Developmental policies in low- and middle-income countries pose immense potential within the agriculture sectors to escalate economic growth and development. Almost one-half of the workforces continue to be engaged in agriculture and allied activities with a relatively lower economic contribution than those employed in other sectors. Hence, realizing such potential however requires tremendous scaling up of skill development activities in the sector. Investing in skill development of workers engaged in agricultural and allied activities can potentially display notable value additions, income generation and therefore reductions in widespread deprivations in the form of food insecurity and undernutrition. Further with the direct link between nutrition and productivity, economic gains, it is further imperative to impart market exposure among subsistence and unskilled workers. This study therefore empirically investigates the association between households’ primary occupation and caloric deprivation in India. In particular, in a multivariate and multilevel framework, we identified how closely primary occupation of households explain the variation in caloric deprivation in India.Drawing upon data from 68th round (2011–12) of nationally representative cross-sectional Household Consumer Expenditure Survey (HCES) of National Sample Survey (NSS), Government of India, we examined the association between occupational backgrounds of households and caloric deprivation  among Indian households.Evidences show that agricultural and fishery labor households have lowest calorie intake  across all the occupational groups. However, market oriented skilled agricultural and fishery workers’  have higher calorie intakes than those belonging to subsistence agricultural . Further, the multilevel logistic regression estimates suggest that in rural areas, households engaged in skilled agricultural and fishery works have significantly (at 5% level) lower odds ratio  of having insufficient calorie intake compared to the unskilled agricultural and fishery laborer households. Estimates from variance partitioning based on multilevel logistic regression models suggest that the households’ occupational group accounts for 7 to 14% of total variation in calorie consumption.These insights when combined with the occupation-specific random-effects suggest that investing in skill development of agricultural and fishery workers may have immense potential to strengthen their nutritional status and to reduce deprivation levels.The online version contains supplementary material available at 10.1186/s12889-021-10644-9. Given the presumptions of low-productivity, developmental policies in low- and middle-income countries usually display a pro-manufacturing bias and largely undermine the potentials within the agriculture and fishery sectors in promoting sustainable growth and development –5. As a While about one-half of the workforce in India continue to be engaged in agriculture and allied activities , it contGiven the context, it is critical to unravel the association between occupational background and nutritional deprivations and thereby develop insights regarding the scope and focus of skill development policies. For instance, it is noted that poverty and nutritional deprivations are generally concentrated among households belonging to unskilled occupational categories such as agricultural labor, casual labor or fishery workers –18. But Given such possibilities, this paper aims to examine the association between occupational backgrounds with caloric deprivation  among Indian households. As such, a focus on caloric intake is critical because it is a fundamental indicator of food security and has a major influence on economic well-being , 25. MorThis study is based on data from nationally representative cross-sectional Household Consumer Expenditure Survey (HCES) conducted in 2011–12 (68th round) by National Sample Survey Office (NSSO), Ministry of Statistics and Programme Implementation (MOSPI), Government of India (NSSO 2014). The HCES is widely used by developmental practitioners and policymakers to assess the levels and patterns of food consumption across various population subgroups in India. The HCES uses a stratified, multi-stage cluster design at state-level to provide reliable estimates at state and for rural and urban areas. Households for survey are selected on the basis of circular systematic sampling. The results are estimated using data from HCES schedule 1.0 (Type 1/ Mixed Reference Period) which altogether has a sample of 1, 01,662 households .The HCES provides occupational categories of households based on the code structure provided in the National Classification of Occupations (NCO), 2004 . Based oBased on a mixed recall period of 30 days and 365 days, the HCES provides direct information on household food and non-food consumption respectively. In this paper, the information on food consumption is used to estimate the average per capita per day caloric intake  across households. The estimation is based on intake conversion parameter prescribed by the NSSO and which is derived from a nutrition chart that provides details regarding energy content of different foods in the Indian diet . For cerrunmlwin module [The analysis is conducted separately for rural and urban areas as they have different average calorie intake norms. It may be noted that the analysis is based on a sample of 94,157 households  after filtering out observations where household NCO codes or other correlates are missing or not specified. Following a bivariate analysis, we use multilevel linear and logistic regression models to understand the association of occupational groups with continuous and binary outcomes, respectively. The analysis is adjusted for sampling weights as prescribed by the NSSO. For brevity, the beta coefficients and standard errors (SE) for the fully adjusted linear regression models and odds ratios (OR) and confidence interval (at 95%) (95% CI) for logistic regression model are reported. We also estimate the variance partition coefficient for both set of regressions to highlight the between-occupational group differences in calorie deprivations , 34. Usin module –37.The statistical distribution of sample households across occupational groups is presented in Table Further, Table Among rural households, multilevel linear regression estimates Table  indicateTo account for the variations in the age and sex composition of the household members, Table SFor rural and urban India, Table Finally, the occupational group-specific random intercepts from the four respective null models are plotted in Fig. This analysis of nationally representative survey across India (2011–12) finds that the patterns of caloric intake and deprivations are significantly associated with occupational background of the households among both rural and urban households. Households dependent on occupations such as casual labour in agricultural and non-agricultural activities as well as those involved in low-end sales and services consumed fewer calories than others and also were at an elevated risk of caloric deprivation. In contrast, households engaged in market oriented skilled agricultural and fishery as well as the high-level professionals and managers had more than adequate calorie consumption and also were at lowest risk of such deprivations. These patterns mirror the evidence on disproportionate burden of poverty and deprivation among unskilled agricultural and non-agricultural workers in rural and urban India , 38–40.The regressions, particularly the occupation-specific random effects Fig. , reveal Conventionally, poverty and nutritional deprivation in India is largely discussed as a state-level phenomenon , 42–47. Pradhan Mantri Kaushal Vikas Yojana (2015) and Kaushal and Rozgar Mela (2016). Our finding offers further scope for research in this domain, such as bottlenecks associated with cohorts of older adults. In the absence on an all-encompassing approaching, it is likely that poverty and deprivation can turn out to be an inter-generational affair whereby only the young generation within poor households is presented with any potential chances to improve upon household well-being. Further research on some practices and success stories  can be explored as they demonstrates a gendered-approach towards market oriented and skilled agrarian workers which can be an effective approach to enhance the income and nutritional status of households [The findings are also relevant from the point of value addition and income generation capacity in agriculture and allied sector. Given the highest share in employment and a meagre contribution towards GDP of the country, the findings depict that skill development and market exposure could be an effective pathway to escalate the income generation capacity in within the sector. While occupational mobility declines with age, it is also important to impart skill and training at the right age to increase the output of skill development programmes. The findings are all more important in the light of the fact that the share of working age population in India increased to 60% of the total population in 2010 . With suuseholds , 57.Besides, the findings also shed significant light on the fishery sector which relatively remains unexplored for its potential impact on nutritional and income security. It is no surprise that the policy paradigm is rather in sync with the developing world whereby poverty among small-scale fisheries has remained a neglected aspect of development , 58–60. It is worth noting the limitations of the analysis that can be largely associated with the nature of survey and the data. First, given the cross-sectional design, the results do not necessarily reveal the casual direction of association between occupation and caloric intake even though this does not impact the results regarding occupation-specific disparities and advantages in caloric intake. Second, although the NCO 2004 classification is sufficiently disaggregated to arrive at some meaningful inferences, but further disaggregation is advisable to understand the intricacies associated with skilled occupations within agriculture and fishery sectors. In fact, in the survey the NCO 2004 codes are missing for about 7.3% households and this can have a certain influence on the relative significance of the estimates. Third, the outcome indicator of household calorie consumption does not provide adequate insights regarding individual-level differences. Besides, to some extent, this indicator marginally underestimates the total calorie intake because of non-inclusion of food consumed outside the home . FinallyTo summarize, the study finds that household level calorie intake for agricultural and fishery workers with market exposure and skills is significantly higher than unskilled and subsistence ones. Further, econometric estimates suggest that households with market oriented and skilled agricultural workers are less likely to succumb to caloric deprivation compared to unskilled agricultural workers’ households. These findings clearly imply a greater scope for enhancing productivity among subsistence level workers engaged in agricultural and allied activities. More importantly, nutritional adequacy further leads to higher productivity and value addition, which can create a potential cycle of high-level income in agricultural and allied sectors.Additional file 1: Table S1. Distribution of Sample Households by Socioeconomic Characteristics, India, NSS , 2011-2012. Table S2. Multilevel linear and logistic regression estimates for the association of household occupational group with per consumer unit calorie consumption per day per household and having insufficient caloric intake in rural and urban India, National Sample Survey, 2011-2012.


