by each participating center. Written informed consent for participation in the trial is obtained from all enrolled patients. Dissemination of the results will include conference presentations and publications in peer‐reviewed journals.3Enrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 enrolled patients was 71 years , and 26% of patients were female.4COPD patients may suffer from exacerbations, defined by an acute worsening of respiratory symptoms beyond normal day‐to‐day variations and leading to a change in medication.The SLICE trial is currently enrolling patients to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE in patients with ECOPD. The trial has the potential to improve the management of exacerbations in patients with COPD. It is anticipated that the findings of this study will enhance our understanding of the exacerbations of COPD. This rigorously designed trial will address the role of PE in the decompensation of patients with COPD, potentially leading to better care.Previous studies and meta‐analyses have assessed the prevalence of PE in ECOPD.Our trial has some limitations. This is an open‐label trial, and ascertainment bias is inherent to the trial design. To mitigate potential bias, all events are adjudicated by a committee whose members are unaware of the intervention assignments. The decision to use a composite outcome that includes readmissions for ECOPD might prove challenging for the interpretation of results. There are some reasons for including readmission as an outcome in the study protocol. First, exacerbations of COPD are associated with accelerated loss of lung function and death.In conclusion, the SLICE trial will provide high‐quality evidence regarding the risks as well as the benefits of using CTPA in the evaluation of ECOPD.The authors declare no potential conflict of interests.APPENDIX S1Click here for additional data file.


Aphelocoma coerulescens) to estimate strength of selection and autosomal and Z‐linked heritability of mean brightness, UV chroma, and hue. Although plumage coloration signals dominance in juveniles, there was no indication that plumage coloration was related to whether or not an individual bred or its lifetime reproductive success. While mean brightness and UV chroma are moderately heritable, hue is not. There was no evidence for sex‐linked inheritance of any trait with most of the variation explained by maternal effects. The genetic correlation between the sexes was high and not significantly different from unity. These results indicate that evolution of sexual dimorphism in this species is constrained by low sex‐linked heritability and high intersexual genetic correlation.Sexually dimorphic plumage coloration is widespread in birds and is generally thought to be a result of sexual selection for more ornamented males. Although many studies find an association between coloration and fitness related traits, few of these simultaneously examine selection and inheritance. Theory predicts that sex‐linked genetic variation can facilitate the evolution of dimorphism, and some empirical work supports this, but we still know very little about the extent of sex linkage of sexually dimorphic traits. We used a longitudinal study on juvenile Florida scrub‐jays ( Sexually dimorphic coloration occurs in several taxa, and numerous studies have demonstrated the selective advantages of conspicuous coloration for mating success (Andersson oecilia reticulata)  Winge  and QTL a) Winge  and is ca) Winge . Althouga) Winge , relativa) Winge .Birds are a particularly interesting group in which to study the nonautosomal sources of variation because Z‐linkage of female preference facilitates the evolution of conspicuous male secondary sexual traits under Fisher's runaway model of sexual selection  is a suitable model organism to study the selection and inheritance of plumage coloration. Both sexually immature juvenile  breeding males produce no breeding offspring over their lifetime and less than 10% produce five or more. Florida scrub‐jays disperse short distances and males frequently inherit all or part of their father's territory   the outermost right tail feather is collected. Feathers are stored in individually labeled envelopes in a museum cabinet in a climate‐controlled room. UV‐blue coloration does not fade over the timespans that our feather samples were in storage , UV chroma (∑Rλ300−400/∑Rλ300−700), and hue (λRmax), where R is reflectance, λ is wavelength, and nw is number of wavelengths measured  connected to a DH‐200 deuterium halogen light source by a bifurcated fiber optic probe. We measured three 3.14 mmμ) with the larger value to the trait mean of the sex with the smaller value so that SD = μlarger/μsmaller. The ratio is assigned a positive value if females had the larger trait value and negative if males had the larger value.While previous studies of Florida scrub‐jay color have demonstrated SD  to estimate whether any metric of plumage reflectance predicted whether or not a bird bred. For LRS, we used the R‐package “mgcv” to run the GAMs  need not be positive, these tests are chi‐squared distributed with 1 degree of freedom. All quantitative genetic models were run using the software ASReml 3.0  and a chi‐squared distribution with null degrees of freedom, because of testing on the boundary of the parameter space , UV chroma , and hue . Compared to females, males had plumage with lower mean brightness that is more UV‐shifted , UV chroma , or hue  on whether or not an individual bred. We also examined nonlinear patterns of selection on mean brightness, UV chroma, and hue between LRS and coloration using GAMs  or females . As a result, the selection gradients estimated from the GAMs were not significant for either sex . For UV chroma and hue, the models that excluded sex had the lower AIC values, so we present the results of these models here. No relationships between reproductive success and UV chroma  or hue  existed, nor were the selection gradients significant . A linear selection analyses revealed significant (before correction for multiple tests) negative selection on mean brightness in 1993  and UV chroma  were moderately heritable. For these traits, we also estimated sex‐specific variances and heritabilities. For mean brightness, the additive genetic variance and heritability estimates were 1.19 and 0.60 for females and 0.74 and 0.39 for males. For UV chroma, these estimates were 0.46 E−3 and 0.43 for females and 0.57 E−3 and 0.46 for males. Hue displayed no genetic variance . Sex linkage of hue was not examined because we found no genetic variance in this trait. Although small and nonsignificant, the addition of sex‐linked genetic variance decreased the estimated autosomal heritability from 0.250 to 0.194  and UV chroma  demonstrating strong evolutionary constraints for sex‐specific evolution of these traits.The genetic correlation between the sexes was strong and not significantly different from unity for both mean brightness  . Although sex‐linked inheritance of sexually dimorphic plumage color has been documented in other species , where sexually dimorphic melanin‐based plumage traits are explained by polymorphisms in autosomal genes rather than by sex‐linked inheritance (Roulin and Jensen Plumage patterns are frequently sexually dimorphic (Hill and McGraw Rice  hypothesEvolution of SD can be constrained if the intersexual genetic correlation is high Lande . We estiBecause UV chroma and hue signal social dominance in juvenile Florida scrub‐jays (Tringali and Bowman Variation in territory identity explained very little of the variation in plumage reflectance, but maternal effects explained 10–25% of the phenotypic variance in all three reflectance variables. Although food limitation affects structural coloration (McGraw et al. To understand the evolutionary dynamics of natural populations, we must know how selection and heritability affect traits of interest. We used a longitudinal study of a population of Florida scrub‐jays with pedigree and fitness data to study the evolution of sexually dimorphic plumage coloration in juveniles. We did not detect any association between plumage coloration and fitness even though juvenile plumage coloration is important in determining dominance relationships in this species. We found that both mean brightness and UV chroma were heritable, but no evidence of sex linkage for any plumage trait. The intersexual genetic correlation for brightness and UV chroma was near unity for both traits. Together, these results indicate that the evolution of sexual dimorphic plumage color is tightly constrained. Maternal effects explained much of the variation in plumage coloration, and it would be interesting to further explore the mechanism of this link.None declared.Data will be deposited in Dryad upon acceptance.


Lung cancer is globally one of the leading causes of malignant tumor‐related mortality and ranks as having the highest incidence found in men and second in women. Osimertinib is a drug used to target lung cancer but its toxicity is not fully understood. Here we present a case of lung adenocarcinoma in a 78‐year‐old man that was treated and responded favorably with Osimertinib after the failure of other therapies. Unfortunately, the patient developed severe interstitial lung disease during the treatment procedure. Lung cancer is the leading cause of cancer associated death and ranks as having the highest incidence found in men and second in women.The target drug, epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are widely used in the treatment of NSCLC and satisfactory results have been previously reported.5 However, drug‐related toxicity is not clearly understood when osimertinib is only administered for a short period. In our study, we present a case treated with osimertinib where a complete response was achieved after other therapies had failed. During the treatment procedure, the patient developed severe interstitial lung disease.In November 2015, the United States Food and Drug Administration (FDA) approved the clinical use of osimertinib treatment for NSCLC patients with EGFR T790M positive mutation and drug resistance after the first and second generation of EGFR‐TKI treatmentA 78‐year‐old male patient presented in April 2015 with suspected lung cancer. Chest CT examination revealed a pulmonary space‐occupying lesion in the left upper lobe of the lung Fig. . Due to The patient had second gene mutation testing at this time which indicated EGFR T790M mutation. Osimertinib 80 mg/day orally was subsequently recommended from March 2017. After only one month of treatment, chest CT scan revealed the disease had almost completely resolved , EGFR mutation status examination is necessary. Overall survival and disease free survival can be significantly prolonged for patients with effective EGFR mutation who are treated with gefitinib or Erlotinib. However, drug resistance developed in most cases that received 9–13 months treatment. In the case reported here, the patient developed gefitinib resistance after 10 months administration. Previous studies have determined that multiple mechanisms of acquired resistance include secondary mutations in EGFR, ERBB2 amplification, MET oncogene amplification, etc.Osimertinib AZD9291), a third generation EGFR TKI, is a mono‐anilino‐pyrimidine small molecule. It has also been approved for second‐line treatment of advanced NSCLC positive for EGFR‐T790M mutations.291, a thThe authors do not report any conflict of interest.


