The cause of schizophrenia is still unknown, the course of the disease is long and its onset is thought to be related to neurodevelopmental, genetic, and oxidative stress factors and so on. There is no means of cure. Typical drug therapy is effective in treating the acute stage of schizophrenia, while the impaired social and life functions of patients are often neglected. Baduanjin is a traditional Chinese physical and breathing exercise that not only strengthens the muscles, and moves the joints, but also exercises the will. Many studies have been reported in the study on the application of Baduanjin to schizophrenic patients to promote recovery, but no research systematically evaluates the therapeutic effects and safety of Baduanjin for schizophrenic patients. This study aims to systematically investigate the efficacy and safety of Baduanjin in the treatment of schizophrenic patients.Reports of randomized controlled trials (RCTs) on Baduanjin for schizophrenia will be searched in the following data sources, including 3 English databases（PubMed, EMBASE, Cochrane Library）and 4 Chinese databases（China National Knowledge Infrastructure, Chinese Biomedical Literature, Wanfang, and China Clinical Trials Registry Database）, and their publication time is restricted from the establishment of the database to October 1, 2022. Two reviewers will independently perform study selection, data extraction, and quality assessment. RevMan V.5.4 software will be used for meta-analysis. The protocol will be performed according to preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) guidelines.The results will provide a systematic overview of the current evidence on the use of Baduanjin to treat schizophrenia.The conclusions of this study will help clarify whether Baduanjin is effective and safe for treating schizophrenia. It often strikes in youth or adulthood and has a long course.,3 It ranks 16th in disability-adjusted life years (DALYs) and has become a major public health problem. The burden of schizophrenia is increasing with population growth and aging. Its treatment consists mainly of pharmacotherapy and psychotherapy.,7 Notably, patients with schizophrenia tend to overlook deficits in somatic functioning, such as poorer than normal static and dynamic balance. Exercise, as a non-pharmacological intervention, can improve social and cognitive functioning by improving lifestyles, and may reduce their risk of cardiovascular diabetes, obesity, and other diseases.–13 Baduanjin exercises not only improve motor coordination but also promote interpersonal interactions and improve functional impairment. However, there are no convincing systematic reviews and meta-analyses to evaluate the effects of Baduanjin on schizophrenia, hence we designed this study to better understand the efficacy and safety of Baduanjin in the treatment of schizophrenia and to provide a more reliable evidence-based basis for its treatment of schizophrenia.Schizophrenia is a serious mental illness with an unknown etiology that requires long-term treatment and is characterized by a high relapse rate and high disability rate. According to the Global Burden of Disease Study, the global prevalence of schizophrenia ranges from 0.33% to 0.75%.This study has been registered on PROSPERO（CRD42022369712）. We will adhere to the recommendations outlined in Preferred Reporting Items For Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement.RCTs of Baduanjin for schizophrenia will be included.,17 No restriction on their age, race, and country.The subjects must meet the diagnosis criteria for schizophrenia including the American Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or the Chinese Classification and Diagnostic Criteria for Mental Disorders or other criteria.The experimental group will include patients treated with Baduanjin, including different genres of Baduanjin. The control group will include patients who receive Western medicine or Chinese herbal medicine, with the exception of Baduanjin.,18,19 The additional outcomes include changes in individual satisfaction and quality of life, as well as adverse events.The main outcomes include changes in patient mental status, psychological status, and behavior scores, and specific aspects such as socialization.From the establishment of the databases to October 1, 2022, we will search RCTs of Baduanjin for the treatment of schizophrenia, and data sources include 3 English databases（PubMed, EMBASE, Cochrane Library）and 4 Chinese databases（China National Knowledge Infrastructure, Chinese Biomedical Literature, Wanfang, and China Clinical Trials Registry Database）. In addition, a manual search of the reference lists of relevant research articles will be conducted. The search strategy for PubMed is shown in Table Two investigators will review the completed articles that meet the inclusion and exclusion criteria, perform a secondary screening of abstracts and conclusions, and ultimately screen all eligible articles by reading the full text. If there is any disagreement in this process, a third study team member will be asked to assist in determining this. The entire study selection process is summarized in the flowchart in Figure Two researchers will independently extract data from the included studies, which will include information about the studies . If there is any disagreement between the 2 reviewers during the screening process, they will consult a third reviewer to make a final decision. The risk of bias for each item will be assessed and the results will be classified as low risk, unclear risk, and high risk.The methodological quality of the investigation will be assessed on the basis of 7 items by applying the Cochrane systematic evaluation tool.Continuous outcome data will be presented as mean differences with 95% confidence intervals.If possible, we will try to contact the corresponding author for complete research or relevant data. If the author cannot be contacted, the available data will be analyzed, and the study will be excluded from the analysis.We will use RevMan V.5.4 for meta-analysis. Continuous outcome data will be presented as mean differences with 95% confidence intervals. We will determine whether to use a fixed-effects or random-effects model based on the results of the heterogeneity of research statistics, and we will use descriptive analysis when quantitative analysis is not appropriate.If there exists significant heterogeneity, we will analyze the age, gender, duration of illness, and the types of Baduanjin used by the schizophrenic patients participating in the study.We will perform sensitivity analysis to improve the stability of the results.We will use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to classify the quality of evidence into 4 levels: very low, low, medium, or high. Negative symptoms and cognitive dysfunction in patients with schizophrenia are strongly associated with their quality of life, social functioning, and poor prognosis. Exercise therapy has been shown to improve patients’ positive and negative symptoms, quality of life, cognition, and hippocampal plasticity, and has been proposed as a primary non-pharmacological treatment modality that can improve patients’ quality of life and ability to return to society and family.–28 Baduanjin is one of the traditional Chinese guided exercises dating back to the 12th century, and has been shown to improve balance in stroke, Parkinson disease, and frail elderly.,30 Compared to ordinary aerobic exercises, Baduanjin is slower, gentler, more consistent, more varied, and more focused on mind-body integration exercises. It is mainly characterized by regular breathing rhythms and slow technical movements and can be used as an exercise therapy for mental conditioning. It does not require expensive fees and can be performed at any suitable place during leisure time. From the existing studies, we are unable to make evidence-based extrapolations for the treatment of schizophrenia with Baduanjin, and this is the first meta-analysis to apply Baduanjin exercise in the treatment of schizophrenia, with the aim of clarifying the efficacy and safety of Baduanjin in the treatment of schizophrenia, and the results of this study may provide a scientific basis for the clinical treatment of the disease.First-generation and second-generation anti-schizophrenic drugs mainly target biochemical changes in the brain of schizophrenic patients, but are ineffective in alleviating negative symptoms such as cognitive and hippocampal deficits primarily target biochemical alterations in the patient’s brain.Conceptualization: Haiyuan Wu, Yonghou Zhao.Data curation: Kaiyuan Xue, Aineng Peng.Formal analysis: Kaiyuan Xue, Haiyuan Wu.Methodology: Jianbo Chai.Project administration: Yonghou Zhao.Writing—original draft: Haiyuan Wu.Writing—review & editing: Kaiyuan Xue.


To the EditorHuman T‐lymphotropic virus (HTLV‐I), identified as the first human retrovirus in 1980, can cause fatal diseases which are HTLV‐I‐associated myelopathy/ tropical spastic paraparesis (HAM/TSP) and adult T‐cell leukemia‐lymphoma (ATL).Since 1972, we performed 46 KT for 41 candidates with HTLV‐1. Long‐term outcome is shown in Table Although HTLV‐1–negative recipients who received KT from HTLV‐1–positive living donors have not been accepted in our institution, KT for candidates with infected HTLV‐1 from HTLV‐1–positive living donors has not being contraindicated in Japan.HTLV‐I displays little genomic variability in the same geographic endemic area, such as southwestern part of Japan. Therefore, there is little possibility of superinfection.None of candidates with HTLV‐1 from HTLV‐1–positive living donors have experienced HAM‐TSP or ATL during the follow‐ups.This data is small and from single center; however, the long‐term outcome is sufficient to be accepted. KT may be the optimal renal replacement therapy even for HTLV‐1 infected candidates.NG wrote the manuscript. NG, KU, TT, KF, MO, TH, SN, and YW collected the samples and data. NG contributed study design and analysis. All authors participated in revising it critically for important intellectual content and approved the final version for publication.