Modeling is widely used in biomedical research to gain insights into pathophysiology and treatment of neurological disorders but existing models, such as animal models and computational models, are limited in generalizability to humans and are restricted in the scope of possible experiments. Robotics offers a potential complementary modeling platform, with advantages such as embodiment and physical environmental interaction yet with easily monitored and adjustable parameters. In this review, we discuss the different types of models used in biomedical research and summarize the existing neurorobotics models of neurological disorders. We detail the pertinent findings of these robot models which would not have been possible through other modeling platforms. We also highlight the existing limitations in a wider uptake of robot models for neurological disorders and suggest future directions for the field. Modeling is widely used in contemporary biomedical research to gain insights into pathophysiology and treatment of neurological disorders. Models may share physiological, behavioral, or other characteristics with humans yet allow for manipulations that are not possible in human studies, and allow faster data collection. They have contributed to our knowledge in a variety of fields by improving our understanding of pathophysiology, from genetics and molecular biology to systemic neural disturbance and behaviors, and guide the search for therapeutic solutions  resulting from stroke during viewing a straight line, Mozer et al. 's computParkinson's Disease (PD) mechanisms are frequently contextualized by network models, allowing easy translation to computational modeling (Albin et al., Embodiment of computational neural models in a robot allows for direct sensory-action closed-loop interactions with a real environment as well as with environmental noise, improving the generalizability of experiments to real world scenarios. This can be advantageous for both understanding human cognition (e.g., Chaminade and Cheng, Computational models have been implemented into virtual robot simulations, thus bypassing the actual construction of the robot but compromising by having an equally simulated environment. These have included more simplified machines such as simulating a 2D robot leg using a neural system with a hierarchical central pattern generator to model leg weakness as a symptom of stroke to explore rehabilitation strategies (Ichimura and Yamazaki, More complex robots have been also used in this context but with different approaches. Pio-Lopez et al.  investigIn some cases, computational neural models have been proposed to investigate disorders implicitly. For example, by modeling synaptic plasticity such as the wheeled robot of Aguilera et al. . They evHere we discuss and summarize the existing neurorobotic models of prevalent neurological disorders and the experiments conducted with them (see Yiping et al.  presenteUnilateral spatial neglect is a disorder of processing and perceiving stimuli, caused not by a loss of sensation but stroke or tumor, on one side of the visual field often contralateral to the damaged cerebral hemisphere, typically the posterior parietal cortex. It is a heterogeneous condition due to the variety of associated lesion locations and may required type-specific rehabilitation as a result. To explore this hypothesis, Conti et al.  embeddedObsessive-compulsive disorder is characterized by repetitive intrusive thoughts resulting in the need to perform certain actions repeatedly. Lewis et al.  conceptuThe authors also further developed the model by implementing “stress”—both internal, related to its needs, and external, due to confinement (Lewis and Cañamero, Schizophrenia is a psychiatric disorder characterized by symptoms of hallucination, delusion, and disorganized thought. Yamashita and Tani  created This model manages to explore a non-anatomically localized network-wide neural process in a real-world environment, difficult to achieve using other models; further work could take advantage of internal monitoring to aim to concurrently simulate other schizophrenia symptoms such as delusions and hallucinations to assess whether a similar mechanism is responsible. Other models also use neural networks but focus on specific symptoms, like deficit in the recognition (Cohen and Billard, ASD encompasses a range of neurodevelopment disorders affecting mostly social interaction and presenting restricted, repetitive patterns of behavior. Focusing on behavioral inflexibility, Idei et al. , 2018 usRobotic experiments not directly modeling a specific pathology can nevertheless inform pathophysiology. For example, neural networks have been used in cognitive neurorobotics to understand human cognitive functions, such as memory (Shibata Alnajjar et al., An early basal ganglia model by Prescott et al.  using thThe models above demonstrate the utility of robotics in investigating neurological disorders, particularly the ability to monitor both internal parameters and external behavior with the environment. They can generate insights and translational outputs by: manipulating internal parameters; simulating more abstract systemic functions, such as prediction; and monitoring internal states in conjunction with external behavior . Some exSP wrote the manuscript and the preliminary designs of the table and figure. RM and PV guided the concept and structure of the manuscript. JP created the final figure design. LW created the final table design. All authors reviewed and edited the completed manuscript prior to submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Due to its chemical properties and multiple molecular effects on different tumor cell types, the sesquiterpene lactone parthenolide (PN) can be considered an effective drug with significant potential in cancer therapy. PN has been shown to induce either classic apoptosis or alternative caspase-independent forms of cell death in many tumor models. The therapeutical potential of PN has been increased by chemical design and synthesis of more soluble analogues including dimethylaminoparthenolide (DMAPT). This review focuses on the molecular mechanisms of both PN and analogues action in tumor models, highlighting their effects on gene expression, signal transduction and execution of different types of cell death. Recent findings indicate that these compounds not only inhibit prosurvival transcriptional factors such as NF-κB and STATs but can also determine the activation of specific death pathways, increasing intracellular reactive oxygen species (ROS) production and modifications of Bcl-2 family members. An intriguing property of these compounds is its specific targeting of cancer stem cells. The unusual actions of PN and its analogues make these agents good candidates for molecular targeted cancer therapy. Tanacetum parthenium) that has been shown to exert both anti-inflammatory . T. T111]. Massive apoptosis was recently found following PN treatment in different both in vitro and in vivo tumor models .Apoptotic activities of PN also account for synergistic action in combination with other antitumor compounds as described in the previous paragraph.It is widely recognized that the induction of nonapoptotic forms of programmed cell death (PCD) can represent a valid alternative when tumor cells appear to be resistant to classic apoptosis . CaspaseThe first evidence that PN could stimulate caspase-independent PCD with necrotic-like morphology  was provNevertheless, necrotic-like phenotype induced by PN was not further characterized, and necroptosis, the main caspase independent necrosis-like PCD form, has not yet been documented to be specifically activated by the compound. However, we have previously found that PN is capable of increasing the expression of RIP1, a major kinase involved in necroptosis .Among caspase-independent cell death types, the type that was originally called “apoptosis-like PCD” includes apoptosis inducing factor (AIF)-mediated cell death. This factor is released by mitochondria under specific stimuli and translocates to the nucleus, where it promotes chromatin condensation and cell death. It has been documented that PN is able to induce cell death through an AIF-dependent mechanism in melanoma and osteosarcoma cells. In this mechanism, dissipation of the mitochondrial transmembrane potential but not the activation of the caspases has been highlighted .Supporting a possible switch toward PN-induced cell death without caspase involvement is the recent observation that, under particular circumstances, PN can reduce the expression of caspase 3 and caspase 9 and is also capable of suppressing their activation .Considering these observations as well as strict crosstalk among different types of cell death, further studies are needed to clarify the mechanisms of PN-induced Caspase independent-PCD in tumor cells.Autophagy is a physiological process that leads to the lysosomal degradation of cellular components and damaged organelles, representing a prosurvival cellular response to various types of stress ,120. UndPN can induce cell death through autophagy activation  without Activation of the autophagic mechanism by PN could be an excellent strategy to enhance the action of chemotherapeutic agents . It has In glioblastoma (GBM) cells, the efficacy of chemotherapy is limited by intrinsic resistance . PN can Targeting intracellular redox pathways can be considered as a therapeutic approach for cancer . OxidatiMany lines of evidence indicate that PN can promote apoptosis in tumor cells through the induction of oxidative stress ,132 Fig. This waThe principal site of ROS production in the cell is represented by the mitochondrial respiratory chain . It has Kim et al.  have furIn addition, it has been reported that PN-induced apoptosis in multiple myeloma (MM) cells involves oxidative stress and that cell sensitivity depends on catalase activity . InteresOther authors have also supported the evidence that PN preferentially acts on tumor cells promoting oxidative stress rather than in normal cells . They shPN and DMAPT also induced oxidative stress through activation of NOX in breast cancer cells ,140. It According to the findings of Kurdi et al., in cardiac myocytes, PN generation of ROS can depend on either mitochondria or NADPH oxidase in relationship with the concentration of the compound used . SpecifiAlthough the precise mechanism of PN induced oxidative stress remains unclear, it seems that its ability to bind thiol groups can account for its effect on reduction of intracellular GSH and protein thiols, such as thioredoxin . In accoA direct action of PN on intracellular thiols, including both free GSH and protein thiols, has been previously described by Zhang et al. . These aIt is evident that PN effects on the cell redox state and mitochondrial activity are key components of its action mechanism.Interestingly, chemoresistance often correlates with an increase in antioxidant activity and a reduction in intracellular ROS level ,143. In Evidence has been provided that PN can selectively induce apoptosis in tumor cells rather than in the normal counterparts ,139,149 In addition, in vivo studies have shown that PN is capable of suppressing tumor growth and, in some cases, preventing metastasis in different mice xenograft models including mammary carcinosarcoma , triple Interestingly, the antitumor efficacy of PN is also sustained by its ability to overcome cell resistance to conventional chemotherapeutic agents or other antitumor compounds.The significant in vivo chemosensitizing properties of PN have been evidenced by Sweeney et al., who obtained reduction in metastasis and improved survival in a xenograft model of breast cancer following a combination treatment of PN with docetaxel .Our previous studies demonstrated that PN and its soluble analogue DMAPT also have a selective effect against triple-negative breast cancer cells and not against normal cells (HMEC) . FurtherTo date, the only clinical trial based on PN administration to patients with cancer is reported by Curry et al. , who conIt should be noted that PN has no toxic effect in normal cells and can protect against oxidative stress. Some studies show that PN has scavenging activity against reactive oxygen species, thus protecting myoblast cells. In particular, it has been shown that PN modulates mitophagy induced by oxidative stress and protects C2C12 myoblasts from apoptosis, suggesting a potential protective effect against skeletal muscle diseases associated with oxidative stress .Many studies have shown that in some forms of cancer, there are cells with specific stem-like properties called cancer stem cells (CSCs) . CSCs arTherefore, a drug capable of targeting both CSCs and cancer cells would be an excellent therapeutic strategy for the treatment of cancer patients. Several studies have shown that PN is a compound capable of acting on CSCs.Breast cancer is the most common form of cancer diagnosed in women worldwide and, despite the development of new diagnostic and therapeutic methods, is a leading cause of death. The presence of CSCs is potentially the cause of treatment failure; drug resistance; metastasis; and relapse after surgery, chemotherapy