Samples were taken in Peak Flows at effluent Treatment Plants. Sampling and tests were conducted according to the standards methods. The collected data were analyzed by SPSS software and excel program. Nickel metal showed higher amounts than the standards required for irrigation agricultural land. Data could be useful from environmental and agricultural sciences to those concerned about heavy metals, Alkalinity, EC, COD, BOD Specifications TableValue of the data●Due to limited data in the area, the data can help to better understand the irrigation water quality in the area and provide further studies.●Crops irrigation with wastewater treatment effluent can take risks on human health as consumers.●The data shown here can be used for health risk assessment of pollutants for effluent disposal.1Crops irrigation with wastewater treatment effluent can take risks on human health as consumers. It is due to absorption and accumulation of heavy metals. A summary of effluent and influent quality characteristics are presented in 22.12 area and locates in southwest of Mashhad . It has a 142 km distance with Mashhad. It locates in the longitude 59° and 12 min east and the latitude 34 degree and 17 min north. Population of city is 267604 according to last census in 2006 Torbat Heydarieh province has a 23.888 km2.2This research conducted on wastewater treatment plant of Torbat Heydarieh province for four months from April to July 2016. Samples were taken in peak hours and transported to laboratory for experimenting under standard conditions. Samplings and experiments took according to the standard methods for water and wastewater treatment handbook


Internet delivery of behavioural weight control interventions offers potential for broad geographic reach and accessibility, but weight losses online fall short of those produced with the same programme delivered in‐person. This pilot study examined feasibility and preliminary efficacy of a video‐based platform for delivering weekly chat as part of a 6‐month, 24‐session online group behavioural weight control programme compared with the established text‐based format, which has produced the best online weight losses to date.Women with obesity (N = 32) were randomized to either (a) weekly video group chat sessions and provided with a cellular‐enabled scale (Video) or (b) Text‐based weekly chat sessions and given a digital scale (Text) and followed for 6 months to determine weight loss and treatment engagement.Women randomized to the ideo condition lost more weight than those in the Text condition  at 6 months, although the difference was not statistically significant. However, women in the Video condition had significantly greater treatment engagement, with greater self‐monitoring and website utilization than those in the Text condition.Videoconference delivery of group‐based online weight control accompanied by a cellular‐connected scale may promote greater treatment engagement and weight loss than text‐based chat. A larger, adequately powered study is warranted to determine which elements drive these enhanced treatment outcomes. Effective behavioural weight control treatments are available,A central question in the efforts to develop a maximally effective online weight management approach is, “What critical elements differentiate in‐person weight control programmes from their online counterparts that might account for the greater weight losses achieved in‐person?” Two distinguishing features between in‐person and online programmes are the actual face‐to‐face time with the counsellor and other group members throughout the session, as well as the pre‐session weigh‐in. These elements are intended to foster accountability and social support.Delivery of treatment in a face‐to‐face setting is the archetype of behavioural weight control and current gold standard format of delivery for behavioural obesity treatment, as exemplified by the Diabetes Prevention Program Lifestyle BalanceSome have argued that face‐to‐face social support is richer with verbal and nonverbal cues  than that available in computer‐mediated social support.Initial explorations of video‐based chats as a delivery platform for behavioural weight control interventions have been promising. A commercial programme demonstrated that self‐reported weight losses among participants who elected to participate in an online videoconference programme were similar to those who selected in‐person treatment.The individual weigh‐in prior to the group meeting is another element of traditional in‐person, group‐based behavioural weight control programmes that distinguishes the approach from their web‐based counterparts. Individuals arrive a few minutes before the scheduled group session for their private weigh‐in, which not only enables treatment staff to obtain an objective body weight measurement and directly view the individual's weight trajectory, but also offers an opportunity for interaction, provision of support, reinforcement, and problem‐solving, as necessary. Individuals then convene in the group meeting room for additional interaction as other group members assemble. The accountability and informal social support provided during the pre‐session weigh‐in period likely enhance weight loss efforts.Collectively, utilizing videoconferencing group delivery platforms and incorporating a virtual weigh‐in and informal social support opportunities prior to group start may narrow the gap between weight loss outcomes achieved in‐person and those achieved with online delivery, effectively marrying the advantages of face‐to‐face contact and social support with the accessibility advantages offered by internet delivery. Therefore, the current pilot study sought to examine the feasibility and preliminary efficacy of a video‐based group chat format and cellular‐enabled scale within an online behavioural weight control programme in comparison with the established text‐based group chat delivery approach within the same online programme22.1http://clinicaltrials.gov (NCT03491293).This 6‐month randomized controlled pilot study was conducted between March and November 2018 at two clinical sites (South Carolina and Vermont) and randomly allocated participants to either (a) a 24‐week, group‐based online behavioural lifestyle programme with weekly synchronous video‐based chat sessions and a cellular‐enabled scale (Video) or (b) the same online group programme with weekly synchronous text‐based chat sessions (Text). Text‐based chat was selected as the comparator because it has the best weight loss outcomes for synchronous online group weight control published to date and has been utilized to produce weight loss for almost a decade.2.22) between 25 and 50. Individuals were ineligible if they had a heart attack or stroke in the past 6 months, had a history of bariatric surgery, lost more than 10 pounds in the previous 6 months, were taking medications for weight loss, had a condition for which weight loss was contraindicated, or would be unavailable for follow‐up data collection. Access to a computer with Internet and a smartphone (compatible with self‐monitoring apps for dietary intake and step‐counting) were required. Participants completed a behavioural run‐in consisting of successfully logging into both the text and audiovisual group chat websites and completing an online food diary for 3 days. Participants also had to agree to create an account with http://myfitnesspal.com to monitor their diet and physical activity daily and allow counsellors to view their diaries (to guide feedback) by “friending” the programme. Finally, they had to agree to be randomized. After baseline data collection, individuals were randomized using a biased coin approach with race balanced across conditions.Women were recruited through word‐of‐mouth and targeted emails using available distribution lists . Potential volunteers entered an online recruitment portal that included a study overview and initial screening questionnaire. A phone interview was conducted to determine likely eligibility, followed by an in‐person orientation session at which informed consent was obtained. To be eligible, women had to be in good health, 18 years or older, and have a body mass index  by accepting an invitation offered 15 minutes before group start time. Once in the chatroom, tiled videos of each participant were seen in real‐time by others in the chatroom, and an individual's video tile enlarged when they spoke. Participants were also provided with a cellular‐enabled digital scale  prior to the first group chat and were instructed to weigh themselves daily. The scale automatically transmitted the weight measurement to the secure BodyTrace website via cellular connectivity where progress could be viewed by the participant and group counsellor, but not other group members.2.5Individuals in the Text condition received the online weight management programme and weekly text‐based group chat meeting, accessed on the Adobe Connect platform . Static pictures of all Text group members were visible at the top of the screen. All interactions occurred via typed comments, and the acceptability of typos and grammatical errors was underscored. For self‐weighing, individuals utilized their own personal scale or were provided with a digital bathroom scale, which did not transmit data; they were counselled to weigh themselves daily and instructed to record their weight on the study website on the day of the group prior to chatting.2.6All measures were obtained at baseline, 2, and 6 months unless otherwise indicated. Sociodemographic data were obtained by secure online questionnaire at baseline.2.6.12).Weight was measured using a calibrated digital research scale (Tanita BWB‐800A). Height was obtained at baseline using a stadiometer. Weight change was calculated as kilograms lost and percent weight loss. BMI was calculated as weight (kg)/height . Statistical significance was defined as P < .05 (two‐tailed).This pilot study was designed to examine feasibility and, therefore, a formal power analysis was not conducted. Weight loss, treatment engagement, and social support were examined to provide preliminary insights into the comparative efficacy of the two chat delivery platforms. Descriptive statistics were conducted for participant characteristics at baseline, as well as retention and process measures. Missing data for primary outcomes (weight losses at 2 and 6 months) were imputed with baseline observation carried forward for intent‐to‐treat (ITT) analyses, and groups were compared using independent samples 33.12 (69% had obesity), and 22% self‐identified as African American or another racial minority group (Table Thirty‐two participants were randomized to the Video n = 16) or Text (n = 16) conditions , but these differences also did not achieve statistical significance, again likely because of the small sample size. Thus, this pilot feasibility study demonstrated weight loss differences supporting the expected benefits of videoconferencing but did not reach the level of demonstrated efficacy that would be expected in a full‐scale trial.Delivery of a 6‐month group‐based behavioural weight control programme utilizing a videoconferencing chat platform was feasible and effective. Weight losses in the Video group were greater than those achieved in the same programme delivered by text‐based chat , but the difference was not statistically significant, perhaps because of the small sample size in this pilot feasibility study. The observed effect size was 0.4, suggesting a moderate effect,Nonetheless, significantly greater engagement in the group‐based programme delivered with videoconferencing was demonstrated across several key domains. Those in the Video group self‐monitored their weight and physical activity on significantly more days than those in the Text condition. Self‐monitoring is consistently and robustly associated with better long‐term weight loss outcomes,Substantially greater website utilization was observed among those in the Video group. Women in the videoconferencing condition were significantly more likely to access lesson materials and to view and engage in discussions with their fellow group members on the bulletin board than those in the Text group. Further, Video participants logged into the website about 50% more