Functional neurological disorders (FND) are disabling medical conditions commonly seen in neurological practice. Neurologists play an essential role in managing FND, from establishing a diagnosis to coordination of multidisciplinary team-based treatment for patients. With this study, we investigated the knowledge and the clinical experience of Italian neurologists in managing patients with FND.Members of the Italian Society of Neurology were invited via e-mail to participate in this ad hoc online survey; 492 questionnaires were returned completed.The term “Functional neurological disorders” in reference to FND was used more frequently than other psychological , or descriptive terms . When speaking with patients, the respondents stated that they preferred explaining symptoms based on abnormal functioning of the nervous system than discussing mental illness and that they would refer their patient to a psychologist rather than to a psychiatrist. Few considered that physiotherapy and psychiatric interventions are useful approaches to treating FND. Some believed that patients simulate their symptoms.Overall, the responses suggest that knowledge about scientific advances in FND is somewhat sparse. A psychiatric-centered view of FND opens the way to an approach in which neurobiological and psychological aspects constitute essential factors of the condition. In this context, professional education could improve understanding of FND and optimize patient management.The online version contains supplementary material available at 10.1007/s00415-021-10840-y. Functional neurological disorders (FND) are disabling neurological conditions characterized by clinical signs that are incongruent with known neurological disease –3. The eThe neurologist plays a substantial role in diagnosis and in explaining the mechanisms of symptoms to the patient, suggesting appropriate treatment and follow-up, and coordinating a multidisciplinary approach . Common To the best of our knowledge, no study to date has surveyed Italian neurologists about their experience with FND. To fill this gap, we conducted an online survey of Italian neurologists. We invited neurologists in different specialties ; this enabled us to investigate the opinions and the clinical experiences of a large cohort of neurologists who encounter a variety of FND phenotypes. The study is part of a larger project involving health professionals who encounter patients with FND in their clinical practice . In our previous study, we surveyed general practitioners about diagnosis, treatment, and management of FND patients . The surThe questionnaire was based on the one used in our previous study that investigated the knowledge, opinions, and clinical experience of general practitioners in Italy . SeveralFive questions concerned demographics  and professional characteristics .The other nine questions investigated opinion, knowledge and clinical experience with FND. Specifically, the first question investigated experience with FND . The second was a multiple-choice question about the terms they used to name FND. The third question focused on malingering and asked respondents to estimate on a scale from “not at all” to “very high” the probability that a patient deliberately feigned symptoms. The fourth was a single-choice question investigating how the respondent explained the disorder to patients. The fifth question regarded predictors of diagnosis. Respondents rated as “not at all”, “only a little”, “to some extent”, “a lot”, “very much” or “I don’t know” the extent to which they felt that each of eight items were predictive for a diagnosis of FND . The sixth question explored opinions about the appropriateness of specialist consultation and treatment and asked respondents to rate the degree of adequacy  of four items related to specialist consultations and five items describing different types of treatment for FND. The seventh question investigated the management strategies the respondents used to deal with their patients. The respondents stated the extent to which they agree  with six items describing interventions in FND. The eighth question concerned their personal satisfaction with managing FND rated on a 11-point scale from 0 (no satisfaction) to 10 (high satisfaction). The ninth was a multiple-choice question on the neurologist’s role in FND diagnosis and treatment. All the survey questions are reported in the Supplementary Information.Data were collected on an online platform (sin.neuro) for 8 weeks (4 June 2020–29 July 2020). Neurologists among the 2974 SIN members were invited to participate in the survey via an e-mail from the SIN. The e-mail explained that the aim of study was to investigate opinions, knowledge, and clinical experience with non-organic neurological disorders. The term non-organic was used to avoid connotations with presumed “functional” or “psychological” mechanisms underlying the disease. An example of what we meant by a non-organic disorder  was also given to exclude potential bias due to misleading terminology. A survey link embedded in the e-mail and allowed direct access to the questionnaire. The first page of the questionnaire was a consent form, together with information about personal data handling (anonymity), and the time needed to complete the survey about 5 min. Respondents had to give their informed consent before they could start completing the questionnaire. Four e-mail reminders were sent by the SIN at 1, 2, 4, 6, and 7 weeks after the initial mailing. Response to all survey items was mandatory. If an item was skipped, a message appeared on the screen alerting the responder to respond to the item to proceed to the next one. The study received ethical approval from the University of Verona and was conducted in accordance with the Declaration of Helsinki. The study findings are reported in accordance with the checklist for reporting results of Internet e-survey guidelines  and to sp < 0.05. Bonferroni correction was applied where necessary. Analysis was performed using SPSS software (version 19).Demographic characteristics and survey responses were examined with descriptive statistics, including frequencies and percentages. Frequencies and percentages of each response to predictors of the diagnosis, specialist consultations, treatment, management strategies, and satisfaction were analyzed according to years of post-specialization by means of the chi-squared test. Additional exploratory analyses have been conducted to compare the responses across the items of every single question (Supplementary Information). Statistical significance was set at n = 470, 96%), while the remaining twenty-two were doctors in training (4%). Specialists and their subspecialty were: movement disorders , cerebrovascular disease , epilepsy , other  , with a fairly balanced male-to-female ratio. The majority were consultant neurologists  thought that less than 10% of their patients presented symptoms without an organic cause. Many  reported a higher proportion of FND (10–25%); a few  stated that 25–50% of their patients might have a FND; very few  reported that more than half of their patients were likely to have a FND or were unable to estimate how many of their patients might have a FND .Half of the sample (n = 21). The majority of respondents  chose more than one term. Overall, “Functional neurological disorders”  and “Somatization disorder”  were the two most frequent, followed by “Non-organic disorder” . The term “Functional neurological disorders” was selected 136 times on its own and 238 times together with psychology-related terms such as “Somatization disorder” (n = 117), “Psychogenic disorder” (n = 87), “Stress related disorder” (n = 21), “Conversion disorder” (n = 80), “Unspecific anxious syndrome” (n = 20), and “Depression” (n = 15). In addition, it was often selected with terms related to an undefined etiology .A total of 1057 responses were collected, including free-text responses (n = 3), symptom description (n = 1), tremor under neurological assessment (n = 1), post-traumatic stress disorder (n = 1), neurological disease with negative neurological investigations (n = 1), gait disorders with negative neurological investigations (n = 1), type of disorder with negative neurological investigations (n = 1), functional neurological disorder in case of positive signs (n = 1), unspecific paresthesia (n = 1), supracortical disease (n = 1), dysfunctional disorder (n = 1), disease with unknown pathogenesis (n = 1), disease without an evident organic cause (n = 1).A field for free-text responses was included to capture any other terms; for example: psychogenic non epileptic seizures  or moderately probable . Very few thought that simulation was highly probable . At the two ends of the spectrum, no respondent stated that simulation was very highly probable and very few thought it highly unlikely that all patients feigned symptoms .Many respondents believed that simulation was little . Many chose “Psychogenic disorder”  and few chose “Absent neurological disorder”  or “Stress” .When asked about their preferred way to explain symptoms to their patients, the majority chose “Disorder due to abnormal functioning of the nervous system” , “Inconsistency” , followed by “Normal or inconclusive neurological examination findings” , “Greater loss of function or disability than found on physical examination” , “Previous mental illness or psychological stress” , and “Litigation” . “Other medically unexplained symptoms”  and “Spontaneous remissions”  were mostly rated as “only a little” or “to some extent” predictive” , with a higher proportion of neurologists with less than 10 years of practice . “Neurological consultation” was frequently rated as “a lot” or “very much” adequate for FND . “Psychiatric consultation”  and “Physiotherapy consultation”  were predominantly rated as “only a little” or “to some extent” adequate for FND , meaning that the neurologists with more than 25 years of practice were more likely to believe “Physiotherapy consultation” as “only a little” or “to some extent” adequate for FND.“Psychotherapy consultation” was rated as “a lot” or “very much” adequate for FND by the majority of respondents n = 79, 57%, n = 255, 52%) and “Psychotherapy with antidepressant or anxiolytic medications”  were the most frequently rated as “a lot” or “very much” adequate, while “Pharmacological treatment” , “Psychotherapy without antidepressant or anxiolytic medications”  and “Rehabilitation ”  were mostly rated as “only a little” or “to some extent” adequate . More precisely, 39% (n = 99/255) of participants who rated “Educational interventions” as “a lot” or “very much” adequate had less than 10 years of post-specialization. Years of post-specialization also influenced responses to “Psychotherapy without antidepressant or anxiolytic medications” , and “Rehabilitation ” . Longer years of post-specialization were associated with a higher proportion of “only a little” or “to some extent” responses to “Psychotherapy without antidepressant or anxiolytic medications”  and to “Rehabilitation  ”.When asked to indicate the suitability of treatments for FND, “Educational interventions” n = 55, 52% an = 364, 74%), “Refer patients to a psychologist or psychotherapist”  or prefer to “Wait to see how symptoms develop” . The management strategies more frequently excluded from clinical practice were “Referral to a psychiatrist” , “Pharmacological prescription” , and “Referral to a physiotherapist”   , “Wait to see how symptoms develop” , “Pharmacological prescription” , and “Referral to a physiotherapist”  were associated with years of post-specialization. The majority of respondents who usually refer patients to a psychologist or psychotherapist  or prefer to wait to see how symptoms develop  were neurologists with 10–25 years of post-specialization. Among those who mostly excluded “Pharmacological prescription” from their practice were respondents with less than 10 years of post-specialization . Finally, respondents who mostly excluded “Referral to a physiotherapist” were neurologists with more than 25 years of post-specialization .