and radiotherapy in breast cancer.There are several studies showing the effect of PN in reducing the presence of CSCs in solid and hematological tumors ,159,160,The first studies on the cytotoxic effect of PN on CSCs focused on hematological tumors. Leukemia stem cells (LSCs) are the main cause of the onset, growth and recurrence of acute and chronic myeloid leukemia (AML and CML). PN induces apoptosis in primary human AML cells and CML cells, and in LSCs derived from AML without effect in normal hematopoietic cells. The apoptotic mechanism induced by PN is associated with the inhibition of NF-κB, the proapoptotic activation of p53 and the increase of reactive oxygen species (ROS) .Recent studies have shown that PN is able to reduce the presence of LSCs in drug-resistant leukemia K562/ADM cells and increase their sensitivity to apoptosis induced by doxorubicin through the downregulation of P-gp mediated by NF-κB .The cytotoxic effect of PN has also been highlighted in multiple myeloma cancer stem cells (MM-CSCs). Multiple myeloma (MM) is an incurable malignant plasma cell tumor in which nearly all patients succumb to relapse. In vitro studies conducted using a three-dimensional tissue culture system have shown that PN has a potent cytotoxic effect against MM-CSCs .Triple-negative breast cancers (TNBCs) are aggressive forms of breast cancer associated with a high recurrence rate. Carlisi et al.  found thZhou et al.  have demPN was found to increase the cytotoxic effect in CSCs derived from breast tumors by vinorelbine, a semisynthetic vinca alkaloid that acts through disruption of microtubule assembly. Liu et al.  developeIt is known that the 5-fluorouracil (5-FU) chemotherapeutic agent has a powerful cytotoxic effect on most cancer cells, but not on CSCs, which can make some cancers resistant to this drug. In general, resistance to chemotherapy is caused by the overexpression of one or more ABC transporters, including ABCG2 and ABCB1/multidrug resistance protein 1 (MDR1) . StudiesFrom the evidence reported so far, PN represents a promising chemotherapy agent. Its effectiveness can be used in synergy with other anticancer agents of various types  Table 1Table 1, The combination of PN with Taxol has also been shown to be effective in lung cancer xenografts as described by Zang et al. . SimilarAs described in the previous paragraph, significant results have also been found by Liu et al. , who comIn breast cancer, PN has also been shown to enhance sensitivity to antiestrogen such as tamoxifen  or fulveOther studies  of triplIn lung cancer cells, Fang et al. have observed an increased susceptibility to low doses of oxaliplatin .In addition to its anticancer properties, PN seems to exert beneficial effects in combination with chemotherapeutic drugs as reported by Francescato et al.  who showMore recently, evidence has indicated that PN strongly potentiates the effect of epirubicin in breast cancer cells .Preclinical studies have also highlighted the efficacy of PN, or its analogues, in combination with nonconventional antitumor agents including COX-2 inhibitors , sulindaDue to inhibition of NF-κB, PN has been shown to increase X-ray sensitivity of tumor cells ,179. MorIt should be noted that the studies conducted with PN have highlighted both its potential and limitations. The limits of PN are due to its poor solubility in water and poor stability. Researchers have tried to overcome these limits to make the compound even more effective. Several studies have been conducted that have aimed to make PN more soluble and stable while preserving its bioactivities ,158 Tab.For example, researchers attempted to make PN soluble in water by adding a methyl group and formulating the DMAPT in the form of fumarate salt ,27.In a recent study by Jia X et al. , the strA valid strategy to increase the solubility of a drug and make it more selective towards cancer cells is nanoencapsulation. Based on these considerations, the researchers sought to improve the effect of PN.Karmakar et al.  used carDarwish NHE et al.  designedGiven the abundance of PN in nature by several researchers, it is used to semisynthesize other sesquiterpene lactones such as arglabin  Figure A. ArglabIn addition, micheliolide (MCL), a sesquiterpene lactone that can be produced from PN  Figure B, has shPN exerts its antitumor action through different mechanisms including transcriptional regulation, epigenetic effects, signal transduction modulation and induction of oxidative stress. Through these modalities, PN is able to induce apoptosis or alternative forms of cell death including “necrosis-like” and “apoptosis-like” programmed cell death as well as autophagic cell death. The compound appears to display selectivity to tumor cells and a particular efficacy in cancer stem cells, which are the cause of relapses and resistance following chemotherapy. Many lines of evidence indicate that PN potentiates the effect of conventional chemotherapeutics or other antitumor drugs in different tumor models. Studies are still underway to make PN a more effective drug by increasing its stability and solubility. For this purpose, some PN analogues have been developed and are currently under investigation in different tumor models. Overall, PN and its analogues represent promising agents in cancer therapy, and studies on these compounds have served as a basis to synthesize or isolate new sesquiterpene lactones that are increasingly effective to specifically target cancer cells.


Healthcare personnel (HCP) are a high priority group for influenza vaccination aiming to protect them but also to protect vulnerable patients and healthcare services from healthcare-associated influenza and HCP absenteeism. Multi-component influenza vaccination programs targeting behavioral, organizational, and administrative barriers are critical, if influenza vaccination rates among HCP are to be raised on a sustained basis. Mandatory influenza vaccination policy is the only single intervention that can achieve high and sustainable vaccination rates in HCP in short term. In this article, we provide an overview of issues pertaining to influenza vaccination of HCP, with an emphasis on organizational issues of influenza vaccination programs. Influenza is a significant cause of morbidity, fatalities, and use of healthcare services globally. A recent study compiling influenza-associated excess respiratory mortality estimates from 31 countries representing five World Health Organization (WHO) regions from 1999–2015, estimated that every year an average of 389,000  respiratory deaths globally are associated with influenza . HealthcAlthough influenza vaccination of HCP is recommended by public health authorities for several decades, influenza vaccination acceptance and advocacy rates among HCP vary across countries and HCP professions . HCP whoRecent articles indicate that there are still gaps in HCP knowledge about healthcare-associated influenza and the expected benefits of HCP influenza vaccination for them and their patients. For example, working despite being ill is common among HCP, including those working in high-risk settings. In an oncology unit, two out of three HCP with influenza continued to work despite their symptoms; approximately half of them did so because they considered their illness too minor to pose risk . SimilarFinally, influenza is a significant cause of absence from work among HCP while influenza vaccination has a significant protective impact on it. A Canadian cohort study of 10,079 HCP of whom 77% were vaccinated, found that unvaccinated employees in winter had a two-fold increased absenteeism due to all-cause illness than vaccinated employees . Imai etGaps in knowledge and misconceptions of HCP about healthcare-associated influenza and influenza vaccine are main barriers for accepting influenza vaccination and complying with recommendations for vaccination ,33,34,35Ideally, an influenza vaccination program is integrated in broader infection prevention and vaccination policies for HCP which in turn will enable a more comprehensive approach to the control of influenza, facilitate HCP compliance with vaccination recommendations, and promote a safety culture for employees and patients . The impEducational activities and communication;Vaccination coverage target;Organization of vaccination campaign;Analysis of vaccination data and feedback of results to HCP;Target achievement award.An annual influenza vaccination program consists of the following:Evidence-based education and promotional communication are key components of successful influenza vaccination programs and are useful in modifying vaccination behavior and improving vaccination rates among HCP ,39,40,41Education should be provided as early as possible and cover all aspects of healthcare-associated influenza, focusing on vulnerable patients, the role of HCP, and the protection conferred through vaccination. Education about infection control measures, respiratory hygiene, and appropriate management of HCP with ILI is also imperative . InformaThe incorporation of psychological and cognitive models ensures a holistic approach of vaccination education programs . A clustSetting vaccination coverage targets is a basic step for the implementation of every intervention to raise influenza vaccination rates among HCP. Vaccination coverage targets have to be feasible considering the past influenza season achievements and available human and other resources. It is suggested that an overall HCP vaccination coverage target is selected as well as specific targets for HCP per high-risk setting . Influenza vaccination coverage targets should be disseminated to employees early in the vaccination period and linked to awards.The vaccination campaign starts early before the vaccination period and peaks during the vaccination period . Evidence-based knowledge and actions to surpass or eliminate barriers of HCP to comply with influenza vaccination recommendations at the level of the specific healthcare facility are critical. It is equally important to early recognize and lift barriers related to accessibility to vaccination services for HCP . Beyond Active participation of the manager of the healthcare facility, designation of a coordinator and a dedicated team, assignment of concrete responsibilities to team members are critical elements of a successful vaccination program. Of equal importance is to ensure the required human and material resources for the implementation of the vaccination program. Communication algorithms should be established in advance and include all involved units and infrastructures  and involved personnel.A mechanism to record vaccinations and estimate influenza vaccination coverage rates should be in place . The numAt the end of the influenza season, the achievement of high vaccination rates in specific clinics and units should be widely disseminated and an award should be offered to the department with the highest vaccination rate.Commitment of managers and administration to the promotion of the principle of “zero-tolerance” to healthcare-associated influenza and common values towards vaccinations is critical. The managers should also be actively involved in all steps of the influenza vaccination program, if influenza vaccination rates among HCP are to be raised on a sustained basis . MeetingMost countries globally rely on recommendations to vaccinate HCP against influenza ,47. Howep-value = 0.022) during the years when vaccine strains and circulating strains matched well [Mandatory influenza vaccination as a condition for employment was implemented for the first time in Virginia Mason Medical Center in Seattle, US . Althoughed well . The larhed well .European countries rely almost exclusively on recommendations to vaccinate HCP against influenza . EvidencMandatory vaccination implies serious ethical hurdles must be taken. A person’s individual freedom must be weighed against collective goals such as obtaining herd immunity and protecting the most vulnerable patients and fellow citizens. There are many duties for HCP, both at the individual and the collective level: a duty to protect oneself, a duty to patients, to one’s family, to colleagues, and to society as a whole. Important principles here are altruism and solidarity. There are very few counterarguments and the risk of side-effects is very low. At the positive side, there is much to be gained . Given tThe principle of “zero tolerance” to healthcare-associated influenza is a key element of modern infection control plans. HCP are a high priority group for influenza vaccination to confer them immunity but also to protect vulnerable patients from healthcare-associated influenza and essential healthcare services from HCP absenteeism, presenteeism, and outbreaks. Multi-component influenza vaccination programs targeting behavioral, vaccine accessibility, organizational, and administrative barriers are crucial, if influenza vaccination rates among HCP are to be raised sustainably. Voluntary influenza vaccination policies have failed to achieve and sustain high vaccination rates in HCP. A mandatory vaccination policy is most probably the only single intervention that can achieve and sustain high (>90%) influenza vaccination rates among HCP.