often than Text participants. Engagement with the website has been shown to be strongly correlated with weight loss in other studies of online behavioural weight control.Surprisingly, perceived social support from group members and the counsellor was not higher among those meeting in the audiovisual forum than those receiving text‐only chat, despite the higher engagement in social support website features among those in Video. Comparable ratings of social support were observed in the two conditions, with participants in both Video and Text reporting relatively high levels of social support from their group and their counsellor. This may have resulted in a ceiling effect. Previous weight control studies using the same measure to characterize perceived group support for text‐based online and in‐person programmes have reported values of 6.4 to 7.9, respectively,Retention differences in the two delivery channels did not rise to the level of statistical significance but were noteworthy in that 31% of women randomized to Text dropped out early on . Only 12.5% of women in Video had dropped out at that point and one additional woman dropped out by the 6‐month assessment. Other quasi‐experimental studies have found greater drop out in the comparator arm relative to the videoconferencing arm,Another puzzling observation is that weight losses achieved in the Text arm of this pilot feasibility study were smaller than produced in previous administrations of the same online, text‐based group behavioural weight control programme. In the current study, women in Text lost an average of 3% at 6 months; in previous studies, individuals receiving the text‐based chat condition averaged weight losses of greater than 5%.The study has several strengths worth noting. The randomized design and the objectively measured weight loss outcomes provide greater rigour than previous studies examining audiovisual chat as part of weight control. In addition, the same counsellor delivered both intervention groups, so differences between groups are unlikely to reflect interventionist skill or style. However, there are substantive limitations that merit discussion, foremost being the small sample size. The study was not powered to detect a 3% vs. 5% between‐groups difference in weight loss; rather, it was intended to examine the feasibility of this innovative approach to online delivery and generate data on which to power a full‐scale trial. Further, study results can be generalized only to women, and it is unclear how men might perform in text‐based versus video‐based delivery platforms. Finally, the video condition combined both audiovisual chats and provision of a cellar‐connected “smart” scale, and the impact of these two factors cannot be dissociated. Provision of a similar scale to individuals in an online commercial weight management programme has been shown to increase weight losses over a 6‐month period,In conclusion, this pilot feasibility study suggests that videoconference delivery of group‐based chat and provision of a cellular‐connected scale within the context of a structured online behavioural weight control programme may promote greater engagement and more frequent self‐monitoring, as well as greater weight loss. A larger, adequately powered study to determine which elements drive these improvements in treatment engagement is warranted, as is exploration of the role of social support in video‐based chat, in efforts to merge the advantages of in‐person implementation of behavioural weight control with the accessibility advantages offered by internet delivery. Online behavioural weight control has such strong promise for overcoming geographic constraints, increasing dissemination of evidence‐based obesity treatment and reducing participant burden that continued investigation to refine internet‐delivered programmes to maximize weight losses and foster high levels of engagement is clearly warranted, and video delivery of interactive group sessions merits strong consideration as the process of refining online programmes progresses.No conflict of interest was declared


HPTN 071 (PopART) trial is examining the impact of a package including universal testing and treatment on community‐level HIV incidence in Zambia and South Africa. We conducted a nested case–control study to examine factors associated with acceptance of home‐based HIV testing and counselling (HB‐HTC) delivered by community HIV‐care providers (CHiPs) in PopART intervention communities.The HB‐HTC (cases) and accepted HB‐HTC (controls), stratified by gender and community, were selected. Odds ratios comparing cases and controls were estimated using multivariable logistic regression.Of 295 447 individuals who were offered testing, random samples of individuals who declined CHiPs ; self‐reported as not previously tested ; considered HTC at home to be convenient ; knowing others who had accepted HB‐HTC from the CHiPs ; or were motivated to get treatment without delay  were less likely to decline the offer of HB‐HCT. Those who self‐reported high‐risk sexual behaviour were also less likely to decline HB‐HCT . Having stigmatising attitudes about HB‐HTC was not an important barrier to HB‐HCT uptake. Men who reported fear of HIV were more likely to decline HB‐HCT .Data from 642 participants  were analysed. There were no differences between cases and controls by demographic or behavioural characteristics including age, marital or socio‐economic position. Participants who felt they could be open with HIV testing, positive attitudes about HIV services/treatment and perception of high sexual risk. Uptake of HB‐HCT among those offered it was similar across a range of demographic and behavioural subgroups suggesting it was ‘universally’ acceptable.Acceptance of HB‐HTC was associated with lack of previous  Great advances have been made in controlling the HIV epidemic over time and especially so in the last decade. HIV incidence worldwide has declined, as have HIV‐related deaths Despite the progress so far, unless uptake of testing is extensive and inclusive in terms of acceptability to all subsets of the population, the full potential of UTT will not be realised. Home‐based HIV testing and counselling (HB‐HTC) has the potential to increase awareness of HIV status in previously undiagnosed individuals in sub‐Saharan Africa The design of the HPTN 071 (PopART) trial has been described previously The nested case–control study was carried out in all the intervention (Arms A and B) communities – eight in Zambia and six in South Africa. The study objectives were to identify differences between non‐acceptors (cases) and acceptors (controls) of HB‐HTC in the first annual round of HB‐HTC in PopART and to identify reasons for non‐acceptance of HB‐HTC.While delivering the PopART intervention, CHiPs captured the details of all individuals who consented to the intervention offered by CHiPs, irrespective of whether or not they accepted HB‐HTC, on an electronic register To be eligible for the case–control study, participants had to be ≥18 years old, able and willing to provide informed consent and have participated in the first year of the PopART intervention. Belonging to the population cohort of the PopART trial  . RAs conducted surveys using standardised questionnaires administered electronically. Questionnaire themes were informed by current evidence in the literature or anecdotal local information on factors that may influence uptake of HIV testing. RAs were kept unaware of participants’ case or control status. In the questionnaire, the question about whether the individual had accepted or declined HB‐HTC was asked at the end of the interview to minimise interviewer bias.While monitoring data as part of routine quality assurance, the study team uncovered some irregularities in data collection in South Africa. In‐depth internal and independent investigations followed, with oversight from the relevant ethical and regulatory bodies responsible for the study. Consequently, data from one community were not used due to concerns about substantive data irregularities, while in the remaining five communities in South Africa, a rigorous data verification process was undertaken to ensure data integrity. Only participants who could be recontacted and whose data were verified as genuine were retained. The verification process involved confirming the identity of the participant and checking that responses to selected key questions matched responses given during the initial CC visit. No irregularities related to this study were identified in Zambia at any stage.α = 0.05). The age/sex distribution of the final study sample was similar to that of the initial randomly selected sample.The final sample size of ~650 participants (1:1 case:control ratio) provided ~80% study power to detect associations with odds ratios of ~1.75 or higher (or ~0.5 or lower), for explanatory variables with 15% prevalence among controls  for which there was at least weak statistical evidence of association with HB‐HTC acceptance were included as potential confounding variables. Likelihood ratio tests (LRT) were performed to assess the statistical evidence for associations. Evidence of effect modification by gender and country was explored. For variables with three or more response categories and potential for a dose–response relationship, test for trends was performed.The study was approved by the Ethics Committees of the University of Zambia, Stellenbosch University and the London School of Hygiene and Tropical Medicine.As shown in Figure Cases and controls were well balanced by trial arm, community and gender, reflecting the sampling strategy of the study. Participants were distributed fairly evenly across age categories with slightly higher proportions in younger age groups Table . The medCases and controls were similarly distributed across almost all the characteristics examined. There were no differences by ethnicity or religion, nor in household conditions, sexual behaviour or health status .However, participants who had lived in the community for more than 3 years had twice the odds of declining HB‐HCT than those who had been resident for <3 years (adjusted odds ratio (AOR):2.01,95% confidence interval(95% CI):1.25–3.22, Neither the number of other household members who were present when HB‐HTC was offered to the household, nor the presence of the participant's partner, were associated with acceptance of HB‐HCT Table .P = 0.03). There is evidence of a trend suggesting that the more strongly a participant agreed that they could talk to the CHiP openly, the less likely they were to have declined HB‐HCT (test for trend P = 0.003). Also, the more strongly participants agreed that providing treatment widely could reduce incidence of new infections, the less likely they were to have declined HB‐HCT (test for trend P = 0.03).As shown in Table P = 0.03). Similarly, those who knew someone who had had an HIV test with the CHiPs ; thought they could get treatment without delay if HIV positive ; accepted the CHiP advice that it was good to have an HIV test ; and considered testing at home as convenient  – were less likely to have declined HB‐HTC. Participants who indicated that their sexual behaviour put them at risk of HIV (as a reason to test) were also less likely to have declined HB‐HTC .When non‐acceptors and acceptors were asked  standardised questions about factors that encourage HIV testing , further associations emerged. Individuals who reported never previously testing for HIV were less likely to have declined HB‐HTC  and reluctance to test again after recent testing (the definition of recency was not specified and left to the interpretation of the participant)  were more likely to decline HB‐HCT.When exploring reasons against accepting HB‐HTC, those who reported confidence in being HIV negative (so there was no need to test) , whereas no such association was noted among women  .There were few differences observed when stratifying associations by gender and country Table a,b. Men Our study provides evidence from large urban communities that were targeted to receive universal testing  Figure . UTT hasOur study sample was frequency‐matched by gender and community to ensure adequate representation of those groups. As such, rather than identify whether there were