“Referral to a psychologist or psychotherapist”  rated their level of satisfaction between 5 and 10. Among these, the majority were neurologists with more than 25 years of post-specialization  .When asked to rate their satisfaction in managing FND on an 11-point scale from 0  to 10 (extremely satisfied), on average, respondents stated that they were satisfied with their care of patients with FND (4.90 ± 2.47). The majority  gave more than one response, with “Following-up the treatment together with other specialists ” the most frequent , followed by “Make a diagnosis and recommend adequate treatment” . Many chose “Referral to a specialist for the patient’s medical condition”  and “Make a diagnosis and personally follow-up the patient” ”, while very few believed their role was to provide “Educational intervention for patients and their families” .When asked about their clinical role in the management of FNDThis web survey investigated opinions, knowledge and clinical experience with FND in a sample of Italian neurologists. The main findings suggest that a multidisciplinary approach to FND is emerging, although a full understanding of the disease in light of current advances still needs to be achieved.Several studies from across the world investigated health professionals’ view on FND, many of them share similar results with our study , 24–26. When asked about the probability that their patients simulate FND symptoms, few respondents stated that their patients do not feign symptoms, while many believed that patients produce symptoms deliberately. One possible explanation for respondents harboring suspicion about whether symptoms are feigned or not might be a lack of knowledge about FND pathophysiology. Recent behavioral and neuroimaging findings have provided evidence for an abnormal sense of agency in patients with FND , 35. ThiOur survey findings cast light on how Italian neurologists view the psychiatric and psychological aspects of FND, especially with regard to specialist consultation, treatment efficacy, and management strategies. For most of the past century, the psychiatric model predominated over a more comprehensive view of the disorder, involving neurobiological, psychological, and social factors . The mecNeurologists need to understand the evidence on emerging therapeutic options for this complex disorder . A multiAnother observation is that in their first intervention the respondents would order diagnostic or imaging studies to exclude neurological damage. This is in line with previous studies, in which neurological investigations  were frequently requested for a diagnosis of FND –26. SuchAs reported in a more recent study involving neurologists with expertise in movement disorders , when asResponses regarding patient education merit special comment. In line with a recent study , educatiThis study has several limitations. The survey response rate may not be fully representative of the entire neurologist community in Italy. It is also possible that only specialists interested in FND responded to the survey, thus limiting the generalizability of our findings. These limitations notwithstanding, with this exploratory study we provide novel insights into current opinions, knowledge, and clinical experience of a large cohort of Italian neurologists, working in different specialties. Investigating the actual view of neurologists on these disorders in a homogeneous geographical area, such as Italy, enabled us to catch local educational needs and develop an ad hoc educational program to improve care for these patients. The findings of the present study add knowledge about current practices in the management of FND in Italy. There is a need for guidance on the mechanisms underlying FND  and evidence-based treatment . This should be provided to ensure that patients receive an appropriate explanation of their symptoms and management. The study enriches our knowledge of the current views of Italian health professionals about FND. The results of the present and the previous study  suggest Supplementary file1 (DOCX 36 KB)Below is the link to the electronic supplementary material.


The high demand for fresh-like characteristics of vegetables and fruits (V&F) boosts the industrial implementation of high hydrostatic pressure (HHP), due to its capability to simultaneously maintain original organoleptic characteristics and to achieve preservative effect of the food. However, there remains great challenges for assuring complete microbial inactivation only relying on individual HHP treatments, including pressure-resistant strains and regrowth of injured microbes during the storage process. Traditional HHP-assisted thermal processing may compromise the nutrition and functionalities due to accelerated chemical kinetics under high pressure conditions. This work summarizes the recent advances in HHP-based combination strategies for microbial safety, as exemplified by several emerging non-thermally combined patterns with high inactivation efficiencies. Considerations and requirements about future process design and development of HHP-based combination technologies are also given. According to both epidemiological and clinical results, it has been consistently demonstrated to show a potential causal connection between the consumption of plant-based foods and the reduction of chronic non-communicable diseases, largely attributing to the presence of substantial phytochemicals in plants –3. CompaUltra-high pressure generally employs water as the pressure-transmitting medium, so it is also called high hydrostatic pressure (HHP), which has shown a wide applicability in the fields of biomedicine , biotechnology , and food processing –11. PartCorrespondingly, this work gives an overview of the major challenges of single high-pressure treatments for completely ensuring food safety and extending the shelf life of the products at the processing conditions which can simultaneously maintain sensorial perception of freshness. After as well as the combination of technologies recently proposed to efficiently improve the applications of HHP.Enterobacteriaceae was lower than in untreated samples and reduced during storage, while the relative abundance of Flavobacteriaceae family (phylum Bacteroidetes) was higher in HHP treated samples than in control samples. Substantial evidence has demonstrated that the effect of HHP on microbial diversity is dependent on food matrix types and processing conditions, thus making it hard to assure microbial safety just relying on single HHP treatments.The application of HHP treatments at room temperature destroys the vegetative cells of microorganisms that spoil food products, with minimal changes in most of the nutritional and sensorial food properties. However, this technology shows its limitation in inactivating microbes, particularly Gram-positive microorganisms and spores . The barBacillus strains of fermented red pepper with a 99.7% reduction, showing effective microbial inactivation  achieved complete inactivation of the natural microflora of the product. The cavitation provoked during ultrasound process caused damage to the microorganisms by increasing the temperature and the pressure locally and then, creating shock waves and hydroxyl radicals, which could be the reason of the increase in the lethal effect. The synergic effect avoids the use of higher levels of HHP to achieve the same effect on the microflora  and germinate during the shelf-life of the product if the temperature is around 40°C. A pre-treatment at 600 MPa for 15 min followed by thermosonication  achieved 4.4 log reduction of Alicyclobacillus acidoterrestris in orange juice. The effect of thermosonication was enhanced by the germination of the spores induced by the HHP (Ultrasonication (US) technology finds increasing applications in the food industry, involving the aspects of food safety and quality enhancement, particularly expecting the reduction of microbial load simultaneously producing limited detrimental effects on the food quality , 29. Subcroflora . In frui the HHP .2)-UV photocatalysis induces the generation of reactive oxygen species (ROS) able to inactivate enzymes and cause oxidative stress in the cellular components of the bacteria. Although TiO2 photocatalysis has been developed for a few decades as an antibacterial technology showing large potential for assuring food safety, its extensive applications in the food industries are restricted due to the limited ability of the wide band-gap of TiO2 to absorb visible light    . SimilarPa/90 s) . EvidencPa/90 s) . It can E. coli O157:H7 and L. monocytogenes in orange and apple juice , ozone, essential oils (EOs), organic acids, and ethanol , 39. Thele juice . The comle juice . The synle juice , 44. The coating .Escherichia coli inactivation (Electrolyzed water (EW) is used as a rinsing agent for fresh-cut V&F products, often combined with other technologies for hurdle enhancement of antimicrobial efficacy, such as modified atmosphere packaging (MAP), US and HHP , 46. EW tivation .On the other hand, in some cases pressure-assisted thermal processing (PATP) is not robust enough to inactivate bacterial endospores so that intensive conditions are still required, e.g., for resistant clostridial endospores where high pressure with up to 120°C was applied to obtain a significant reduction . Thus, aL. innocua population  processing, has been successfully used for improving food safety . This coeatments , 53, att2) is an antimicrobial substance, it is mentioned herein as a separate section because this gas can act as the medium for maintaining the pressure when applied at high pressure conditions, with unique processing features and differential impact on quality properties. CO2 demonstrates bacteriostatic and/or fungistatic activities which can be absorbed into food matrix resulting in the acidification and a fluctuation in pH values. CO2-assisted HHP treatments, such as high CO2 MAP in combination with HHP, sub- or supercritical CO2 under pressure conditions , as well as carbonation followed by HHP, have been proposed in recent years for liquid samples . Compared with single HHP, CO2-assisted HHP treatments have demonstrated their capacity to achieve significantly higher microbial inactivation, related to the explosion, penetration, and acidification effects of carbon dioxide. For example, HPP (400–600 MPa/2 min) in combination with MAP combined was reported to achieve the sublethal injury of over 99.9% of surviving Listeria innocua  The overall working mechanisms explaining the enhanced microbial inactivation efficiencies of HHP-based combination technologies are related to the synergistic or additive effects of different inactivation factors . However, the synergies between different technologies in combined treatments remains to be carefully proved. In the cases examining the efficiencies in inhibiting microbial population of HHP-based combined treatments, some experimental designs are not robust to demonstrate the reasonability and necessity of the combination, since combined treatments are only compared with the individual treatments and related analysis of interaction/additive effects are absent or fails to provide satisfied reliability. Synergistic effects and additive effects should be differentiated in terms of inactivation mechanisms and reliable statistical analysis. Therefore, the specific mechanisms for enhanced microbial inactivation should be further explored, in order to justify the need of the combined strategies.