This comedicine .With this Frontiers special issue, we intended to increase awareness among caregivers that precision medicine has a proven track record in e.g., oncology, and is likewise, also very promising to improve outcome in (pre)term neonates. Unfortunately, neonatal medicine is lagging behind in implementing this concept. To further quantify this, a PubMed for “precision medicine” on April, 23 2021 resulted in 64,080 hits, with an exponential increase from 2010  onwards, while “precision medicine + newborn” only resulted in 826 hits, with a delayed increase from 2015 onwards.This reflects the relevance of this focused Research Topic on precision medicine in neonates, as the concepts related to precision medicine and the anticipated gains in clinical outcome matter to (pre)term neonates: the neonatal community  should move from one “uniform” protocol for every newborn toward precision driven, patient tailored treatments and support . Its feaOnland et al.).Bronchopulmonary dysplasia (BPD) remains the most common complication of preterm birth with long lasting sequelae. Most intervention studies to prevent BPD were conducted on a population level, without “precision concepts” like variation in clinical and biological diversity, genetic predisposition or environmental factors. In a review paper, Onland et al. explored potential approaches to implement precision concepts in neonatal BPD care, summarizing the available evidence on electrical impedance tomography and electromyography of the diaphragm, genomic variation in caffeine metabolism, and volatile organic compound analysis in exhaled breath . While a second dose of surfactant (up to 300 mg/kg) is still standard of care, nitric oxide remains much more controversial based on the available evidence on benefit/(long term) outcome data . The current analysis hereby paved the way for a precision medicine approach within this population by providing evidence that a specific subgroup of preterm neonates  had better outcome.Two other original studies focused on outcome and risk stratification for two medical interventions for respiratory distress syndrome (RDS), i.e., the need for a second dose of surfactant or nitric oxide. Preterms in need of a second dose of surfactant for RDS had identifiable risk factors . Interestingly, this more severe RDS (reflecting the need for a second dose), phenotype was associated with lower survival, but with similar outcome in survivors .Despite a machinery of tools  to assess neurological (dys)function during neonatal stay, predictive performance for the subsequent individual neurodevelopmental, long-term outcome remains poor. Machine learning approaches were suggested as powerful approach to change performance of prediction and prognosis in the field of neonatal neurology (Yang and Dong). Based on the same gut-lung axis concept and BPD risk, the correlation between intestinal and pharyngeal microbiota was explored in 13 premature neonates. While intestines and pharynx shared some microbiota (like streptococcus), both sites also had unique profiles, so that linking of data on microbiota to gut-lung crosstalk outcome data (like BPD) should also consider the site of collection .The evidence of lung microbiota dysbiosis and the applications of probiotics to prevent BPD were examined and discussed .Colonization patterns are obviously also affected by our practices and antibiotic prescription  . Keij etDe Boode).Individualized hemodynamic management, tailored to the cardiovascular (patho)-physiology, and clinical characteristics of each individual patient or subgroups is another promising application of precision medicine. De Boode applied this concept to three clinical syndromes commonly observed in the neonatal unit: patent ductus arteriosus, shock, and hypotension and persistent pulmonary hypertension of the newborn . Along the same line, but integrating preterm birth with asphyxia, renal function profiles in preterm neonates with birth asphyxia within the first 24 h of life were described. Different profiles between preterms with or without asphyxia were identified. This facilitates identification of relative risks to develop renal impairment, and brings this population closer to precision medicine, and subsequent needed studies on long-term cardiovascular and renal outcome (Zhang and Zeng).Renal precision medicine also holds the promise to support decision making on pharmacotherapy, signal detection of adverse (drug) events and to improve accuracy prediction of short- and long-term prognosis. Recent advances in this field  and the potential clinical impact (secondary prevention and feasibility of nephrotoxicity risk mitigation) were discussed .Finally, the retinal circulation and the related retinopathy of prematurity (ROP) forms another relevant morbidity in former preterms. The extent of temporal avascular area of the retina (disc diameter) and duration of mechanical ventilation at first examination of the newborn  predicted the subsequent need for an ROP-related intervention during neonatal stay. Such indicators can be used in a risk calculator to predict the need for treatment or to power preventive studies (Overall the different papers added ideas and some provided small pieces of the puzzle that we need for precision medicine. In most areas stratified medicine is still work in progress and it still quite far away from where we aim to be in neonatology. We are confident that the illustrations provided in this Research Topic will further boost the clinical research on precision medicine concepts as a powerful tool to further improve neonatal management, quality of care, and outcome.All authors contributed to the Editorial and agreed on the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bouillon cubes are a staple ingredient used in Sub-saharan African countries providing flavor enhancement to savory foods. Bouillon has been identified as a vehicle for fortification to overcome micronutrient deficiencies in Sub-saharan Africa. However, bouillon has a high sodium content (and in addition with other foods) contributes to dietary sodium intake above recommended guidelines. High dietary sodium intake is a key risk factor for hypertension and cardiovascular disease (CVD). Africa has the highest rates of hypertension and CVD globally with nearly half the adult population above 25 years affected. This review presents current state of research on sodium reduction strategies in bouillon. The key challenge is to reduce sodium levels while maintaining optimal flavor at the lowest possible production cost to ensure bouillon continues to be affordable in Sub-saharan Africa. To produce lower sodium bouillon with acceptable flavor at low cost will likely involve multiple sodium reduction strategies; direct reduction in sodium, sodium replacement and saltiness boosting flavor technologies. Efforts to reduce the sodium content of bouillon in Sub-saharan Africa is a worthwhile strategy to: (i) lower the overall sodium consumption across the population, and (ii) deliver population-wide health benefits in a region with high rates of hypertension and CVD. The culinary concept of bouillon is to create an intense flavourful extract or essence from cooked meat and animal products (and/or vegetables). The sodium content of bouillon is high  and provides a significant contribution to the flavor enhancement of bouillon. Sub-saharan Africa has broad use and frequent consumption of bouillon. The objective of this review is to examine the evidence for the contribution of bouillon to total dietary sodium intake in Sub-saharan Africa, the current regulation/initiatives for sodium levels in bouillon and review strategies for sodium reduction through bouillon reformulation as a means to contribute to improved population health in Sub-saharan Africa.Sodium is an essential nutrient necessary for normal body function. The minimum sodium intake required for an average adult is ~0.5 g per day. However, the level of dietary sodium intake worldwide is above the World Health Organization (WHO) recommended amount of 5 g of salt  a day (~2 g sodium a day) , 2. LongLong term excess sodium intake has serious health consequences. High sodium levels are a key risk factor for increased blood pressure (due to increased water retention) resulting in hypertension and the potential to develop cardiovascular disease (CVD), increased risk of a stroke and other health complications . These lNCD have a higher frequency in low to middle income countries (LMIC). Within Africa, 20 million people suffer from CVD and hypertension affects nearly half the population of adults >25 years, representing the highest incidence worldwide –19. FurtIn 2015, WHO released the Sustainable Development Goals (SDGs) outlining 17 global goals to achieve a better and more sustainable future for all . Goal nuIn addition, a reduction in dietary sodium intake is a central component to achieve SDG Target 3.4 which aims is to reduce premature deaths from NCDs by one third by 2030. Specifically, WHO suggests multiple strategies for salt reduction having the greatest cost effectiveness in LMIC including reducing salt intake through the reformulation of food products and, reducing salt intake through a behavior change , 26. FurFew studies have assessed the health and economic costs of sodium reduction in Sub-saharan Africa. The limited studies completed to date show lowering sodium across the population results in significant direct and indirect health cost savings and health gains . ModelinThere are three main sources of dietary sodium intake: (i) naturally occurring sodium present in non-processed foods, (ii) added sodium in packaged or processed foods, and (iii) sodium added during cooking or during eating at the table. The sodium reduction strategies employed on a country/regional basis should target the largest source of discretionary salt intake.In developed countries, the majority of sodium is consumed from processed foods (75–80%) with small contributions from sodium found naturally in foods or sodium salt added during and at the end of cooking . TherefoSimilar strategies to reduce sodium intake that have been successful in developed countries will not likely translate to other LMIC nations, as the contributors to sodium intake differ significantly. In Sub-saharan African countries, seasoning of foods during cooking is reported to be the major contributor to sodium intake, for example use of salt, soup mix or bouillon cube added while cooking , 6, 34. Bouillon cubes are a staple food in Sub-saharan African countries  and could be a key target for sodium reduction. Bouillon has a high rate of consumption across country, age, gender and socio-economic levels and also contains a high sodium content –37. Whilper se in Benin [but higher total salt intake] is the use of condiments cubes . These are used in sauces eaten with staple foods and are rich sources of salt.”From Melse-Boonstra et al. : “We speAdeyemo et al. : on inteLeyvraz et al. : “…salt Mezue : “… the Queiroz et al. : “SodiumMenyanu et al. : “…the GThis provides evidence that bouillon contributes to daily dietary sodium intake in Sub-saharan African countries above recommended levels. Therefore, decreasing the sodium content of bouillon may contribute to a significant reduction in the overall sodium consumed across the population and contribute to population wide health benefits through reduction in the rate of hypertension and death from CVD.As outlined, sodium reduction strategies should target the largest sources of discretionary salt intake. There are several approaches to reduce dietary sodium intake across a population, including:(1) The reformulation of foods having high sodium content with frequent consumption patterns to contain lower levels of sodium and/or,(2) Increased consumer education about common foods high in sodium (including bouillon cubes) and the negative health impacts from a diet high in sodium (therefore driving behavior change to reduce sodium intake).Reducing sodium intake at a population level to achieve health impacts will require a whole food system approach, for e.g., greater health gains can be achieved if interventions are targeted across the food system, of which bouillon should contribute given the evidence of high consumption patterns. Indeed, there have been several intervention studies aimed at reducing dietary sodium intake (which have included bouillon) showing positive impact on health outcomes , 43. In The remainder of this review will focus specifically on strategies for sodium reduction in bouillon  as a direct mechanism to contribute to lowering overall population sodium intake. While consumer education to limit bouillon consumption may reduce population level sodium consumption, this approach is likely to be less impactful as consumer education will take longer to achieve public health benefits  and as outlined above, may reduce the impact of other population health initiatives that aim to fortify bouillon to overcome micronutrient deficiencies in Sub-saharan African countries , 38, 39.Bouillon cubes typically contain a number of ingredients including salt, taste enhancers , fat , hydrolysed vegetable proteins, starch, herbs, spices and other flavorings . BouilloSalt, added in the form of crystalline sodium chloride (NaCl), is generally the main ingredient and contributes most to the sodium content of bouillon . Salt is also a convenient bulking agent and natural preservative. However, salt is not the only source of sodium. There are other ingredients that may also contribute to the overall sodium content, including: meat/chicken flavor extracts, hydrolysed vegetable protein (HVP), vegetable flavor extract, yeast extract, monosodium glutamate (MSG), and disodium guanylate and inosinate salts. These ingredients are present in lower quantities and hence contribute a smaller portion of the overall sodium content of bouillon. Thus, lowering the salt (NaCl) content is the most effective reformulation strategy to reduce sodium levels in bouillon. However, as saltiness is such an important and desirable sensory attribute of savory foods, even small reductions in the amount of salt can have large negative consequences on consumer liking. Therefore, understanding how the sensory loss can be compensated through the use of ingredient/technologies is an important area of research to ensure consumer satisfaction.Understanding the current average sodium levels in bouillon is an important benchmark to assist with developing appropriate targets for sodium reduction and the strategies and technologies employed to meet those targets. Currently, there is no published analysis of sodium content of bouillon products in different world regions, including for Sub-saharan Africa, and only a few country specific reports –46. Two National and international based initiatives are important tools to define maximum sodium levels through voluntary or mandatory standards. These initiatives can provide population level controls to reduce sodium intake and improve public health. In Sub-saharan African countries, there are only a few guidelines or legislation which set benchmark levels of sodium in bouillon. South Africa has implemented mandatory legislation for the reduction of sodium levels across a wide range of processed foods including bouillon. The legislation commenced in 2013, providing specific sodium levels for different food groups to be introduced over time. For bouillon/stock cubes, the legislated sodium levels were <18,000 mg/100 g in June 2016 and then a further reduction below 13,000 mg/100 g in June 2019 , 48. SenOther worldwide initiatives include: (i) the Pan American Health Organization (PAHO) has set regional levels/guidelines for sodium levels for 11 food categories . Regional sodium targets for bouillon are 20,500 mg/100 g and a lower target of 18,000 mg/100 g . (ii) ArWhere legislated or voluntary sodium reduction levels have been introduced, the reduction has been completed in a stepwise approach of multiple smaller increments over time with significant lead time (2–5 years) provided per reduction step. The differences in legislated sodium levels in African countries of 22% in Senegal and Burkina Faso compared to 13% in South Africa are significantly large and demonstrate a strong role for industry and government leadership in long term sodium reduction strategies. Further, the implementation of low sodium targets on bouillon by South Africa and Argentina shows that it is technically feasible to reduce sodium in bouillon at significantly lower levels than current average sodium levels across Africa. The challenge is to complete this in the most affordable way while maintaining consumer acceptance.In addition to government legislation, the food industry has also committed to lowering sodium levels in their products. Multinational companies are recognizing sodium levels in the products contribute to excess dietary sodium intake and are showing leadership in product reformulation to reduce sodium. Several multinational food companies dominate the African bouillon market including Maggi (Nestle), Knorr/Royco (Unilever), and Jumbo (GB Foods) . Each ofUnilever has developed a salt reduction position and has set benchmarks for sodium levels for different product groups. The benchmarks were formulated/modeled based on a total diet approach considering the contribution of the product group to overall daily salt intake , 53. ForNestle has launched the Nestle Nutrition Profiling System (NNPS) developed to guide reformulation of their products , 55. The+) and chloride anions (Cl−). Free sodium cations are detected by dedicated taste receptors on the tongue and in other organs and cells throughout the body. The perception of sodium as saltiness is a primary taste modality and is an important and desirable attribute of many foods. Salt is added to foods and beverages (including bouillon cubes) for multiple functions, including:Sodium salt is a major ingredient used in the food industry and is a core component in all bouillon formulations. The term salt is commonly used to refer to sodium chloride (NaCl) and is composed of 40% sodium and 60% chloride by weight. When crystalline NaCl is dissolved in aqueous solvent (water) it dissociates into free sodium cations (Na(1) Taste/flavor enhancement: The addition of salt to food has a significant impact on consumer liking and acceptance. Salt addition to a food results in increased taste/saltiness, boosts/enhances flavor intensity, and can mask other tastes . Although sodium increases the palatability of foods, synergistic interactions of sodium ions with other food components like the amino acid glutamic acid and 5′-nucleotides are well-known to increase saltiness perception and umami or savory characteristics , 57.(2) Preservation/food safety: The growth of pathogens and food spoilage microorganisms can be inhibited by the addition of salt. Salt lowers the availability of water (water activity) which is essential for microbial growth. The addition of salt as a preserving agent is important for both the shelf stability of food products during manufacture, transport and storage/display in a shop and, the safe preparation, cooking, consumption, and storage of a food/meal after the product is purchased by a consumer.(3) Processability/friability: Salt can provide further product specific attributes. For example, in the production of bread, salt addition assists to control yeast fermentation impacting on bread texture and affects the rate of Maillard reaction flavor formation in baked foods. The presence of salt in powdered food ingredients helps to prevent clumping and increases product flow or friability. In meat products, salt has a significant effect on quality  as salt solubilises proteins within the myofibrillar network, facilitating water entrapment. In bouillon, salt can contribute up to 50–60% of the product and therefore functions to provide a significant contribution to the size/weight of the cube (in addition to the flavor enhancement). Additionally, bouillon salt is commonly fortified with iodine and has a function to contribute to population wide health to reducing iodine deficiency .(4) Carrier for micronutrient fortification: due to universal consumption across populations, many countries have legislated for salt fortification . Iodine is the main micronutrient added to salt to prevent iodine deficiency and goiter. In Sub-saharan African countries, the salt in bouillon is commonly fortified with iodine.Simply reducing the sodium content of processed foods can have far ranging effects not only on the saltiness and flavor, but also other important qualities. Hence, reformulating foods for lower sodium is often a significant and considerable technological challenge. Salt has techno-functionality that is specific per product , and therefore the sodium reduction strategies that work in some foods may not be applicable to bouillon.When a food is eaten, the flavor perceived is primarily due to a combination of taste/gustation (originating from stimulation of taste receptors on the tongue and in the mouth) and smell/olfaction (originating from the stimulation of olfactory receptors in the olfactory epithelium in the nose). The terms “taste” and “flavor” are often confused and in the current paper, the term taste refers to the technical sense  and the term flavor refers to the entire summed experience  that an individual perceives when consuming a food.The taste system includes five primary accepted taste modalities: sweet, bitter, umami (savory), salt, and sour . Taste iThe detection mechanism for each of the five primary tastes is different. The detection of bitter, sweet and umami tastes are detected by a specific set of G-coupled protein receptors (GPCR) including:(1) Bitter taste: 25 different single GPCR (TAS2R1-48) –62.