any differences in uptake by gender  and those who declined HB‐HCT (cases). Our data indicate that there were no specific subsets of the population who were systematically less likely to accept testing, once contacted, suggesting that HB‐HTC has the potential to be universally acceptable to those offered it. Evidence indicates that there are fewer men found at home than women and HB‐HTC providers may therefore encounter less men Cases and controls did seem to differ in perceptions held about issues related to HIV and HIV services. Most participants gave favourable responses regarding HIV services, and those who held positive views about the CHiPs were less likely to have declined HB‐HTC. There were several factors that encouraged testing at the individual level. Participants who had not tested for HIV previously were more likely to accept HB‐HTC in contrast to those who had previously tested HIV negative or had tested recently and felt that repeat testing was not warranted.et al [Participants who declined HB‐HCT were less positive about treatment for HIV than those who accepted. Further, those who declined were more likely to hold the view that they were not at risk of HIV and it was therefore not a reason for them to test. Low‐risk perception as a reason not to test was also observed by Naik et al . Yet wheOther views that might have been assumed to encourage or discourage testing had no association with observed acceptance of HB‐HTC. For example, concerns about confidentiality with testing in the home, or the presence of other household members during delivery of HB‐HTC (including partner), were not associated with acceptance and so these factors did not appear to inhibit testing. Contrary to other studies We found surprisingly few differences between responses given by men and women. However, the data do suggest that among men, fear of an HIV‐positive result was associated with HB‐HTC non‐acceptance.Further research is needed to explain some study findings, including the association of longer duration lived in the community with non‐acceptance, or the finding that greater mobility is associated with increased likelihood of acceptance in Zambia. Several of the communities studied have been exposed to HTC campaigns in the past. Individuals who have been resident for longer periods may have been tested before and therefore declined HB‐HTC when offered by PopART CHiPs. In contrast, mobility is associated with higher sexual risk Our study had some limitations to consider. To comply with ethical principles and good research practice, only individuals who were encountered and agreed to participate in the PopART intervention, and who were recontacted and provided informed consent for the CC study, could be recruited as participants. Due to high mobility in the study communities, randomly selected individuals from the CHiP database were often difficult to trace, to ask permission for contact by the research team. As such, it may be that the study sample is not fully representative of all community members and our results should be interpreted in the light of this limitation. However, the response rates in cases and controls were very similar  such a hypothesis. In contrast to much of the existing literature on acceptability of HIV testing, our study is specific to the context of attempting to provide universal testing and at large scale. Further, we directly compared those who accepted HB‐HTC with those who did not to provide evidence of differences rather than simply describing individuals without comparators. Also, by frequency matching our study sample by gender, we ensured an adequate sample of men who are often under‐represented in studies of HIV test uptake despite (or because of) the fact that they are more frequently non‐engagers with HIV services. Finally, the study covered an extensive range of themes. The null findings make an important contribution to identifying which areas may be less important when designing public health information to encourage HB‐HCT.While firm evidence of causality cannot be inferred from this observational study, our study findings provide opportunities for tailoring services and public health messaging to extend the reach of HB‐HTC, to those who may currently be avoiding it. Our first key recommendation is with regard to decision‐making about testing being based on whether one needs a test. We found that those who had previously tested HIV negative or had tested recently felt that repeat testing was not warranted. Also, participants who indicated that their sexual behaviour put them at risk of HIV were less likely to have declined HB‐HTC. We recommend that service providers reinforce the importance of testing irrespective of self‐held perceptions of risk of HIV, especially where universal knowledge of HIV status is sought. WHO guidelines do not recommend retesting to cover a ‘window‐period’ This case–control study, which is nested within the largest HIV prevention trial to date, provides valuable insights into the acceptability of HB‐HTC. We found that that there were no differences in uptake of HB‐HTC by demographic and behavioural characteristics suggesting that HB‐HTC has the potential to be universally acceptable – to those who can be contacted and offered it – although to achieve universal coverage, innovative ways to make contact and offer HB‐HTC extensively will be needed. Ideally, a mixture of approaches  should be made available, so that individuals have a choice and coverage may be maximised. We have identified perceptions and opinions held by community members that could help tailor public health messaging with a view to achieving universal knowledge of HIV status in high‐prevalence settings.Table S1 (a) Factors with effect modification by gender, of association with case/control status. (b) Factors with effect modification by country, of association with case/control status.Click here for additional data file.


Neurodegenerative and cerebrovascular diseases cause considerable human suffering, and therapy options for these two disease categories are limited or non‐existing. It is an emerging notion that neurodegenerative and cerebrovascular diseases are linked in several ways, and in this review, we discuss the current status regarding vascular dysregulation in neurodegenerative disease, and conversely, how cerebrovascular diseases are associated with central nervous system (CNS) degeneration and dysfunction. The emerging links between neurodegenerative and cerebrovascular diseases are reviewed with a particular focus on pericytes—important cells that ensheath the endothelium in the microvasculature and which are pivotal for blood–brain barrier function and cerebral blood flow. Finally, we address how novel molecular and cellular insights into pericytes and other vascular cell types may open new avenues for diagnosis and therapy development for these important diseases. In addition, there is an even larger number of supporting glial cells, i.e., astrocytes and oligodendrocytes, the latter forming myelin sheets around neurons and making up a large part of the white matter in the brain. Another important cell category is the microglia—macrophage‐like cells important for scavenging cellular debris and protein aggregates, but when activated they also become central players in brain inflammation. While neurons and glial cells traditionally have been classified into sub‐categories based on morphological and anatomical criteria or differences in neurotransmitter repertoire, a new and more fine‐grained view of neurons and glial cell sub‐types is now emerging as a result of recent transcriptomic analyses of the brain at the single‐cell level. Thus, more than 500 molecularly distinct classes of neurons and glial cells have been identified in the mouse brain The brain constitutes ≈2% of the adult human body weight but receives 20% of the cardiac output and consumes 20% of our oxygen and glucose. However, it has almost negligible capacity for long‐term storage of energy and is therefore dependent on an elaborate vasculature that continuously fuels the brain with oxygen and nutrients. The vasculature of the brain has an intricate architecture: Feeding arteries follow the outer rim of the brain via the meninges and make branches that penetrate perpendicularly into the brain parenchyma (sometimes referred to as penetrating arterioles), where they further split into smaller arterioles and eventually into capillaries Fig A–C. The The blood vessels are built from two principal cell types: an inner lining of endothelial cells surrounded by an outer layer of mural cells. The mural cells have different phenotypes and are called by different names depending on vessel type: vascular smooth muscle cells (VSMC) cover arteries, arterioles, and veins, and pericytes cover capillaries and venules Figs D and 2. in vitro conditions during pericyte–endothelial cell co‐culture For the most part, the interface area between the pericytes and endothelial cells is physically separated by basement membrane. However, at specialized sites, often located at the end of secondary processes, the pericyte and endothelial cell membranes come into close apposition. These sites are referred to as peg‐socket contacts and adhesion plaques. In the peg‐socket contacts, pericytic cytoplasmic projections (“pegs”) protrude into endothelial membrane pockets (“sockets”), whereas the adhesion plaques are flat areas of contact. An important question related to both of these contact types is if one pericyte contacts one or more endothelial cells, thereby potentially integrating their functional behavior. The peg‐socket structures have thus far mostly been observed at the ultrastructural level in transmission or scanning electron microscopy analysis of animal tissues A particular feature of the brain vasculature is the blood–brain barrier (BBB), which serves to separate the blood from the extracellular fluids of the brain  and hinders pathogens and xenobiotic substances from entering the brain. The non‐fenestrated endothelial cells in the brain vasculature are interlocked via tight junctions and adherens junctions, forming a tight physical barrier. This contrasts with the endothelium in, for example, the liver, kidney, and endocrine organs, which is fenestrated and therefore freely permeable for solutes and small proteins. To allow for efficient, precise, and regulated transport of ions, sugars, amino acids, nucleic acids, lipids, and proteins, the BBB is equipped with a wide range of specific influx transporters, as well as receptors that engage in receptor‐mediated transcytosis. In addition, in order to bounce off unwanted and potentially neurotoxic substances present in the blood, including xenobiotics taken up from the gut, the BBB endothelium also expresses several efflux transporters that nonspecifically recognize and export small lipophilic molecules. This feature of the BBB is a major barrier against low molecular weight pharmaceuticals and poses a problem for efficient drug delivery to the brain.Whereas the specific features of the BBB described above mostly can be attributed to the endothelial cells, surrounding peri‐endothelial cells also play important roles as inducers and regulators of the BBB properties of endothelial cells as well as by taking active part in the homeostatic functions of the BBB. The latter is suggested by the many transporter molecules that are specifically expressed in brain pericytes as compared to lung pericytes Pdgfbret/ret mouse, produces only a truncated PDGFB ligand (PDGFB‐ret) lacking a C‐terminal stretch of amino acid residues referred to as the retention motif. This motif mediates binding of the secreted PDGFB wild‐type molecule to proteoglycans on the cell surface or in the extracellular matrix Pdgfb or Pdgfrb genes have been fully or partially ablated. In Pdgfb and Pdgfrb null mutants (heterozygous or homozygous) as well as in the Pdgfbret/ret mouse, there is a reduction in pericyte numbers, coupled with BBB dysfunction and leakage as well as defects in endothelial transcytosis Pdgfbret/ret mice differs in different brain regions PdgfrbF7/F7 mice, which reduces signaling competence on the receptor side PdgfrbF7/F7 mice, both pericytes and VSMC are affected, but BBB breakdown was observed in the PdgfrbF7/F7 