(ii) Combined treatment conditions should be optimized because, at current stage, most researches employ several process parameters to confirm the enhanced microbial inactivation compared with the individual processing approaches.(iii) The commercialization of the combined technologies may be one of the major limiting factors for employing at industrial applications. The combination or coupling of two processes not only considers the technical feasibility, but also the cost.(iv) The variability in endogenous microbial flora could be an important factor resulting in differences between kinetic modeling and experimental results. Most of the works reviewed tend to study specific microorganisms in model systems or food matrix, but, in practical, food samples present a lot of microorganisms and the role of microbial interaction could influence the efficiency on the microbial inactivation of proposed novel pasteurization technologies.(v) Cost analysis and environmental impact; it is noted for combination processes there are two patterns including “simultaneous processes” and “sequential processes.” For example, PEF treatments under high pressure conditions are referred as simultaneous processes; while PEF treatments followed by HHP treatments are referred as successive processes. Generally, additive effects are found in successively applied combination processing modes while synergistic effects in simultaneous modes. However, current research lacks information regarding cost  and environmental impact for both two types of combination processing modes, which should be carefully considered in the future research and industrial application.QX: conceptualization, writing – original draft, writing, review, and editing. GD: writing – original draft, writing, review, and editing. CY: writing, review, and editing. QL, HY, and XC: conceptualization, writing, review, and editing. FB: writing, review, and editing. All authors contributed to the article and approved the submitted version.HY and QX were employed by Bright Dairy & Food Co., Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Environmental contamination contributes to hospital associated infections, particularly those caused by multi-drug resistant organisms (MDRO). This study investigated bioburden presence on surfaces in a critical care center’s patient rooms following typical environmental services (EVS) practices and following intervention with hybrid hydrogen peroxide™ (HHP™) fogging.Geobacillus stearothermophilus biological indicators for sporicidal validation monitoring. Following fogging, rooms were sampled again, and results were compared.Upon patient discharge, following standard cleaning or cleaning with ultraviolet (UV) light use, patient rooms were sampled by swabbing for adenosine triphosphate (ATP) and aerobic colony counts (ACC) from five preset locations. Rooms were then fogged via HHP technology using chemical indicators and Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa were identified following EVS practices and not detected following HHP fogging. ATP samples were reduced 88% by fogging application. Chemical and biological indicators confirmed correct application of HHP fogging, as seen through its achievement of a 6-log reduction of bacterial spores.A 98% reduction in ACC was observed after fogging as compared to post EVS practices both with and without UV light use. No statistical difference was seen when comparing cleaning to cleaning with UV light use. Methicillin-resistant HHP fogging is a thorough and efficacious technology which, when applied to critical care patient rooms, significantly reduces bioburden on surfaces, indicating potential benefits for implementation as part of infection prevention measures. Pseudomonas aeruginosa alone [Clostridioides difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii, and P. aeruginosa can survive on dry surfaces for extended time periods and are difficult to eradicate even with terminal cleaning protocols [Despite ongoing efforts to advance strategies for infection control, the challenge of preventing hospital associated infections (HAIs), particularly those caused by multi-drug resistant organisms (MDROs), persists in healthcare today. In a prevalence study conducted at 1,150 centers across 88 countries the overall rate of suspected or confirmed infection of intensive care unit (ICU) patients was 54%, higher than rates seen in previous years [sa alone . Patientsa alone . Once shThe link between environmental contamination, or bioburden, and acquired infection rates has been well studied –7. ResidS. aureus and C. difficile. [2O2) technologies have significantly higher disinfection potential [C. difficile, norovirus, S. aureus, and others, including in the presence of biofilms and soil loads [Considering the necessity for reducing or eliminating the presence of pathogens in the patient’s environment, a novel disinfection technology, hybrid hydrogen peroxide™ (HHP™) fogging was introduced to examine its potential effects on bioburden relative to current facility practices. The HHP system delivers a hybrid mixture of vaporous and micro-aerosolized hydrogen peroxide fog via pulse technology. This novel fogging delivery accounts for naturally decomposing hydrogen peroxide by periodically replenishing the HHP fog during the disinfection cycle. This patented delivery system automatically induces the fogging dwell time, the time needed for the hydrogen peroxide fog to achieve maximum efficacy. The HHP system has demonstrated efficacy against potential HAI pathogens such as fficile. –15 Whileotential –19 combail loads , 15, 20.Geobacillus stearothermophilus (1 × 106 and 2.2 × 106 organisms) which can be disinfected alongside room surfaces giving a visible confirmation of sporicidal efficacy and providing confidence in the inactivation of lesser-resistant pathogens as well [This study was undertaken in the northeast United States at a regional hospital. With over 250 annual admissions and a 6-day average length of stay, this facility’s verified adult and pediatric burn center presented a unique opportunity due to the inherent vulnerability to infection of patients recovering from burn injuries . Indicat as well , 23.Certified staff from a third-party disinfection service  conducted environmental sampling and HHP fogging implementation. Data was collected from within single occupancy patient rooms following occupancy of greater than 10 days. EVS staff performed either SC, or, for rooms where the patient had a positive MDRO culture, SC + UV  in 2–3 locations for 3–5 min per location in accordance with manufacturer guidance . Disinfe2. For each swab, 25 swabbing movements were applied horizontally, vertically, and diagonally. Collected swabs were closed, sealed with paraffin tape, and maintained at 35–46°F (2–8 °C). ATP swabs  were collected from an approximate 4 inch × 4 inch square (10 × 10 cm2) area of countertop adjacent to the room sink. This location was also chosen as a potential contact point, furthering the distribution of swabbed surfaces within the patient room  were collected from 5 preset surfaces within the patient room: telephone, bed rail, touch screen monitor, toilet seat, and bathroom sink backsplash. Locations were selected spanning the room and adjoining bathroom in potential contact points for patients, staff, or visitors. Swabbed locations and room configuration are shown in Fig. 2O2 chemical indicators (CIs)  were placed throughout the room to monitor the dispersion of HHP fog. G. stearothermophilus BIs  and  on steel carriers were employed as a measurement for determining adherence to the fogging protocol, failure constituting the exclusion criteria for this study. Indicators were placed throughout the room in three locations selected to challenge the HHP fog dispersion: forward of the fogging device (room sink), above and behind (patient shelf), indirect in the adjacent room (bathroom)  paired with the CURIS portable fogging device  which together produce HHP fog. The HHP device was placed in the room along with dissipation devices . Dissipation devices are automatically initiated by the HHP device after the HHP cycle is complete to enhance the decomposition of any remaining HHP fog, increasing the speed at which the room is returned to initial environmental conditions. Environmental conditions were monitored to confirm the operating range ≤ 70°F (21 °C) and 25–55%Rh . Heating ventilation and air conditioning (HVAC) airflow was turned off, vent covers employed, doors were closed and visible gaps taped to stop air flow. Prior to the start of the study period, room dimensions for the burn center were measured from facility diagrams and dimensions were recorded in the HHP device’s data management software by the technician or authorized personnel. HHP cycle parameters were determined by room volume accounting for the drop ceiling, as calculated by the device’s software. The fogging cycle was initiated remotely from outside the room via an electronic tablet through the CURIS Decon application (app). HHP device cycle time for the rooms of this burn center averaged 42 min. Following cycle completion, the dissipation devices were initiated by the HHP device. H2O2 levels were monitored with a portable hand-held device  prior to safe re-entry.The HHP disinfection system consists of a 7% HP. aeruginosa.Following dissipation, swabbing samples were collected in the same manner in immediately adjacent locations to the initial swabs. Swabs were vortexed, eluted onto tryptic soy agar plates in triplicate, incubated at 36 °C (96.8°F) for 48 h and ACC results recorded. Swabs were additionally plated on organism-specific chromogenic media  for identification of MRSA and CIs were collected, analyzed, and recorded. BIs were transferred into tryptic soy broth , incubated for 7 days at 60 °C (140°F), observed for turbidity or color change indicating growth, and results recorded. Positive BI controls accompanied each BI lot to verify viability. Challenged (exposed to HHP fog) BIs were used as a benchmark for proper sporicidal protocol and process.Data generated from the HHP device including room parameters, HHP dosage, and cycle duration, uploaded automatically to the online data management system, and service reports were generated from that system. Information on patient length of stay and presence of MDRO (if known) was recorded. ATP results were compared post EVS practices (SC and SC + UV) and post HHP fogging. A two-sample t-test was performed to compare the non-normally distributed ATP RLU values. ACC swab results were analyzed using GraphPad Prism version 9.1.0 for Windows . The Mann–Whitney test was used to analyze post EVS and post fogging, and the Kruskal Wallis test for significance between SC, SC + UV, and post HHP fog.2 = 0.04, p = 0.49). Average center occupancy was 6.5 patients, with a maximum occupancy of 12.During the study period of December 2020 through May 2021, 17 patient rooms were sampled. Inclusion criteria for the study was not met on three occasions when HHP fogging protocols were not followed. On these occasions data following EVS practices were unaffected and thus included in the analysis; however, no further comparison to after-HHP fogging could be made. On all other swabbing occasions, results including swabs with a non-detection were included. Patient room occupancy prior to discharge averaged 23.6 days with no detectable correlation between days occupied and baseline ACC levels  . However, there was no statistical difference between standard cleaning (SC) and UV light use (SC + UV) (p = 0.186).A total of 150 ACC swabs were collected . Following EVS practices (SC and SC + UV), 5 swabbed surfaces ranged from 0 to 153 ACC . 