(2) Sweet taste: 1 heterodimer composed of two GPCR (TAS1R2/TAS1R3) , 64.(3) Umami taste: 1 heterodimer composed of two GPCR (TAS1R1/TAS1R3) , 65.Bitter, sweet, and umami tastes are activated when a compound physically binds to the taste receptor that activates the taste cell and sends a signal to the brain. Salt and sour taste are initiated with the transport of salts or acids into the taste cells through ion channels, rather than activation of cell surface receptors like sweet, umami and bitter.Salt taste is detected by ion channel receptor(s) and the exact mechanism is still not understood . When soThe scientific literature suggests two independent mechanisms for saltiness detection. These two mechanisms are commonly referred to as amiloride sensitive and insensitive pathways due to the ability of the compound amiloride to partially suppress salt taste. Current evidence supports the epithelial sodium channel (ENaC) being responsible for amiloride sensitive salt taste detection . Salt tavia the salt ion channel). Therefore, due to this selectivity, there has not been and may likely not be, a true salt substitute identified  have an impact on the type and range of food compounds that can activate that specific taste and determine the ability to find compounds/molecules that may function as taste substitutes. For example, the activating compounds of the sweet taste receptor are many and diverse due to the number of possible interacting sites on the sweet taste receptor . As the entified .Additionally, a limitation on the ability to identify salt substitutes or salt enhancers is the fact that the receptors and mechanisms involved in salt taste are still yet to be identified. For example, novel compounds imparting sweet or umami taste can be rapidly identified using screening methods with the receptors for sweet and umami. Such screening to identify new salt compounds are not possible without the identification and understanding of the salt taste receptors and cellular mechanism(s) leading to saltiness perception.Human taste response is complex. The interaction between salt concentrations within a food and perceived saltiness taste intensity does not follow a linear response . Salt ta(1) Threshold region: a flat plateau region at low concentrations of sodium where no taste is perceived that leads into expansive phase resulting in exponential increase in taste,(2) Linear phase: small increases in sodium results in a corresponding increase in perceived saltiness, and(3) Plateau phase: compressive region at high sodium concentrations, where added sodium has little impact on increasing the perceived saltiness.Understanding the region in which the sodium concentration in a food product is located on the sigmoid response provides a strategy for sodium reduction. For example:(1) If a product is in the linear phase, small changes in sodium content will have a significant impact on perceived saltiness(2) If a product is in the plateau phase, large reductions in sodium may be possible with no significant change in the perceived saltinessSub-saharan African bouillon has significant amounts of sodium (see Section Sodium levels in bouillon), with no published studies to date assessing bouillon saltiness in relation to this sigmoid response.The flavor of a food is created due to a summation of individual inputs  detected by the type and concentrations of compounds in a food. When activated in combination during eating, different tastes, and aromas can have synergistic enhancing effects on the total flavor perceived or may result in taste suppression. These interactions are referred to as taste-taste and taste-aroma interactions. These taste-taste/taste-aroma interactions can be harnessed to modify taste or flavors perceived, having the potential to enable reduction in specific ingredients  or masking undesirable tastes . Most of the research into taste-taste or taste-aroma interactions are completed in plain water or simple model foods. While there is evidence that the outcomes from these studies can be translated in foods, the ability to translate these directly into products is complex as salt ions will interact with different matrices depending on many factors  and this will affect the perception –73.The original culinary concept of bouillon is essentially creating a concentrated flavourful extract or essence from cooked meat and animal products  often ameliorated with the addition of strong-tasting herbs and alliaceous vegetables . Bouillon normally involves roasting of components to exploit flavor, generating Maillard, and caramelization reactions. Flavors are extracted into a liquid and further concentrated into a reduction or can be formed through the mixing of raw ingredients for a dried powder or compressed cube form. The final composition is a rich mixture of flavor components, including glutamic acid, taste active umami and kokumi peptides, 5′-nucleotides , and other molecules.Umami represents a key component of the taste of bouillon and is activated by the amino acids L-glutamate and L-aspartic acid as well as several organic acids, umami taste enhancing compounds 5′-ribonucleotides, guanosine monophosphate (GMP) and inosine monophosphate (IMP), and peptides containing a combination of these compounds , 75. It The flavor of a food is a key determinant of food choice and repeated use. The impact of consumer liking on food choice will generally override other factors including for example health claims or packaging . Salt imAnother challenge for sodium reduction is due to population health initiatives that aim to fortify bouillon to overcome micronutrient deficiencies in Sub-saharan African countries , 38. ForA further challenge specific to Sub-saharan Africa, is to reduce sodium levels while minimally influencing the production cost and the cost for the consumer. Bouillon cubes are a low-cost staple food used in Sub-saharan African countries across all sociodemographic groups. Therefore, uptake of sodium reduction in bouillon by the food industry will only be successful if sodium reduction is completed in a manner to maintain affordability and availability to all sociodemographic groups including to low-income families. This is particularly important to ensure there is not a reduction in the frequency or amount of bouillon consumed to maximize nutritional benefit from large scale micronutrient fortification initiatives. To date, there is limited information regarding bouillon costs in Sub-saharan Africa and further the best way to cover increased costs which may be associated with sodium reduction in bouillon. Therefore, further research is required on surveys of bouillon across markets, modeling the effect of different sodium reduction strategies on bouillon cost and to understand who could cover the costs .There are several major approaches to reducing the overall sodium content of food. With emphasis on flavor, the first is to remove sodium to a point where the consumer is unable to detect a reduction in sodium concentration in the food and the second is to replace sodium-based salts with other non-sodium salts, such as potassium chloride. The third is to exploit interactions with other taste components to enhance either the perceived saltiness and/or the overall flavor of a food. This section reviews current evidence for these sodium reduction approaches to reduce sodium in bouillon. Where there is limited research in bouillon, findings from bouillon-similar matrixes are also reviewed. The critical review of the different strategies/technologies is essential to assist both large and small bouillon producers for the Sub-saharan Africa translate research into their existing commercial products and highlight where further research is required.It is likely that not one approach in isolation will provide the ability to significantly reduce sodium levels while maintaining the high flavor impact of bouillon. Therefore, reformulation of bouillon to lower sodium level will likely require the use of multiple strategies and technologies in combination. Additionally, many technologies and ingredients that could or are used to reduce sodium levels in the food industry are not economically viable in the Sub-saharan African market. For example, adding in higher levels of flavor from meat  would increase bouillon flavor, but this strategy would result in a significant increase in cost. Therefore, the strategies for sodium reduction in Sub-saharan bouillon need to balance taste, cost and suitability for use in bouillon.The simplest and cheapest method for sodium reduction is to simply remove salt from bouillon without the addition of other ingredients to counteract lower saltiness or overall flavor. However, a too large reduction in sodium will have a negative impact on consumer liking. Consumer food choices are known to be affected when the reduced sodium product does not match the characteristics of the regular sodium product . TherefoDirect salt removal has been assessed in a range of different foods [see  for rece(1) The matrix  of the product which affects the spatial distribution, and release and interaction of sodium with the taste receptor,(2) The sodium content of the product, with higher sodium products allowing greater scope for significant sodium reduction, and(3) The contribution of the perceived saltiness to the overall flavor of the product .There is only one study which has assessed straight sodium reduction specifically in relation to bouillon . This stOther studies have been completed assessing sodium reduction in matrices similar to how bouillon is used, however, these studies assessed sodium reduction from salt rather than specifically from bouillon. Studies assessing soup-based matrices show the ability to remove sodium and maintain overall flavor or consumer acceptance. An overall trend is observed with the level of reduction, with a 20–33% sodium reduction associated with maintaining consumer acceptability or overall flavor –93. HoweIn the context of Sub-saharan African bouillon, the sodium levels are high, suggesting straight reduction for a portion of the sodium may be possible and if implemented as small steps over time provides the greatest chance to maintain consumer acceptance.Sodium replacement is the process of partially substituting sodium with other mineral salts which provide a salty taste. Sodium replacement is one of the most common methods to reduce sodium content in food and beverages. Sodium replacers can include