mice at the stage when only pericytes were affected, indicating that the BBB impairment in these mice develops as a result of the loss of pericytes, rather than due to loss of VSMC Platelet‐derived growth factor signaling is critical for pericyte recruitment, differentiation, and homeostasis Pericytes and endothelial cells are engaged in a complex cross‐talk, which is only partially understood. There are several ligand–receptor interactions operating between pericytes and endothelial cells, including PDGF‐PDGFR, Ang1‐Tie‐2, and TGFβ signaling Pdgfbret/ret mice, which nevertheless eventually develop a seemingly stable pericyte‐deficient brain vasculature with specific attenuation of the endothelial transcytosis barrier Pdgfb and Pdgfrb mutants) leads to changes in Cldn5 expression are partly inconsistent The complex role of pericytes at the BBB is underscored by studies of mice with reduced pericyte numbers, such as the above‐mentioned The brain needs to rapidly increase oxygen and nutrient supply to the brain areas that at a given point of time are most active. Thus, the local cerebral blood flow (CBF) needs to be constantly adjusted to increase blood flow to active brain regions. The neurovascular unit (NVU), which is a conglomerate of endothelial cells, pericytes, VSMC, astrocytes, and neurons, is an important regulator of CBF Fig . The conα‐SMA) (Acta2) mRNA was very low in brain pericytes, which adds to the active discussion on the distribution and role of α‐SMA in pericytes. While some reports fail to detect α‐SMA immunoreactivity in the pericytes of a healthy mouse CNS α‐SMA mRNA expression from the transcriptomic analysis versus higher protein levels observed by immunohistochemistry remains to be explored, and such information will be important for the understanding of the putative contractile properties of pericytes.These divergent views suggest that a deeper molecular understanding of pericytes and other cell types in the brain vasculature is warranted. The first transcriptomic maps of vascular cells were generated by RNA sequencing at the cell population level Aqp4 gene In addition to the vascular system proper, there is a second major important fluid‐transporting system in the brain—paravascular flow—regulating the flow of CSF and ISF in the brain parenchyma Fig . CSF is Pdgfbret/ret mice shows a defective development and persistence of glymphatic function, suggesting that PDGFB signaling plays an important role in the development of the glymphatic system Pdgfbret/ret mice correlates with relocation of Aqp4 from astrocyte endfeet to the astrocyte cell soma at these sites Pdgfbret/ret mice is more generally altered, including capillary dilation and impaired BBB function Lama2 gene in mice causes BBB abnormalities and loss of Aqp4 polarization to astrocyte endfeet Do pericytes play a role in the glymphatic system? A recent analysis of pericyte‐deficient In addition to molecularly defining the different mural cell subtypes, the scRNA‐seq analysis of the brain vasculature also identified a novel fibroblast‐like cell type—the perivascular fibroblast—with a localization close to or within the PVS There is an emerging view that neurodegenerative diseases are characterized not only by decaying neuronal cells but also by vascular aberrations, and conversely, that diseases with an origin in the brain vasculature affect the surrounding CNS. To establish whether the CNS and vascular phenotypes represent incidental co‐occurrences or whether there are casual relationships between a dysfunctional CNS and problems in the brain vasculature is an important topic to address, with high relevance for understanding the pathobiology of the disease and to develop novel therapeutic strategies.presenilin and APP genes, but most cases are sporadic, with a specific APOE allele (APOE4) as risk factor et alApoE4 genotype. The ApoE expression levels are allele‐specific with the lowest being for ApoE4 APOE4 allele as risk factor in AD. App transgenic mice exhibiting high levels of Aβ40 show defects in vasodilatory response revealing that Aβ40 has toxic effects on the vascular system APP gene, which change the Aβ sequence at amino acid 22, induce a strong CAA characterized by pronounced Aβ40 deposits in the vessel walls ) and tau in neurofibrillary tangles are hallmarks for AD. In a minority of patients, mutations are found in APOE4 carriers, CAA is additionally observed in capillaries and frequently in arterioles, and this aggravated form of the disease is referred to as CAA type I APOE4 allele‐specific vulnerability of the pericytes to Aβ and changes in the transport of Aβ over the BBB. However, astrocytes are also major contributors to ApoE production, and in the presence of CAA, they exhibit pathological changes such as swelling of their endfeet. In severe cases of CAA, an altered ionic and water balance is observed due to changes in potassium and water channels and eventually astrocyte loss will occur In Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by loss of motor neurons, and mutations in more than 30 genes, including superoxide dismutase 1 (SOD1), have been identified in the disease PDGF‐β mRNA expression in pericytes Huntington's disease (HD) is a neurodegenerative disease caused by mutations in the Huntingtin gene, leading to CAG repeat/poly‐glutamine expansions Aqp4 aggravates the TBI‐induced tau pathology in TBI mice, indicating a role for the glymphatic system in the clearance of tau In addition to the neurodegenerative diseases, vascular problems are also observed following traumatic brain injury (TBI) and in neuropsychiatric disorders , which account for approximately 20% of all ischemic strokes. SVDs are characterized by changes in the small vessels in the brain accompanied by enlarged PVS FOXF2, which is expressed in pericytes and endothelial cells Foxf2 in the mouse affects pericyte differentiation and BBB integrity Which additional molecular mechanisms may get derailed in the brain vasculature in SVD? PDGF signaling is, as discussed above, a key signaling mechanism in pericytes but there are also other signaling mechanisms important for the BBB and pericytes, including angiopoietin‐1/Tie‐2 and TGFβ signaling et alPericytes are, in addition to controlling BBB integrity, likely involved in the aftermath of an ischemic stroke, in which the blood flow to the brain is suddenly disrupted by a post‐stroke CBF reduction in the microvessels. This capillary constriction exacerbates the ischemia, and damage to the brain and pericytes have been implicated in the post‐stroke CBF regulation and capillary constriction. It was proposed that pericytes constrict capillaries after reduction in ATP levels  In addition, pericytes have been proposed to shift their cellular phenotype toward microglia Enlarged PVS are a hallmark of and diagnostic criterion for SVD As discussed above, loss or impairment of cell types in the CNS affects the vasculature, and conversely, vascular problems lead to a dysfunctional CNS. While there are obvious large‐scale neuronal and white matter changes as a result of stroke, there are, however, also effects in the CNS resulting from more subtle modulations of the vasculature. Identifying molecular mechanisms operating in the CNS–vascular communication and which “relay” injury information from the neural to the vascular part, and vice versa, is important. Cell type‐specific modulation of genes in genetic mouse models is increasingly used to address these issues. This field is still at an early stage, but progress in genome‐editing techniques combined with improved opportunities for tissue‐specific expression of CRE recombinase and specific genes facilitates advancement in making more precise mouse models, and below we provide some examples of progress in the area of genetically modified mice.APOE4 allele The NVU is an important node for CBF control and constitutes a physical interface between cells from the CNS and the vasculature Fig . As suchGlut1 from the mouse endothelium causes BBB breakdown, accompanied by a worsened neuropathology and decline in cognitive function GLUT1 defects in humans give rise to infantile seizures, microcephaly, and ataxia, underscoring the importance of a functional BBB  leads to white matter degeneration, changes in oligodendrocyte number, and dilation of PVS at a time window where pericytes but not VSMC are affected Notch3 gene in VSMC in the mouse results in white matter lesions, similar to those observed in CADASIL patients Conversely, experimental manipulation of gene functions in vascular cells in the mouse affects the CNS. Removal of in vitro systems could clearly accelerate research and allow high‐throughput screens to be conducted  is used for thrombolysis, but beyond a few hours‐long time window of therapeutic opportunity, tPA treatment is associated with intracerebral hemorrhage, a consequence of induced BBB breakdown. Recently, it has been demonstrated that PDGF signaling (PDGF‐CC/PRGFRα) may become induced downstream of tPA as a consequence of tPA‐mediated cleavage and activation of latent PDGF‐CC, and that modulation of PDGF may improve post‐stroke BBB function While restoration of the BBB is the goal in disease situations characterized by an aberrant and leaky BBB, there are also situations where transiently enhanced BBB permeability could be advantageous. The barrier function of the BBB currently poses a problem for many therapeutic agents to effectively be transported from the blood to the brain, for example, in the treatment of brain tumors such as glioblastoma. Novel strategies to selectively enhance BBB permeability, possibly by transiently inhibiting pericyte function, can be considered. Approaches enhancing transcytosis have been attempted in the area of immunization‐based AD therapies, for example, by using transferrin receptor‐mediated transcytosis of anti‐Aβ antibodies using a bivalent antibody strategy Neurodegenerative and cerebrovascular diseases have major medical, social, and economic consequences. Although progress is made in identifying pathomechanisms for these disease categories, it is an emerging notion that there are several links between neurodegenerative and cerebrovascular diseases, and to understand these links may provide new angles for therapy development and for a more complete understanding of the disease process. A central cell type at the interface between the CNS and vasculature is the pericyte, which is a universal component of the microvasculature, but nevertheless seems to play specific roles for the BBB. Investigation into the organ‐specific specialization of pericytes is still at its infancy, but data collected thus far point to the presence of specific functions for brain pericytes  What is the molecular nature of pericytes? Establishing the molecular nature of pericytes in different brain regions and across different organs will be important to understand the full spectrum of pericyte intra‐ and inter‐organ molecular heterogeneity. Progress in single‐cell transcriptomics combined with new strategies to sort pericytes will aid in this process. What is the function of pericytes in paravascular flow? How fluids  are transported to the brain is yet poorly understood, but evidence for a role of pericytes is emerging. Precise genetic perturbations in pericytes of the mouse combined with emerging techniques to record brain fluid transport may shed further light on this topic. How do neurodegenerative diseases affect pericytes? It is increasingly apparent that pericyte function is damaged by neurodegenerative diseases, but the molecular underpinnings of this dysregulation are not fully understood. Progress in the analysis of the vasculature in genetic mouse models for neurodegenerative disease and in post‐mortem material from patients suffering from neurodegenerative disease may provide new important insights. How do pericytes change the properties of the blood–brain barrier? To find ways for how to tune pericyte function in the blood–brain barrier to regulate permeability will be important. To enhance blood–brain barrier integrity would be advantageous, for example, after stroke and potentially also in AD, while a transiently increased transcytosis across the blood–brain barrier may facilitate uptake of drugs from the vasculature into the brain.