63.4% of samples detected bacterial presence, with 85% of these demonstrating a result greater than or equal to 1 ACC. Following HHP fogging, ACC ranged from 0 to 1.33 ACC  for a further reduction of 98% compared to post EVS practices . This small sample size did not allow for a full statistical analysis, however the swabbing occasion with the maximum value of 12.67 colonies was reduced 100% following fogging. P. aeruginosa represented 2.44% of the overall collected samples.MRSA was detected on five sampling occasions, following both SC and SC + UV . Four of the five occasions with MRSA results met the inclusion criteria and demonstrated a 100% reduction of MRSA (Table p = 0.013).Following EVS practices (SC and SC + UV), mean ATP results were 9,021  relative light units (RLU). Following HHP fogging, ATP averaged 1,109 RLU (SD = 855) for an overall average reduction of 88%. A two-sampled t-test revealed a statistically significant difference in mean RLU after EVS practices and RLU following HHP fogging  is promising.These results were evaluated to compare the effects of HHP fogging to current facility practices, demonstrating HHP significantly reduced environmental contamination. Following HHP fogging, ACC in patient rooms dropped 98% from levels post SC and SC + UV, consistently averaging less than one colony count. All locations where MRSA was identified post EVS practices were negative for MRSA following HHP fogging. These results in combination with laboratory testing , 13 showP. aeruginosa on two occasions, irrespective of UV light application, affirming the known difficulties in eliminating these common pathogens. MDRO’s survivability as well as rapid propagation create particular risk of infection for the subsequent room occupant, emphasizing the importance of achieving their elimination [The ACC data collected following SC and SC + UV reflected a wide variance in bacterial levels, with 63.4% of tested surfaces remaining contaminated. This finding is neither unexpected nor surprising, as it is well understood that manually applied cleaning methods are inherently imperfect despite best application efforts . The furmination .C. difficile spores in a three-part soil load [C. difficile in a healthcare environment. On three occasions, a less than 6-log reduction of one or more indicators coincided with failures in adherence to fogging protocols which require airflow control within the room for the duration of the fogging cycle. Fogging technologies must be contained within the room to achieve optimal contact of the disinfectant. Incomplete vent coverage as well as activation of the facility’s HVAC before HHP cycle completion did not allow for optimal contact. These results demonstrate the transparency of biological efficacy in real time and confirm the applicability of BIs as an effective tool for monitoring the proper use of this technology.Biological indicators introduced into the room to monitor the HHP fogging cycle repeatedly resulted in successful inactivation demonstrating sporicidal efficacy of the disinfection treatment and indicating efficacy against less hardy pathogens , 22, 23.oil load , 15, whiDespite rigid cleaning protocols and heightened awareness of infection risks in a critical care environment, including burn units, ATP levels post EVS practices were consistently found to be high . While AThe reduction in ACC, and ATP RLU’s are strong indications that bioburden present after EVS practices have been inactivated or reduced by HHP fogging to levels associated with a risk reduction for HAIs from environmental surfaces , 31, 33.P. aeruginosa limited the ability to draw statistical inferences despite the data that was obtained. Further study regarding disinfection of these and other epidemiologically important pathogens in the healthcare setting is needed. Although this testing targeted bacterial counts as well as specific pathogens, a further investigation into the impact of HAIs within the tested department is warranted.There are some limitations to this study. Though typical patient volumes were seen, the time period studied overlapped with enhanced cleaning practices in response to the COVID-19 pandemic, limiting the ability to compare these results with those of a similar time period. In consideration of the enhanced demands placed on the environmental services team during the pandemic, the EVS staff was not blinded for the purposes of this study. This awareness may have influenced the individual practices of staff members. This study focused on efficacy of outcome as the most important consideration for disinfection practices. Due to the additional time needed to collect samples and place indicators to determine efficacy, the time needed for each disinfection intervention was not recorded, though may be of interest. The facility’s application of UV light following known MDRO cases enabled comparisons presented here; however, additional head-to-head investigations would be of interest to aid in the understanding that disinfection technologies have wide ranges in achievable efficacy, particularly in real-world applications. Though detected, the small sample size of MRSA and In closing, this study examined patient rooms of a critical care center, finding that HHP fogging following current EVS practices, with or without UV light use, resulted in a significant reduction in bacterial presence on the environmental surfaces. The confirmed sporicidal efficacy may denote significantly lower risk posed by environmental contamination and play an important role in preventing HAIs. This real-world application of HHP fogging demonstrates a thorough and efficacious treatment method for patient spaces, indicating integration of HHP technology in hospitals could further enhance infection prevention.


Regulators of G protein signaling (RGS) act as guanosine triphosphatase activating proteins to accelerate guanosine triphosphate hydrolysis of the G protein α subunit, leading to the termination of the G protein-coupled receptor (GPCR) downstream signaling pathway. RGS16, which is expressed in a number of cells and tissues, belongs to one of the small B/R4 subfamilies of RGS proteins and consists of a conserved RGS structural domain with short, disordered amino- and carboxy-terminal extensions and an α-helix that classically binds and de-activates heterotrimeric G proteins. However, with the deepening of research, it has been revealed that RGS16 protein not only regulates the classical GPCR pathway, but also affects immune, inflammatory, tumor and metabolic processes through other signaling pathways including the mitogen-activated protein kinase, phosphoinositide 3-kinase/protein kinase B, Ras homolog family member A and stromal cell-derived factor 1/C-X-C motif chemokine receptor 4 pathways. Additionally, the RGS16 protein may be involved in the Hepatitis B Virus -induced inflammatory response. Therefore, given the continuous expansion of knowledge regarding its role and mechanism, the structure, characteristics, regulatory mechanisms and known functions of the small RGS proteinRGS16 are reviewed in this paper to prepare for diagnosis, treatment, and prognostic evaluation of different diseases such as inflammation, tumor, and metabolic disorders and to better study its function in other diseases. G protein-coupled receptors (GPCRs) are the largest superfamily of membrane proteins that control most cellular signaling and regulate key biological functions, including immune, inflammatory, oncological, and metabolic processes, by coupling to G proteins to transmit extracellular signals into the cell . In the The regulators of G protein signaling (RGS) proteins, , which were discovered at the end of the 20th century, are a family of molecularly diverse and multifunctional proteins and are capable of binding to G protein-activated α-subunits, activating guanosine triphosphatases (GTPases) and accelerating the hydrolysis of GTP , thereby terminating the G protein signaling pathway . DysreguMembers of the B/R4 subfamily include RGS1-5, 8, 13, 16, 18 and 21, which are the smallest RGS proteins except for RGS3 . RGS16, C. elegans and mammals  was identified in yeast,  mammals , and the mammals . RGS pro mammals   induces activation of macrophages via the TLR-2/nuclear factor-κB (NF-κB) signaling pathway, further aggravating liver fibrosis  and the RGS16 is a crucial modulator of inflammatory responses and can inhibit pro-inflammatory responses . Suurväl+) T cells and B cells of GCs, which can accelerate the intrinsic rate of the Gα GTPase reaction and down-regulate the response of lymphocytes to chemokines, thus delaying the migration of CD4+ T cells and B cells of GCs  open reading frame 3 (ORF3) indicates that it is closely related to human and murine RGS16. Immunofluorescent labeling has confirmed the induced expression of poRGS16 at the protein level and revealed that PCV2 ORF3 protein co-localizes with poRGS16 in LPS-activated porcine peripheral blood mononuclear cells . AdditioAs one of the candidate biological clock/bio-clock control genes, RGS16 is mainly expressed in the suprachiasmatic nucleus (SCN) and thalamus of the brain and in the liver, suggesting that RGS16 is associated with central and peripheral circadian clocks . The SCNIn terms of the peripheral biological clock, Huang J reported that RGS16 is predominantly expressed in periportal hepatocytes during the last hours of the daily fast, which are predominantly lipolytic and gluconeogenic . InteresPlatelets have no nucleus and are cytoplasmic fragments derived from bone marrow megakaryocytes . Their pSince its discovery at the end of the 20th century, there has been tremendous progress in understanding the structure, function and regulatory mechanisms of RGS16, as well as its potential role in various pathophysiological states. Despite its simple structure, the studies discussed in the present review suggest that RGS16 is an important regulator in immune, inflammatory, tumor, biological rhythm and metabolic disorders, and coagulation dysfunction. It has been demonstrated that the function of RGS16 can be affected at the transcription and post-translation levels, including by induced expression, and modification through phosphorylation and palmitoylation, although this has not been well established and has mostly been reported in cell models, with a lack of studies on specific cells or disease models. RGS16 is expressed in a variety of immune cells and affects the function of these immune cells involved in the development of immune and inflammatory diseases, and this aspect has not been studied in detail. In addition, RGS16 serves a non-negligible role in tumorigenesis, especially in the progression of breast cancer, for which it may be a novel therapeutic target, and its expression levels are also a biomarker for the diagnosis and prognosis of pancreatic cancer, PDA, colorectal cancer and glioma; however, its expression has only been tested in relation to prognosis. In addition, RGS16 is a candidate biomarker for the regulation of central and peripheral biorhythms, and its role has been confirmed in knockout mice; however, the specific mechanism is not clear. Furthermore, it also affects platelet function, and thus, the development of coagulation through non-classical signaling pathways. Finally, although RGS16 is involved in the regulation of classical and other non-classical signaling pathways, its specific interacting molecules and phosphorylation or palmitoylation modification status in these signaling pathways remain to be studied. In conclusion, RGS16 serves an important regulatory role in the development and process of various diseases via GPCRs and other non-classical signaling pathways. Although this has not yet been examined in-depth, it may suggest potential mechanisms and targets for the treatment of these diseases.