salts containing potassium, calcium, magnesium, or ammonium. As described previously , there is no current direct substitute for sodium, as these replacers generally impart also negative tastes , have a lower saltiness level, or are not safe for general consumption .Potassium chloride is the most common sodium substitute used in food industry –99. PotaSeveral studies assessing the efficacy of potassium chloride substitution for sodium chloride have been completed in bouillon. These studies show the ability of potassium chloride or combination of potassium with ammonium salts to substitute 15–40% of sodium chloride while maintaining saltiness and acceptability as determined by sensory assessment using a range of both trained and untrained panelists , 102. HoTaste improving agents (TIA) can also be used in combination with potassium to reduce the undesirable bitter/metallic notes. The TIAs previously studied include mineral salts, umami ingredients, food acids, amino acids, spices, simple carbohydrates, or food polymers . For somPotassium chloride is already widely used by the food industry to reduce sodium levels, and on a cost basis, is one of the cheapest ingredients to enable sodium reduction in bouillon in Sub-saharan Africa. Given the high sodium salt concentration of bouillon, partial substitution with other salts may be a possible strategy for sodium reduction and should be explored as a low-cost sodium reduction strategy, particularly, in association with the other low-cost sodium reduction technologies.The concept of bouillon is to create an intense flavor addition to foods. Instinctively, cooks and chefs have been exploiting interactions between sodium, Maillard and umami molecules for optimal savory flavors and liking for a long time. With the discovery of umami in the early 1900s the complex chemistry of umami and related kokumi taste have slowly become understood by scientists , 104. AnCompounds creating savory or umami taste include synergy between glutamic acid and sodium as well as flavor boosting 5′-nucleotides; 5′-guanosine monophosphate (5′-GMP) and 5′-inosine monophosphate (5′-IMP) , 78. HowThe primary role of glutamic acid in enhancing savory and saltiness perception has been well-known for decades. Glutamic acid occurs in high abundance naturally in many foods . Glutamate is also added to many processed foods in the form of its sodium salt, MSG. The optimum pleasantness concentration of glutamate, as a flavor enhancer of food, has been established to be between 0.2 and 0.8 %w/w depending on the food matrix , 118. EuSimilarly, 5′-GMP and 5′-IMP in the presence of glutamate are widely known to boost umami character and saltiness perception. The optimum ratio of MSG to these nucleotides is usually between 100:1 and 50:1 . Howeverhttps://www.umamiinfo.com/umamidb/). While these ingredients continue to be explored in markets where there is a desire for “clean label” ingredients and minimally processed foods, they are expensive alternatives to MSG. Until those ingredients can be sourced and processed at minimal cost, it is expected that enzyme hydrolysates and powders of natural foods won't be suitable alternatives in the production of affordable reduced sodium bouillon.Enzyme protein hydrolysates (soy and other protein) and dried mushroom and tomato powders are naturally rich in umami free amino acids and small peptides which can boost savory and overall flavor of a food , 122. YeThere is significant research on the cross-modal interaction between odors and aroma (olfactory receptor stimulants) and taste  , 124. SaMechanical salt enhancers (MSE) refer to food ingredients which change the overall microstructure of the food matrix, increasing either the availability of sodium ions in solution or the localized sodium ion concentration near sodium receptors on the tongue. A recent study showed that addition of the slightly acidic polysaccharide gum Arabic  enhanced the saltiness perception of salt solution by up to 30% . The autChitin is one of the most abundant biopolymers in nature, present in arthropod exoskeletons fungi and cell walls. Normally chitin is only sparingly soluble in aqueous solution. Researchers recently produced chitin nanoparticles using an ultrasound cell grinder, increasing the water solubility . The autThe versatility of bouillon use is the key challenge for sodium reduction and is a unique challenge to bouillon compared to other processed foods. Firstly, bouillon undergoes changes in structure, starting off as a dry cube and generally undergoing transformation in liquid matrix or spread through a solid matrix. Secondly, bouillon has a diverse range of uses and can be added to any variety of savory dishes. This could include:(1) Dissolving and use as a liquid stock, i.e., diluted in water then added to food or added directly to a liquid matrix (soup/stew),(2) Crushed and added to food while cooking, e.g., coated over meat as a dry rub/marinade, or(3) Crushed and sprinkled over food after cooking.Additionally, bouillon cubes can be stored for long periods of time potentially in humid conditions, and when used, they are exposed to extreme conditions during preparation of a meal .Thus, technologies employed for sodium reduction in bouillon need to consider these factors and are different to other processed foods where sodium reduction technologies are “set” within the product and are maintained until consumed. Therefore, strategies/technologies commonly used for sodium reduction in these other processed foods  are not suitable for use in bouillon cubes. Examples include, manipulating salt crystal size  or alterA key area that is not well-defined is the correct matrices/meal format to use in sensory analyses to assess sodium reduction technologies in bouillon. The matrix that is used in the sensory analysis (for example as a liquid broth or in a stew) will have a large impact on the ability and magnitude for a sodium reduction method to reduce sodium levels while retaining flavor . The res(1) The reconstituted bouillon represents a strongly concentrated form of the product which is not representative of how the product is normally consumed  The bouillon only contributes a small component of the overall flavor in a stew or complex meal.In both these instances, the matrix selected may overestimate the possibility for sodium reduction (while maintaining consumer acceptance). Therefore, prior to assessing different sodium reduction technologies in bouillon, there is a need to test and define the optimal matrices for sensory analysis to ensure research findings can be translated by industry into their products.Bouillon is receiving increasing attention as a fortification vehicle for delivery of micronutrients in Sub-saharan Africa , 142. FoFlavor intensity may be lower in salt reduced products and still accepted by the consumer, but in this frame, off-flavors or other organoleptic changes may become more obvious due to added fortificants. As efforts for bouillon fortification increase, there is a need to understand when the possible organoleptic changes occur between the matrix and the fortified nutrients. Therefore, understanding and integrating information on volatile and non-volatile composition of bouillon will allow to identify possible flavor enhancers, ingredients, or technologies to either mask or reduce the effect of fortification, in addition to potential flavor loss due to reducing sodium levels of bouillon.The work presents an overview of the salt reduction strategies with focus on Bouillon cubes. Bouillon cubes provide flavor enhancement to savory foods and contain high levels of sodium. Bouillon consumption in Sub-saharan African countries is high, with daily consumption across all sociodemographic groups. This has resulted in efforts to fortify bouillon to overcome micronutrient deficiencies. However, there is growing evidence that bouillon consumption is a contributor to sodium intake in Sub-saharan African countries above recommended levels and further research is required to better quantify this contribution. Therefore, population level health effects to reduce NCD could be achieved through the reduction of sodium levels in commercial bouillon products in Sub-saharan African countries. While there is currently not a single low-cost ingredient to replace salt having the same taste and flavor profile, reformulations of bouillon using multiple low-cost strategies are a viable solution to enable significant sodium reduction resulting in population wide health outcomes to reduce hypertension and CVD in Sub-saharan Africa.NA: conceptualization, writing—original draft, writing—review and editing, and project administration. MC-B, MM, and GG-B: writing—original draft and writing—review and editing. PL-S and LL: conceptualization and writing—review and editing. DF: conceptualization, writing—original draft, and writing—review and editing. All authors contributed to the article and approved the submitted version.This work was supported by a grant from the Bill and Melinda Gates Foundation under Grant INV-002988.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Replicating the structure and orientation of full-thickness skin by magnetically-induced assembling of micro tissue cores. Skin wounds are immense medical and socioeconomic burdens, and autologous skin grafting remains the gold standard for wound repair. We recently found that full-thickness micro skin tissue columns (MSTCs) can be harvested with minimal donor site morbidity, and that MSTCs applied to wounds “randomly”  can accelerate re-epithelialization. However, despite MSTCs containing all the cellular and extracellular contents of full-thickness skin, normal dermal architecture was not restored by random MSTCs. In this study, we developed a magnetically induced assembly method to produce constructs of densely packed, oriented MSTCs that closely resemble the overall architecture of full-thickness skin to test the hypothesis that maintaining MSTCs’ orientation could further hasten healing and restore a normal dermis. Our method led to faster and more orderly re-epithelialization but unexpectedly did not improve the retention of dermal architecture, which reveals a hitherto unappreciated role for tissue morphology in determining dermal remodeling outcomes. When biological tissue is damaged by disease or trauma beyond its capacity to regenerate, replacing the defective tissue by transplantation is often the only curative option. However, harvesting tissue for grafting creates a donor site wound. Donor site morbidity and the limited availability of donor tissue are major drawbacks for autologous grafting, while allogeneic transplants pose major risks from graft-versus-host reactions and from life-long immunosuppression. The field of tissue