Lung cancer is a leading cause of cancer‐related deaths with an increasing incidence and poor prognoses. To further understand the regulatory mechanisms of lipidomic profiles in lung cancer subtypes, we measure the profiles of plasma lipidome between health and patients with lung cancer or among patients with squamous cell carcinomas, adenocarcinoma or small cell lung cancer and to correct lipidomic and genomic profiles of lipid‐associated enzymes and proteins by integrating the data of large‐scale genome screening. Our studies demonstrated that circulating levels of PS and lysoPS significantly increased, while lysoPE and PE decreased in patients with lung cancer. Our data indicate that lung cancer‐specific and subtype‐specific lipidomics in the circulation are important to understand mechanisms of systemic metabolisms and identify diagnostic biomarkers and therapeutic targets. The carbon atoms, dual bonds or isomerism in the lipid molecule may play important roles in lung cancer cell differentiations and development. This is the first try to integrate lipidomic data with lipid protein‐associated genomic expression among lung cancer subtypes as the part of clinical trans‐omics. We found that a large number of lipid protein‐associated genes significantly change among cancer subtypes, with correlations with altered species and spatial structures of lipid metabolites. Lung cancer is a leading cause of cancer‐related deaths with an increasing incidence and poor prognoses, due to the lack of knowledge on heterogeneity complexity.® 4000 and 6500, Sciex, Framingham, MA, USA). Both negative and positive ESI modes were used, the Q‐Trap was operated in the MRM mode, and different precursor/product ion pairs were scanned. Each experiment was repeated thrice. MRM data were processed with MultiQuant™ software (AB Sciex), and peak area of each pair was used for further quantification. Lung cancer specificity was identified to compare the pooled group of all subtypes with the health. The subtype specificity was defined as the level significantly higher or lower than that in the health (>twofold and P < 0.05), but not in other subtypes.About 388 lipid molecules of plasma harvested from 8 health and 26 patients with SCC, ADC or SCLC were measured by MRM analysis performed with normal phase HPLC/MS. Patients with lung cancer as the first diagnosis and before any treatment were prospectively recruited at the initial clinic in Fudan University Zhongshan Hospital, without diabetes or other diseases. The study was approved by the Ethical Committee of Zhongshan Hospital. Total lipids were extracted from 200 μL plasma, performed with a modified method of Bligh & Dyer.It was firstly reported that circulating levels of PS and lysoPS significantly increased, while lysoPE and PE decreased in patients with lung cancer. Our data demonstrated that the circulating levels of PE40s or lysoPE20s lipid species were significantly higher or lower in patients with lung cancer, respectively, of which about 28 lipid species co‐existed in all subtypes of lung cancer. It indicates that the systemic inflammation is in a high reactive condition, where cytokines may interact more with or cross local and systemic leucocytes or tumour cells.Our results deliver the significant message that the heterogeneity of lipidomic profiles among lung cancer subtypes should be seriously considered and has the unique value of early diagnostics. For example, PI significantly increased with a decrease in PS in cancer tissues of patients with non‐small cell lung cancer,Lipid synthesis and its metabolites were suggested as a metabolic liability and potential biomarkers of lung cancer.A number of genes and proteins are suggested as molecular biomarkers or therapeutic targets, which may contribute to the transit process from chronic obstructive pulmonary diseases to lung cancer.The authors confirm that there are no conflicts of interest.


KANK (kidney ankyrin repeat‐containing) proteins. Vertebrates have two talin genes, TLN1 and TLN2. Although talin1 and talin2 share 76% protein sequence identity (88% similarity), they are not functionally redundant, and the differences between the two isoforms are not fully understood. In this Review, we focus on the similarities and differences between the two talins in terms of structure, biochemistry and function, which hint at subtle differences in fine‐tuning adhesion signalling.Talins are cytoplasmic adapter proteins essential for integrin‐mediated cell adhesion to the extracellular matrix. Talins control the activation state of integrins, link integrins to cytoskeletal actin, recruit numerous signalling molecules that mediate integrin signalling and coordinate recruitment of microtubules to adhesion sites via interaction with  ABS, actin‐binding siteDD, dimerisation domainECM, extracellular matrixFA, focal adhesionFERM, 4.1 protein, ezrin, radixin, moesinIBS, integrin‐binding siteIF, intermediate filamentPTM, post‐translational modificationVBS, vinculin‐binding siteIntegrin‐mediated adhesions to the extracellular matrix (ECM) are found in nearly all cell types and mediate a diverse range of functions. There are 24 αβ heterodimeric integrins, which show distinct patterns of cell‐type and tissue‐specific expression, and support different forms of cell‐ECM and cell‐cell attachment. Integrins connect to the ECM via their large extracellular domains but, in contrast, the cytoplasmic domains, the ‘integrin tails’, are generally short (~ 40–60 amino acids). Despite this diminutive size, large multiprotein complexes assemble on the cytoplasmic face of integrins, providing linkages to the cell cytoskeleton and to numerous intracellular signalling pathways.The complexity of cell‐matrix adhesions has been highlighted by the analysis of the ‘integrin adhesome’ using mass spectrometry on multiple integrin adhesion complexes. This identified a network of > 240 proteins Most of the attention on talin has focused on talin1, primarily due to its essential role in mediating cell adhesion as shown by studies on talin1 knockout This Review aims to summarise what is currently known about the structural, biochemical and functional differences between the two talin isoforms. Evolutionary genomics has been used to study talin isoforms in the past, and here, we combine genetic analysis with the recent wealth of structural information to highlight the emerging functions of the two talins as signalling platforms.and coupled to actin. If these conditions are not met, then nascent adhesions will not experience sufficient force to recruit vinculin and will disassemble. However, once vinculin is recruited to nascent adhesions, it crosslinks talin to actin, and the core, linkages are stabilised. How such complexes mature depends on multiple variables including cell type, ECM composition, matrix stiffness, integrin subtype, mechanical signals, etc. This leads to the development of a variety of adhesion complexes including nascent adhesions, focal adhesions (FAs), fibrillar adhesions, podosomes, invadopodia, etc., all of which have at their core the same integrin–talin–actin connection. In their recent Review, Klapholz and Brown eloquently describe the myriad of different roles that talin plays in adhesion, and provocatively call talin ‘the master of integrin adhesions’, a view we share Strikingly, despite the structural complexity of cell‐ECM adhesions, the majority of these dynamic adhesion complexes comprise a simple and robust core of three proteins: talin which binds to and activates integrins and couples them to the actin cytoskeleton Fig. . All of Talin is a large 270 kDa actin‐binding protein that was first discovered in 1983 as a component of FAs and ruffling membranes Tln2 gene by promoter methylation Tissue expression and cellular localisation vary considerably between the two isoforms; talin1 is expressed in all tissues. In contrast, talin2 expression is more variable, and it is absent entirely from some cell types, for example, no talin2 is present in endothelial cells possibly via silencing of the Tln1‐knockout mouse embryonic fibroblasts There is clear interplay in the expression of the two talin isoforms, although the mechanism for this is not known. Talin2 expression is rapidly upregulated following knockout of talin1, both transiently In fibroblasts, both talins localise to FAs, and talin1 is recruited directly to the leading edge, via proteins like the Rap1 effector RIAM (Rap1‐interacting adapter molecule) Tln1 and Tln2, which have conserved intron–exon boundaries The two talins are encoded by separate genes, Tln gene appears to have undergone duplication in chordates with the emergence of vertebrates to give rise to talin1 and talin2 Petromyzon marinus  Dictyostelium discoideum. The Dictyostelium talin genes, TalA and TalB, encode proteins with distinct functions, with TalA required for cell–substrate adhesion, phagocytosis and cytokinesis, and TalB required for the force transmission required to support morphogenetic movements during differentiation The ancestral Remarkably, despite millions of years of evolutionary time since talin first appeared and since the two talins diverged, the length of both the major talin isoforms has remained almost identical . Furthermore, both major isoforms have identical domain structure and contain 18 domains. This invariability is in stark contrast to many other multidomain proteins such as titin, spectrin and filamin – these have varied in length, increasing and decreasing in size through evolution until reaching the length we see today Talins consists of an atypical N‐terminal FERM  domain, known as the talin head containing four subdomains F0–F3 