A network with appropriate quality and quantity of intercellular and intracellular communication is fundamental for healthy brain function. In other words, molecular, cellular, and structural impairments of brain cells are associated with a broad range of pathophysiological conditions, including aging and age-associated diseases, motor and behavioral symptoms, and metabolic syndromes. A neural tissue-specific epidermal growth factor (EGF)-like protein was first identified in 1995 in chick embryos and named NEL , 3. Amon2+-binding ability. The physiological function of these domains remains largely unidentified; however, accumulated investigations have recognized that these domains share common characteristics with extracellular matrix proteins known to be critical in neural growth and development  , a precuInterestingly, recent studies have also demonstrated a role for NELL2 in competitive synaptic remodeling in neurons , 9. BothAs mentioned above, qualitative and quantitative information on NELL2-dependent molecular and cellular mechanisms is now available. However, a physiological NELL2 function has not been well determined in adult mammalian brains. Interestingly, our anatomical approaches to determining brain distribution of NELL2 revealed a relatively high expression of NELL2 in terms of both mRNA and protein levels in multiple cardiometabolic nuclei, including the subfornical organ (SFO), paraventricular and ventromedial hypothalamic nucleus , and the arcuate nucleus (ARC) in adult rodent brains , 20. EspNELL2 is a secreting neuropeptide and thus believed to be an extracellular signaling molecule with an autocrine, paracrine, and/or endocrine nature. At the same time, NELL2 also possesses the ability to modify ER-initiated intracellular signaling pathways. A striking finding from us and other groups is that the outcome of NELL2 signaling is dependent on the site of NELL2 action: the effects of intracellular NELL2 signaling in terms of downstream gene expression and/or synaptic reorganization could be reversed by the NELL2 signaling initiated extracellularly.In spite of recent efforts, NELL2-mediated cellular signaling and physiological functions are still largely unknown. For example, NELL2 is able to bind to certain receptors as described above; however, specific receptor-dependent NELL2 signaling has not been elucidated. Additionally, there is a possibility that some cells utilize NELL2 only as an intracellular modulator while the other cells use it exclusively as an extracellular molecule. Therefore, in-depth and targeted investigations to address these questions are clearly necessary.NELL2 is a newly identified rising molecule in the field of brain physiology, and the site of NELL2 action should be considered in future studies.BL and JJ equally contributed to the design and development of the draft, and approved the final manuscript.This research was supported by the Priority Research Centers Program (2014R1A6A1030318) through the National Research Foundation of Korea (to BL).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.


Immune-inflammatory conditions in the central nervous system (CNS) rely on molecular and cellular interactions which are homeostatically maintained to protect neural tissue from harm. The CD40–CD40L interaction upregulates key proinflammatory molecules, a function best understood in the context of infection, during which B-cells are activated via CD40 signaling to produce antibodies. However, the role of CD40 in neurological disease of non-infectious etiology is unclear. We review the role of CD40–CD40L in traumatic brain injury, Alzheimer’s Disease, Parkinson’s Disease, stroke, epilepsy, nerve injury, multiple sclerosis, ALS, myasthenia gravis and brain tumors. We also highlight therapeutic advancements targeting the CD40 system to either attenuate the neuroinflammatory response or leverage the downstream effects of CD40 signaling for direct tumor cell lysis. Neuroinflammatory responses are mediated by neurons, astrocytes, microglia, and endothelial cells through a complex signaling network of cytokines, chemokines, and secondary messengers that alter the chemical composition of the neural microenvironment . WhereasThe CD40 receptor and CD40L ligand are transmembrane proteins that belong to the tumor necrosis factor (TNF) receptor superfamily and are critical to the initiation and sustainment of the inflammatory response . The CD4The CD40 receptor TNFRSF5) is 48-kDa type 1 transmembrane protein . Althoug is 48-kDCD40 and CD40L are also found in soluble forms, sCD40 and sCD40L respectively, which are synthesized via cleavage of the extracellular domain from their membrane-bound counterparts  10,11].,11.10,11CD40–CD40L signaling is upregulated by (1) the JAK/STAT pathway (2) TNFα through NF-κB and SMAR1, (3) IFN-γ through STAT1, and (4) IL-1β ,15.While the majority of neurological diseases described below have several factors contributing to pathogenesis, aberrant neuroinflammation mediated by CD40–CD40L increases BBB permeability, exacerbates edema, neuronal, and glial cell damage, and promotes the formation of occlusive microthrombi . Brain tTraumatic brain injury (TBI), although caused by a single event, is considered a disease process in which post-traumatic edema and increased intracranial pressure are associated with poor neurological outcomes . CD40 anThe CD40–CD40L interaction is associated with both the developmental and neurodegenerative aspects of aging .CD40 signaling promotes neurite organization, survival, and growth of axons in sympathetic neurons during the perinatal period via nerve growth factor (NGF) . This pr1–42 plaques [Alzheimer’s disease (AD), the most common neurodegenerative disease in the United States, has a significant inflammatory component, largely resulting from microglia and astrocytes activated via CD40–CD40L signaling ,24. CD40 plaques ,24,25. TCurrent therapies available for the treatment of Parkinson’s Disease (PD) have focused on improving patient cognitive and motor function; however, they do not inherently alter the neurodegenerative processes underlying PD, such as neuroinflammation .When microglia and astrocytes are stimulated via CD40 signaling, inducible nitric oxide synthase and cyclooxygenase-2—two molecules known to contribute to the pathogenesis of PD—are upregulated and cause the selective loss of dopaminergic neurons in cell cultures . This evCD40 signaling plays a significant role in both the predisposing neuroinflammatory etiology and the effects of ischemic stroke—the largest neurological contributor to global burden of disease ,29,30. CTherapies for stroke are beginning to focus on targeting the ischemic penumbra, an area that is still salvageable if neuroinflammation is reduced and reperfusion is established . As infaNeuroinflammatory pathways, activated in pharmaco-resistant epilepsy, which ~30% of epileptic patients suffer from, contribute to both the development of epilepsy and the maintenance of a chronic epileptic state .In patients with epilepsy following a stroke, plasma sCD40L levels and CD40 expression in leukocytes were significantly elevated . In addiIn animal models of spinal injury, there is an increase in CD40+ microglia in the dorsal horn, which promotes the infiltration of CD40L+ T-cells and perpetuates cytokine-mediated damage ,37. WhenFurther, CD40-mediated enhancement of both calcitonin gene-related peptide (CGRP) expression in peripheral ganglia and chemokine ligand 2 (CCL2) production in the spinal cord contributes to neuropathic pain ,39. CD40Demyelinated plaques in multiple sclerosis (MS) contain inflammatory infiltrates predominantly composed of T-cells and microglia expressing CD40L and CD40 respectively . When CDDisruption of the blood–brain barrier (BBB) in MS permits the recruitment of inflammatory cells into the brain, which then significantly disrupt myelinated axons. Inflammatory lesions resulting from MS were shown to be accompanied by CD40-mediated disturbance of the blood–brain barrier ,44. CrosLastly, attempts have been made to counteract dysregulated CD40 signaling in MS: defective regulation of CD40-stimulation on brain-derived neurotrophic factor levels in untreated relapse-remitting MS was found to be reversible with IFN-beta1a therapy .CD40 signaling between antigen presenting cells (APCs) and T-cells is upregulated in the blood of 56% of patients with amyotrophic lateral sclerosis (ALS); a discovery that inspired the development of a monoclonal antibody to CD40L, which delayed the onset of paralysis and extended survival in murine models . CD40 signaling is necessary for B-cell activation and antigen-specific antibody production inherent to the development of myasthenia gravis (MG)—the most common disorder of the neuromuscular junction ,50. CD40Dysregulated CD40 signaling compromises immune tolerance by allowing auto-reactive T-cells to avoid negative selection; and overexpression of CD40 leads to the production of pro-inflammatory cytokines that activate such autoreactive T-cells . These TThe CD40/CD40L axis is under investigation for its role in the progression and treatment of both primary and secondary brain tumors including gliomas  Figure , Table 1Increased CD40/CD40L expression in gliomas is associated with good prognoses  and CD40(1)Attenuating CD40-mediated neuroinflammation: CD40–CD40L signaling potentiates neuroinflammatory damage in the CNS. The majority of CD40 therapies used in the treatment of autoimmune and neuroinflammatory disorders such as MG, MS, and ALS, exist in the form of antagonistic monoclonal antibodies against CD40 or CD40L and are administered either as a single agent or in combination with other antibodies, chemotherapeutic agents, and/or corticosteroids .Using this treatment strategy, CD40 antagonists have the potential not only to limit edema, demyelination, BBB permeability, and neural tissue damage, but also to limit the disease-specific mechanisms that CD40 activation typically exacerbates; for example, the dysregulation of amyloid precursor protein (APP) processing and tau phosphorylation that contributes to the formation of neurofibrillary tangles and β-amyloid plaques in AD .(2)Employing CD40-mediated recruitment of inflammatory cells to enhance tumor lysis: Motivations for targeting the CD40 axis in cancer treatment include (1) CD40 ligation initiates antigen-specific activation of B and T cells (2) the CD40 axis bridges innate and adaptive immunity as it activates natural killer cells for tumor killing and (3) CD40 expression by antigen presenting cells such as macrophages enhances their antigen presentation and co-stimulatory capacity, allowing for activation of cytotoxic T cells even without CD4+ helper T-cell signaling .CD40-based therapies tested in in vivo tumor models include recombinant CD40L molecules, intratumor adenoviral vectors which lead to CD40L expression, and agonistic monoclonal CD40 antibodies . CD40 liRegarding the safety of agonistic CD40 antibodies, clinical trials have noted that adverse events such as cytokine storm, hepatotoxicity, and thromboembolic events were transient and clinically manageable . Trials We define two therapeutic approaches used to combat neurological disease via antagonism or agonism of the CD40–CD40L interaction :(1)AttenCD40–CD40L signaling leads to a pro-inflammatory microenvironment—a key physiologic response to cellular infection, cancer, and injury. However, this can progress to increased permeability of the BBB, edema, the formation of microthrombi, and subsequent CNS damage. We have reviewed the role of CD40–CD40L in neurological diseases of non-infectious etiology and distinguished two general classes of CD40–CD40L therapies used to combat neurological disease: those that inhibit CD40–CD40L mediated neuroinflammation to attenuate the immune response and those that upregulate CD40 signaling for tumor cell lysis. Both cases present the opportunity to expand and repurpose current CD40 immunotherapies in future translational research as new therapeutic avenues to treat neurological disease.