engineering emerged in recognition of these drawbacks, and skin was the first engineered tissue to be applied to patient care, with initial clinical use reported in the early 1980s  samplings of natural full-thickness skin tissue, which we have called micro skin tissue columns (MSTCs). An important advantage of this approach is that each MSTC can be small enough that the donor site can spontaneously heal without scarring or other long-term morbidity. Because MSTCs are sampled randomly from natural skin tissue, they include all the different cellular and extracellular components of the tissue, including those that are yet to be fully characterized, and within each MSTC, all of these components retain their respective natural organization, structure, and microenvironment. In other words, rather than trying to fabricate complex multicellular tissues de novo, we are instead “copying” from nature by using as starting material, fragments of tissue in which all its normal physiologic complexities are already in place. This approach allows us to bypass the need to reproduce the microarchitecture of natural tissue , and the main challenge becomes rather how to assemble MSTCs into constructs at the “macro” scale of natural tissues.We previously found that applying MSTCs “randomly”  into wounds substantially accelerated wound closure and reduced secondary wound contraction (3O4) particles with a commercially available silicone-based wound adhesive. Iron oxide was chosen both because of its magnetic properties and its safety profile—It is a pigment common in black tattoo inks, with a long history of tolerance by the human body, and can be removed by laser treatment if necessary. We call this method MagneTEskin—It is easily scalable and enables the assembly of large numbers of MSTCs into densely packed, properly oriented skin constructs, resembling natural full-thickness skin in both content and structure. The conceptual framework for this method is illustrated in To replicate the structure of natural skin, with the full complement of cellular and extracellular skin components all in their respective proper microanatomic locations, we sought to develop a method to satisfy the following key design criteria: (i) ability to induce and maintain the alignment of MSTCs along the epidermal-dermal orientation; (ii) assemble the aligned MSTCs into three-dimensional skin constructs resembling natural skin structure; (iii) the process should be rapid, consistent with clinical use in minutes instead of hours; (iv) the process should be scalable and customizable to fit different wound dimensions; (v) we avoided in vitro culture or other processes that would render the MSTCs more than minimally manipulated from a regulatory standpoint; (vi) minimize inclusion of exogenous materials—if any is needed, then preference will be given to Food and Drug Administration (FDA)–approved materials, and the materials must not negatively interfere with the healing process; and (vii) the final construct should be able to withstand mechanical perturbations that are typical of wound environments . After testing multiple methods, we identified an effective option: By coating the donor skin with a magnetic surface layer before harvesting, the epidermal heads of each MSTC can be manipulated using an external magnetic field to control the orientation, density, and distribution of MSTCs. The coating was made by combining iron oxide –N′-ethylcarbodiimide hydrochloride (EDC) combined with N-hydroxysuccinimide (NHS). Details on the cross-linking parameters are described in Materials and Methods. Collagen gels cross-linked with d-ribose were still too fragile, but gels cross-linked with rose bengal or EDC/NHS, as well as collagen-fibrin gels, were all mechanically robust and were selected for further in vivo testing.To test their mechanical robustness, MSTC constructs were placed into excision “wounds” in ex vivo porcine skin tissue and subjected to manual manipulation and compression, simulating the mechanical forces that the constructs would be subjected to in the in vivo setting. Collagen alone was fragile and broke apart easily with routine handling. To strengthen the collagen gel, we cross-linked the collagen with different nontoxic cross-linking reagents that have been used in other in vivo applications—specifically A second option for securing the aligned MSTCs was by binding them only at the epidermal surface. Compared to the previous option, this second option is faster and simpler and avoids introducing exogenous materials into the body. The drawbacks are that the connections between individual MSTCs are less secure, and the loss of potential biological benefits conferred by the biomaterials. For the topical binding process, after MSTCs are oriented and assembled, they are placed into the wound site, and then a protective layer is applied to the epidermal surface. Three candidate materials were investigated for this layer: fibrin sealant, polyurethane film dressing, or cyanoacrylate surgical adhesive. All three materials performed satisfactorily in ex vivo testing of mechanical stability (as described in the previous section). Because there were no discernable differences between the different materials at this stage, the two materials that were the most inexpensive and convenient to use, namely, polyurethane film dressing and cyanoacrylate surgical glue, were chosen for in vivo evaluation.The various MSTC assembly options chosen from ex vivo testing were evaluated in the porcine full-thickness excision wound model, because the pig is, by far, the most faithful model for human wound healing . The colThe topically bound MagneTEskin constructs were first evaluated in the short term, specifically the initial 1 to 2 weeks after implantation, for their ability to maintain overall structure and MSTC alignment over this period, because this assembly option was thought to be less secure, and in our experience, wound implants are most vulnerable to mechanical disruptions during the first 2 weeks. Similar amounts of MSTCs implanted randomly into similar wounds were used as controls. In the topically bound MagneTEskin group, the successful maintenance of MSTC alignment under in vivo conditions was visually apparent in biopsy samples  and confGiven the encouraging short-term healing results, MagneTEskin constructs with topical binding were evaluated for long-term outcomes, particularly whether the dermal collagen architecture could be retained [as it is in full-thickness skin grafts (FTSGs)]. Compared with untreated wounds, the MagneTEskin constructs significantly reduced the time for wound healing and reduced wound contraction. The MSTCs’ normal dermal architecture appeared intact at week 1 and was still present but slightly fading by week 2. By 4 weeks after implantation, the crisscrossing basket-weave collagen architecture could no longer be seen; instead, the dermis was occupied by thin collagen fibers largely oriented in parallel with the skin surface. This disrupted architecture continued into the eighth week . MirroriIn this study, we established a practical method to manipulate and organize large numbers of tissue cores into defined structures and patterns and showed that this method could be used to produce constructs of densely packed, oriented MSTCs that closely resemble the natural architecture of full-thickness skin. The ability to manipulate and assemble small “building blocks” into larger tissue constructs has long been recognized as a key capability need toward enabling the engineering of complex solid tissues, as evidenced by the many different approaches that have been developed over the years aiming to achieve this goal  in each photograph was outlined by two independent evaluators who were blinded to the experimental group assignments. The outlined areas were quantified from the photographs using Fiji  at a 2:1 (w/w) ratio. This coating was applied in a thin layer over the donor tissue surface and then allowed to dry and set for about 30 to 45 min, followed by MSTC harvest as described above. About 0.8 g of MSTCs, which corresponded to roughly 80% the weight of the excised tissue (and the maximum packing density of reassembled MSTCs based on preliminary studies), were placed into individual petri dishes filled with either a biomaterial solution  or sterile saline . For the embedding assembly option, candidate biomaterials were chosen on the basis of physical characteristics , compatibility with cell growth, existence of FDA-approved versions of the material, and previous utility for engineering skin tissue. Biomaterials tested included neutralized bovine type I collagen , fibrin surgical adhesive , thermoreversible hydrogel , and a 1:1 mix of collagen and fibrin [similar to mixtures of collagen and fibrin that have been previously used for skin tissue engineering (2 irradiation from a KTP (potassium titanyl phosphate) solid-state laser, OcuLight OR, IRIDEX). These cross-linking options were selected on the basis of prior utilization in regenerative medicine   oxide Feineering . At thisFor the topical binding option, the densely packed, oriented MSTC constructs were dabbed lightly on sterile gauze and then left to dry further for at least 30 min to increase adhesion between individual MSTCs. The constructs were then gently lifted from the magnets with nonmagnetic forceps or surgical rulers and implanted into the recipient excision wounds. The surface of the construct was further protected by applying either a polyurethane film dressing  or a thin layer of cyanoacrylate surgical adhesive .To verify the robustness of the various MagneTEskin constructs against mechanical perturbations, the constructs were placed into excision wounds in ex vivo porcine skin tissue and subjected to manual manipulation and pressure to simulate the mechanical forces that the constructs would be subjected to during standard handling and grafting procedures. Only constructs that were able to retain the MSTC constructs’ alignment and overall structure were selected for in vivo evaluation.Tissue samples were fixed in 10% formalin for about 48 hours and embedded in paraffin. Sections (5 μm) were stained with hematoxylin and eosin for general histology and Gomori’s trichrome for collagen. Stained slides were scanned and saved in digital format using the NanoZoomer . To evaluate the alignment of MSTCs, histologic images of the MagneTEskin constructs were loaded into Fiji (t test (for two groups). P values ≤ 0.05 were considered statistically significant. Results are plotted as means ± SE.For statistical analysis, each wound site was considered an independent sample. Wound contraction data were analyzed using GraphPad Prism version 9.0.1 for macOS . Comparisons were made using the two-tailed Student’s