2 (PIP2) in the plasma membrane; a basic surface on the F2 subdomain mediates interaction with the plasma membrane, which applies torque on the integrin to stabilise the active conformation However, whilst F3 is the only talin head subdomain that engages the integrin, F3 in isolation is not very effective at activating integrins and the other head subdomains are also required to make an effective ‘integrin activation lock’ and maintain the integrin in the active, high‐affinity conformation Galpha13) and RIAM As well as binding to integrins, Rap1 and the membrane, the talin head (via the F3 subdomain) has been shown to bind to PIP kinase gamma The talin head is connected, via an 82‐amino acid unstructured a priori was not possible. Part of the reason for the lack of homology of the talin rod to other proteins turned out to be that 8 of the 13 talin rod domains – R1, R5–R7, R9–R12 – contain a 5‐helix bundle fold, the ‘talin rod fold’, that has so far only been recognised in talin.Structural analysis of the talin rod was complicated as only two regions of the rod have sequence homology to other proteins: R13, which contains an I/LWEQ domain Although 4‐helix bundles are common in nature ] forms an antiparallel dimer with another talin molecule To date, all the ligands that bind to talin1 have been shown to bind talin2 although the affinities for the different isoforms can be markedly different. Binding partners can interact with the talin rod domains via a number of different modes, that is, to the folded rod domains, to the unfolded rod domains or to some strained conformation between these two extremes. Mechanical force can drive transitions between these conformations and so dramatically alter the binding affinities of different ligands.Elucidation of the domain structure of the talin rod has enabled the precise mapping of established ligand‐binding sites, and the location of these sites is shown in Fig. As well as interacting with the talin head, the beta‐integrin tail also interacts with the R11–R12 domains of the talin rod [integrin binding site 2 (IBS2)] via a structurally undefined mechanism The talin rod contains two actin‐binding sites, ABS2 R4–R8)  8, 86 whVinculin, discovered in 1979 While the integrin‐, actin‐ and vinculin‐binding interactions define the primary adapter function of talin, there are an increasing number of additional ligands that bind to the talin rod that contribute to its mechanosignalling capabilities. These are summarised below.A common mechanism for talin rod‐binding proteins is via helix addition, whereby a helix from a ligand packs against the side of a talin rod domain. A number of talin ligands have now been identified that contain an ‘LD‐motif’ The C‐terminal part of the talin rod has also been shown to bind directly to the FERM domain of moesin, an interaction that is required to recruit the sodium/hydrogen exchanger (NHE‐1) to adhesion sites Another ligand that has been linked to talin which has the potential to have a significant impact on our view of adhesions is alpha‐synemin In vivo, talin is initially extended by actin retrograde flow and then by actomyosin contractility and the resulting forces exerted on the talin rod drive structural transitions. Depending on the precise mechanical environment, individual talin molecules will experience different forces, and the different conformations may engage different ligands.The mechanosensing abilities of talin rely on its force‐dependent interactions with its binding partners. Some ligands  bind only to folded talin domains, whereas vinculin is known to require domain unfolding and exposure of cryptic VBS. Force‐induced talin domain unfolding will therefore release binding partners that bind to folded talin and stimulate binding of vinculin, triggering mechanosensing signals. The mutually exclusive interactions between talin and RIAM and talin and vinculin provide the perfect example of how talin can convert mechanical forces into biological signalling responses. The initial mechanosensitive domain in talin has been shown to be R3 In vivo measurements of talin extension have shown that talin length is normally between 90 and 250 nm in vitroExpanding this to the rest of the talin rod, it seems likely that each of the talin rod domains can also serve as mechanochemical switches, and under different conditions, individual talin rod domains can adopt different conformations that support different signalling pathways. The R8 domain is a hotspot for protein interactions, suggesting it represents a major signalling hub. R8 is a 4‐helix bundle, uniquely protected from mechanical force by being inserted into the loop of a 5‐helix bundle (R7), creating a novel 9‐helix module, and a branch in the talin rod A striking feature of the talin rod's response to force is that even after complete unfolding, the removal of force leads to refolding to the original native state, and this response is maintained through multiple cycles of extension and relaxation. The robustness of the mechanical response of the talin rod is perfectly suited to its role as a mechanosensor; when the mechanical force is relieved, the sensor reverts back to its original state.Together, these features suggest that talins can sense and respond to mechanical forces with remarkable versatility. Depending on the applied force, different domains will unfold, and depending on the repertoire of expressed ligands, different signals will be generated. Depending on the mechanism of linkage to actin (e.g. via ABS2 vs. ABS3), or to microtubules via KANK, different regions of talin will be under tension. This network of protein interactions thus provides a mechanism for context and force‐dependent regulation of multiple signalling pathways.It will be important to characterise the mechanical response of talin2 as differences in mechanical responses of individual rod domains might help pinpoint sites of functional divergence. Recent work has shown that the two talins provide different mechanical linkages in cells An interesting feature of talins is that the binding sites described above are not all accessible all of the time. Talin activity is regulated by multiple layers of autoinhibition where binding sites are masked, and only made available for binding in response to different signals. Talin autoinhibition mediated via the interaction between the integrin‐binding site in F3 and the talin rod domain R9 maintains talin in a compact cytosolic form http://www.addgene.org/ben_goult). We have recently solved the structures of a number of these talin2 rod domains and it is striking how structurally similar they are to the equivalent talin1 domains (our unpublished data).Due to the high homology between talin1 and talin2, we used Modeller The two talins are highly conserved , and it is likely that identical regions between the two isoforms carry out equivalent functions. What has not been explored in detail is the 24% of the sequence that is not identical – it is here that differences in isoform function might be found. In particular, we sought to identify conserved differences between the isoforms in these divergent regions as these might provide the key to understand the differences in isoform function. We set out to look at differences in ligand specificity, affinity tuning, tertiary structure and the conservation of post‐translational modification sites (PTMs).We used BlastP to align the sequences of the corresponding domains from each isoform to establish the identity and similarity of each domain and to look for local variations. Interestingly, although the sequence identity between the two talins is 76%, sequence identity at the domain level shows much greater variation. The F2 (86%), F3 (89%) and R13 (92%) are highly conserved between isoforms, supporting their role in assembly of the core adhesion complex. In contrast, other regions of the talin rod show considerable variation in conservation between isoforms with R5 (60%) being the most divergent.Kd) of these domains for their respective ligands, that is, the KANK 1 and KANK 2 binding site on R7 and the RIAM‐ and DLC1‐binding site on R8. These proteins bind in the same manner and with the same affinity to both isoforms  Finally, a number of additional PTMs have also been identified in talin1. For instance, the affinity of the talin1:actin connection is controlled via the methyltransferase Ezh2 which methylates talin at lysine K2454 in ABS3 in silico with force extension molecular dynamics simulations Gene duplication is often viewed as an evolutionarily advantageous process, with duplicated genes giving rise to two proteins that can acquire distinct or completely new functions . Gene duplication may also allow more complex patterns of gene expression in different cell types and tissues Many different adhesive structures form on talins which signal in a highly reproducible manner. Precisely how talins’ mechanosignalling capabilities are integrated with the more classical signalling pathways to give rise to these robust metastable cellular responses that facilitate all our cellular processes remain to be determined. The signalling pathways that regulate talin function, localisation, post‐translational modifications, etc. coupled with the forces that define the conformational status of its rod domains, which cumulatively lead to the correct cellular responses are still poorly understood. For talin to generate robust, reproducible signalling responses and specialised adhesive structures in response to such diverse, multiple inputs suggest that there must be a code underpinning talins mechanotransductive response. Deciphering this ‘talin code’ is the next major challenge.