Ellagitannins (ETs) are a large group of bioactive compounds found in plant-source foods, such as pomegranates, berries, and nuts. The consumption of ETs has often been associated with positive effects on many pathologies, including cardiovascular diseases, neurodegenerative syndromes, and cancer. Although multiple biological activities  have been discussed for ETs, their limited bioavailability prevents reaching significant concentrations in systemic circulation. Instead, urolithins, ET gut microbiota-derived metabolites, are better absorbed and could be the bioactive molecules responsible for the antioxidant and anti-inflammatory activities or anti-tumor cell progression. In this review, we examined the dietary sources, metabolism, and bioavailability of ETs, and analyzed the last recent findings on ETs, ellagic acid, and urolithins, their intestinal and brain activities, the potential mechanisms of action, and the connection between the ET microbiota metabolism and the consequences detected on the gut–brain axis. The current in vitro, in vivo, and clinical studies indicate that ET-rich foods, individual gut microbiomes, or urolithin types could modulate signaling pathways and promote beneficial health effects. A better understanding of the role of these metabolites in disease pathogenesis may assist in the prevention or treatment of pathologies targeting the gut–brain axis. Numerous beneficial effects on human health, such as antioxidant, anti-inflammatory, anti-carcinogenic, cardioprotective, and prebiotic properties, have been reported following the consumption of many fruits, fruit juices, nuts, seeds, and beverages, these effects being due to their high content of antioxidant polyphenols, including tannins ,5,6,7,8.Tannins are secondary plant metabolites present in plants, foods, and beverages ,10,11. AOf the two main groups of tannins, namely, hydrolysable tannins and condensed tannins, ellagitannins (ETs) belong to hydrolysable tannins. They are non-flavonoid oligomeric polyphenols, which provide very high free-radical scavenging in vitro activity. While condensed tannins are composed only of flavonoids , without a sugar core, hydrolysable tannins are composed of ellagic acid (EA) and gallic acid with a sugar core . After hCamellia sinensis teas), and herbal medicinal products pyran-6-one (UA) of 42-fold and 3570-fold lower than that of punicalagin with DPPH and ABTS assays, respectively. Recent studies also reported for UA an antioxidant activity 23-fold lower than that of EA, in the DPPH assay [Thus, the first study supporting these claims, conducted by Cerda et al. , reportePH assay ,105.The results obtained by other antioxidant tests, such as FRAP or thiobarbituric acid reactive substances (TBARS), did not confirm the antioxidant activity of UA in plasma or colon mucosa .However, using the ORAC assay, Ito  reportedIn another similar study, comparing the antioxidant activities of polyphenol metabolites with those of intact functional polyphenols geraniin, chlorogenic acid, and (−)-epigallocatechin gallate (EGCG) by an ORAC assay, stronger antioxidant activity was reported for the metabolites than for their original compounds, with UA showing the most potent antioxidant activity among all metabolites .UA/ORACEA ratio was 1.57.The greater antioxidant capacity of urolithins compared to EA was also confirmed in the study carried out by Kallio et al. , where tThus, the antioxidant capacity of urolithins proved to be questionable following the results obtained through the DPPH, FRAP, and ABTS antioxidant assays , while only the ORAC assay identified urolithins as antioxidants ,95,104. Just based on the fact that they exert their antioxidant effects exclusively by the HAT mechanism, urolithins cannot be considered less potent antioxidants, especially since the HAT mechanism and oxidation induced by peroxyl radicals are considered to be more biologically relevant than the SET mechanism or oxidation induced by other oxygen radicals ,108.Therefore, the assumption that urolithins could have a higher antioxidant capacity than originally thought is still being investigated, aiming to prove that these metabolites can have an important contribution as antioxidants in the body after the oral administration of intact ETs.ETs, high molecular weight polyphenols, are metabolized by animal and human gut microbiota to bioavailable urolithins, low molecular weight metabolites. As urolithins rapidly undergo phase II metabolism following gut absorption, the in vitro studies should be conducted on urolithins, as well as their phase II respective glucuronides to fully evaluate the biological activity mechanisms.The gut–brain axis is a bidirectional communication system involving many signaling molecules between the enteric and central nervous system (CNS). Scientific evidence suggests that crosstalk along the gut–brain axis regulates inflammatory responses, antioxidant activity, cell growth, and proliferation, modulating the homeostasis of functions in these systems. Alterations in gut–brain interactions have been recognized in several digestive and neurological disorders . HoweverOxidative phosphorylation (OXPHOS), a metabolic pathway that produces energy inside mitochondria, could generate an over-production of ROS under stressful conditions revealing a link between mitochondrial function and aging . If the In SK-N-MC human neuroblastoma cell line, UA significantly attenuated intracellular ROS production and oxidative stress-induced apoptosis, increased cell viability, decreased the Bax/Bcl-2 ratio, and suppressed the p38 MAPK pathway phosphorylation . AdditioAnother UA anti-inflammatory activity mechanism was mediated through the aryl hydrocarbon receptor (AhR), a ligand-activated transcription factor implicated in numerous physiological and pathological cellular mechanisms, such as immunity, energy homeostasis, and epithelial barrier function . The stuKnowing that endothelial Akt-kinase plays an important role in the pathogenesis of cardiovascular complications in diabetic patients, the effects of different polyphenols, including UA, on Akt phosphorylation (pAkt) in endothelial cells were assayed . UA, butThe in vitro anti-inflammatory activities of UA, iso-UA, UB as well as their respective glucuronides were performed on THP-1 human cell line-derived macrophages, RAW 264.7 murine macrophages, and human primary macrophages. UA, the most active metabolite, inhibited the human immune cell inflammatory response induced by TLR4 receptor stimulation and increased the production of anti-inflammatory cytokines, IL-10 and transforming growth factor beta 1 (TGF-β1). The anti-inflammatory activity mechanism was based on the inhibition of NF-κB translocation to the nucleus and MAPK phosphorylation contribution .Further studies on RAW 264.7 cells showed that UA treatment prevented NF-κB and AP-1 activation, inhibited Akt and Jun N-terminus kinase (JNK) phosphorylation, significantly diminished the intracellular accumulation of ROS, reduced the activation of NADPH oxidase (NOX), the main source of ROS in activated macrophages . These oIn murine J774.1 macrophages, UA also inhibited the production of proinflammatory proteins, ROS, and NO, and blocked p65 NF-κB nuclear translocation .2 and HKD2), novel mediators of inflammation [A common anti-inflammatory strategy includes the decrease in biosynthesis of prostaglandins and leukotrienes via inhibition of the COX-2 and 5-lipoxygenase (5-LOX) pathways. A recent in vitro study revealed that UA, iso-UA, and UC could reduce the formation of the 5-LOX/COX-2 pathway hemiketal eicosanoids  and suppressed the activation of murine CD4+ T cells [UA might be used as a natural immune-suppressant in some inflammatory diseases, as UA treatment decreased CD4 T cells .There are many in vitro studies that assessed the neuroprotective effects of EA or urolithins an different line cells in different experimental conditions and revealed several molecular mechanisms of action.Investigations on LPS-stimulated BV2 microglia cells confirmed that UA significantly reduced the production of proinflammatory cytokines, TNF-α and IL-6, via the activation of SIRT-1 and autophagy initiation . EquallyIt was suggested that the potential mechanisms of the anti-inflammatory activity of UA and UB in LPS-treated BV2 murine microglia could be via the inhibition of NF-κB p65, Erk1/2, p38 MAPK, and Akt phosphorylation and signaling pathways. The two urolithins suppressed mRNA levels of proinflammatory TNF-α, IL-6, IL-1β, iNOS, and COX-2 genes .Interestingly, in an experimental autoimmune encephalomyelitis (EAE) study, the most common model for MS, the EA treatment did not affect the cause of inflammation like urolithins did but rather the consequences, such as demyelination, through the