Extracellular vesicles (EVs) derived from mesenchymal stromal cells (MSCs) have emerged as a promising form of regenerative therapy and immune modulation. Fundamental advances in our understanding of MSCs and EVs have allowed these fields to merge and create potential cell‐free therapy options that are cell‐based. EVs contain active cargo including proteins, microRNA, and mRNA species that can impact signaling responses in target cells to modify inflammatory and repair responses. Increasing numbers of preclinical studies in animals with various types of injury models have been published that demonstrate the potential impact of MSC‐EV therapy. Although the emergence of registered clinical protocols suggests translation to clinical application has already begun, several barriers to more widespread clinical adoption remain. In this review, we highlight the progress made in MSC‐derived small EV‐based therapy by summarizing aspects pertaining to the starting material for MSC expansion, EV production, and isolation methods, studies from preclinical models that have established a foundation of knowledge to support translation into the patient setting, and potential barriers to overcome on the path to clinical application. Cumulative number of published articles investigating the therapeutic efficacy of extracellular vesicles derived from mesenchymal stem cells in preclinical animal models of disease.*Number of articles published in 2018 was extrapolated based on the total number of published articles until May of 2018. Bioactive cargo in extracellular vesicles, including proteins, microRNA, and mRNA species, can impact signaling responses in target cells to modify inflammatory and repair responses. Although translation to clinical application has already begun, several barriers to more widespread clinical adoption remain.2Extracellular vesicles (EVs) have a phospholipid bilayer membrane encapsulating cargo from their cell of origin and are released as paracrine effectors to influence target cells as a form of intercellular communication. Mesenchymal stromal cells (MSCs) give rise to stromal and microenvironmental supporting cells found in many tissues of the body and release small EVs as a means of supporting tissue growth such as hematopoiesis in the bone marrow but also modulate inflammatory responses and facilitate tissue repair across a range of tissue injury and organ dysfunction. Since the initial observations that small EVs could facilitate tissue repair, we have learned that most cells release EVs and that signaling molecules such as microRNA, mRNA, proteins, and other small bioactive compounds are packaged as cargo.3MSCs can be readily expanded from bone marrow, adipose tissue, and placental tissues such as Wharton's jelly or umbilical cord blood. The International Society for Cellular Therapy established minimal criteria to distinguish MSCs from other stromal cells or plastic‐adhering fibroblast‐like cells based on specific cell surface marker expression and retention of multilineage differentiation capacity.The role that specific ex vivo culture conditions exert on MSC‐derived EV production is interesting and may be a major component of future EV manufacturing and production methods. Hypoxia, for instance, can activate signaling pathways in MSCs to enrich EV content of specific signaling molecules that augment their capacity to promote angiogenesis and facilitate tissue repair in animal models.3.1g for prolonged periods are needed to separate the small particles that are <200 nm in size. Unfortunately, UC has been associated with contamination by non‐EV cellular material and reduced yield of RNA compared with density gradient isolation methods which could impact therapeutic efficacy.Initial studies of EV isolation used ultracentrifugation (UC) to separate EVs based on their size. Very high forces in excess of 100 0003.2Initial studies that demonstrated how MSCs could modulate immune responses reported a range of cell‐cell contact dependent or independent mechanisms to induce anti‐inflammatory signals and immune tolerance states. In brief, secreted factors such as IL6, IL10, prostaglandin E2 (PGE2), transforming growth factor β (TGFβ), hepatocyte growth factor and IDO have been implicated in affecting target cells of the innate and adaptive immune system.MSC‐derived EVs have also been implicated in vascular repair following ischemic injury in various animal models. Although mechanisms of vascular repair remain under active study, activation of vascular endothelial growth factor receptors and downstream angiogenesis pathways has been reportedIn a recent study addressing scalable production of MSC‐derived EVs,3.3In a systematic review of published studies (up to May 2013) of MSC‐derived EVs, we identified 13 controlled preclinical studies addressing MSC‐derived EV therapy in acute kidney injury, myocardial infarction, hind limb ischemia, liver injury, and hypoxic lung injury while four studies addressed the immune‐modulatory effects of MSC‐EVs in models of cancer.An update to our systematic search was recently performed and reveals a significant increase in the number of publications Figure . A total4http://clinicaltrials.gov/ addressing cardiac dysfunction, to the best of our knowledge. A forthcoming meta‐analysis of MSC‐EVs as a potential therapy will provide an unbiased estimate of the benefits of this novel cell‐free treatment in the context of cardiac disorders.In our recently published systematic review, the most commonly studied models of organ injury for MSC‐EV therapy were myocardial ischemia and acute kidney injury.We identified a total of six preclinical studies of kidney injury in mice (three studies) or rats (three studies) using human (four studies), mouse (one study) or rat‐derived (one study) MSCs to generate EVs that were isolated by UC (five studies) or density gradient centrifugation (one study).5Interest in the role of MSC‐EVs in attenuating alloimmune responses may be best exemplified through studies of GVHD following hematopoietic cell transplantation in mice. A total of four controlled preclinical studies of MSC‐EVs addressing the treatment or prevention of GHVD were recently identified in our updated search of literature.5.1In our systematic review published in 2015, we identified four studies addressing acute kidney injury , hind limb ischemia  and tumor growth  that included MSCs as a control. The remaining studies used placebo as controls and/or used EVs derived from other cell types in the control group. In the studies using MSCs as controls, MSC‐EVs were at least as effective as MSCs and in one case they were more effective, suggesting much of the therapeutic efficacy associated with MSCs can be ascribed to EVs, however, we and the authors recognize that MSCs retain homing abilities that may be superior to EVs and collectively, small numbers of animals were treated in these studies. An updated analysis of control groups used in preclinical studies is forthcoming in our updated systematic review of preclinical studies which may add more insight to this question. On the other hand, MSCs have been associated with potential risks including infusion‐related adverse events such as respiratory compromise and fever, and longer‐term issues such as organ system complications, risk of ectopic tissue formation and malignancy that have required extended follow‐up in clinical trials of MSCs. A meta‐analysis of the safety of MSCs used in clinical trials was reviewed in 2012 and included data from eight randomized controlled trials enrolling a total of 321 patients,5.2http://clinicaltrials.gov/  with at least two of these protocols actively recruiting and/or enrolling patients. In one registered trial (NCT03437759) from a group in China that was first posted in 2018, the investigators are actively recruiting patients with macular holes and significant vision loss who will receive umbilical cord blood MSC‐derived exosomes isolated by UC and will be compared with patients receiving MSCs in a control group. In a second study from Egypt (NCT02138331), the impact of umbilical cord blood‐derived microvesicles on β cell mass in patients with type I diabetes is being examined and continues to enroll patients by invitation. An Iranian team has registered a planned trial (NCT03384433) of intravenous MSC‐derived exosome treatment in patients with acute ischemic stroke using allogeneic MSCs transfected with miR‐124 to enhance neurite remodeling and neurogenesis. Lastly, a study registered by a group at the National Cancer Institute in conjunction with a team at the MD Anderson Cancer Centre in the United States (NCT03608631) outlines a clinical protocol for treatment of patients with metastatic pancreatic cancer harboring a KrasG12D mutation using MSC‐derived exosomes that contain small interference RNA against KrasG12D. Although we are not aware of other published clinical experience with MSC‐derived EVs, it is possible that other investigators have not yet communicated their protocols, results, or experience. With reference to methodological details from these clinical reports, only one of the clinical protocols identified on http://clinicaltrials.gov/ outlined a method for EV isolation . Furthermore, there is a lack of clear information regarding EV characterization and dosing at this juncture. The final publications from these completed studies should offer more insight.There are scant reports of MSC‐derived EV administration to patients. In one case report, a patient with steroid‐refractory acute GVHD following allogeneic hematopoietic cell transplantation received MSC‐derived exosomes.5.3Preclinical reports of MSC‐EV therapy are highly encouraging across a range of tissue injuries and for modulation of immune responses in disorders such as GVHD and cancer. It appears evident that translational studies in patients are imminent and there are multiple ongoing clinical trials that are actively recruiting patients. Although regulatory approval of EV‐based treatments appears highly feasible and may be simplified in comparison with cell‐based therapies, several possible barriers may contribute to challenges in translating MSC‐EV therapy into the clinical domain. The International Society of Extracellular Vesicles recently published a position paper that provides a thorough discussion of important considerations regarding regulatory and safety issues for EV‐based therapeutics in clinical trials.6MSC‐derived EVs have been studied increasingly in preclinical models of organ injury and immune disorders and appear as a promising cell‐free regenerative cell‐based therapy for clinical application. More definitive preclinical trials that overcome potential threats to bias by using random allocation of animals to treatment groups and blinding of outcome assessments will accelerate the design of informative initial clinical trials. Translation to clinical studies that meet regulatory approval appears readily feasible. Manufacturing facilities capable of large‐scale EV production will be needed in the near future to support this growing field of study.D.A. declares consultancy/advisory role with Canadian Blood Services. The remaining authors declare no potential conflict of interest.All authors contributed to the manuscript and approved the final version.7