stimulation of ceramide biosynthesis .The characteristic features of the Alzheimer’s disease (AD) brain are the accumulation of amyloid beta (Aβ) in extracellular senile plaques and intracellular hyper-phosphorylated tau protein, as well as oxidative stress accompanied by mitochondrial dysfunction .As mitophagy deficit is a key factor in AD mitochondrial dysfunction, the use of urolithins can restore mitochondrial homeostasis by inducing mitophagy and biogenesis . ActivatOne of the main strategies for the treatment of AD is the inhibition of Aβ-induced neurotoxicity. An in vitro study revealed that EA and its metabolites, UA, UB, UM5, UM6, attenuated the Aβ-induced toxicity in PC12 cells promoting neurite outgrowth, reducing ROS production, and inhibiting neuronal apoptosis. The results identified AKT1, Insulinlike growth factor1 receptor (IGF1R), NFKB1, epidermal growth factor receptor (EGFR), and MAPK14 genes as main targets of EA and urolithins, therefore, the possible neuroprotective action mechanisms were associated with PI3K-Akt, MAPK, and Ras signaling pathways .Another approach for the prevention of AD is the regulation of mitochondrial calcium influx and mitochondrial ROS (mtROS) accumulation, which were noticed in diabetic patients. In neuroblastoma cell line SH-SY5Y, UA treatment reduced high glucose-induced amyloidogenesis, maintaining mitochondrial calcium and ROS homeostasis . Additio− and O2−, thus could modulate oxidative stress, a significant factor in the progression of chronic diseases, such as dementia [2O2-treated neuron-2a cells, UB significantly reduced apoptosis rate and ROS production, and increased viability.UB presented suitable radical scavenging potential against ABTS, DPPH, OHdementia . MoreoveMonoamine oxidase (MAO) enzymes (MAO-A and MAO-B) are responsible for the inactivation of monoamine neurotransmitters and could generate neurological disorders, such as depression and Parkinson’s disease (PD). Treatment with UA, UB and UC significantly repressed the MAO-A activity, but none of the tested urolithins displayed strong inhibitory activity against MAO-B . SimilarUrolithins have been revealed to modulate cell cycle, upregulate tumor suppressor pathways, inhibit proliferation and induce apoptosis in many in vitro experiments on cancer lines including colorectal, liver, pancreas, kidney, and bladder cancer.In a recent study, UA treatment at concentrations consistent with those found in the intestine triggered autophagy in the human colorectal cancer (CRC) cell line SW620, thereby inhibiting cell survival and metastasis . UA also2/M phase [UA treatment revealed anti-proliferation in HCT-116 cells through senescence induction associated with the upregulation of p21 and p53 expressions. Moreover, UA and urolithin metabotype B reduced colony formation via the inhibition of cell cycle progression at the G/M phase .The anti-proliferative and anti-invasive effects of UA were also demonstrated in hepatitis B virus (HBV)-positive hepatocellular carcinoma (HCC) . Data shAnother mechanism for UA-induced anti-proliferative and proapoptotic effects was through downregulation of the PI3K/AKT signaling and mTOR pathways. mTOR, a serine/threonine kinase, contributes to cancer cell growth and survival, while PI3K signaling activation is associated with poor prognostic in cancer patients . In pancThrough downregulation of the PI3K/Akt/mTOR pathway, UA inhibited the proliferation and migration of PDAC cells and increased apoptosis. Even EA, the upstream compound of UA, blocked the cell cycle and reversed epithelial to mesenchymal transition in PDAC by restraining several carcinogenic pathways activated in PDAC, such as NF-κB, COX-2, and Wnt .UA could be a promising therapeutic candidate for cholangiocarcinoma (CCA), the second most common primary hepatic malignancy. In a study on the human intrahepatic CCA cell lines HuCCT-1 and SSP-25, UA treatment-induced G2/M phase cell cycle arrest, thus repressing cell proliferation, and exerted anti-tumor effects by suppressing the Akt/WNK1 signaling pathway and inducing autophagy .The anti-proliferative effect of UA was also demonstrated in the UMUC3 bladder cancer cell line. UA treatment could inactivate the cyclin B1/cdc2 kinase complex and additionally lessened phosphorylation of Akt and ERK, thus downregulating PI3K/Akt signaling pathway .In order to capture the most relevant results of recent research studies, in this manuscript, we have focused our attention on in vivo original articles and trials published in the last 5 years that revealed the effects of ETs, EA, and urolithins on the gut–brain axis.Xu et al.  highlighThe protective effects of EA also extend to the ileum, as demonstrated by Chen et al. . In an aThe ability of EA to modulate different signaling pathways was noticed by Lu et al.  by transParisio et al.  comparedFotschki et al.  demonstrCampylobacter jejuni and attenuated the proinflammatory immune responses in the intestinal tract as well as in the extraintestinal compartments [Infections of the digestive tract or pelvic region are usually associated with dysbacteriosis and inflammatory status. Li et al.  studied artments . A pomegranate peel extract containing 11% EA-activated caspase-3, an apoptosis executor, in a colonic inflammation model induced by dextran sodium sulfate (DSS) in mice, in a dose corresponding to 26 mg EA/kg bw, which is considered to be the effective anti-inflammatory dose of EA, according to the literature . NeverthWeizmannia coagulans. In addition, the combination of EA and W. coagulans BC2000 inhibited HFD-induced endotoxemia and activated the hepatic autophagy pathway in a manner similar to that of urolithin [In a high-fat diet (HFD) model in rats, rich ET chestnut bark extracts normalized intestinal contractility and exerted antioxidative and antiadipose activities suggesting a potential approach to overweight-related diseases . Insulinrolithin .Several recent studies have shown a strong correlation between gut microbiota dysbiosis and inflammatory processes both in the gastrointestinal tract and extraintestinal compartments ,172. TheAging is a complex process involving multiple pathophysiological events, such as oxidative stress, chronic low-intensity inflammation called “inflamm-aging”, mitochondrial dysfunctions, impaired protein homeostasis, and epigenetic mechanisms . D-galacThe development of AD is related to genetic factors but also depends on oxidative stress conditions and neuroinflammation . EA has 3. The ERC is the most affected cortical area in AD patients and its progressive deterioration is involved in early memory loss. By the antioxidant activity, EA treatment restored the discrimination index in NORT test and reduced the structural changes in the ERC sections in AD rats, thus restoring episodic memory.Ramadan et al.  tested EThe sleep disorder (SD) could affect neurobehaviors, including cognition and memory. EA (50 mg/kg and 100 mg/kg) mitigated the neurobehavioral abnormalities associated with memory impairment and anxiety , and elevated plus maze (EPM) tests) in SD mice after i.p. administration for 21 days. The EA treatment ensured neuron survival and the high dendritic spine density in the hippocampus of SD mice by reducing oxidative stress via the Nrf2/ARE pathway activation and by inhibiting the neuroinflammation via Toll-like receptor 4 (TLR4) downregulation .In an animal model of brain inflammation induced by cerebral ischemia/reperfusion (I/R) performed in Wistar rats, Falahieh et al.  found thThese outcomes are very important because they demonstrate the ability of EA or its microbial metabolites, the urolithins, to improve/restore not only the permeability of the intestinal barrier but also the permeability of the BBB affected by pathophysiological processes as cerebral ischemia/reperfusion or traumatic brain injury, and encourage further research to explain the mechanisms of action on the gut–brain axis in more detail.Juglans regia  rich in EA and ETs and tested them in a diabetic mouse model with cognitive dysfunction. GC extracts had the ability to restore the neurobehavioral and memory dysfunction induced by high glycemia . Moreover, GC extracts showed antioxidant effects, anti-inflammatory activity via the JNK/NFκB signaling pathway, suppressed synaptic disorders by regulating the cerebral cholinergic system, regulated mitochondrial activity and neuronal apoptosis pathway.Moon et al.  preparedPD is another neurodegenerative disease that develops progressively under conditions of oxidative stress and neuroinflammation. It is characterized by loss of dopaminergic neurons and dopamine depletion in the midbrain substantia nigra pars compacta (SNpc), motor and olfactory dysfunctions, and the accumulation of the misfolded α-synuclein that forms Lewy bodies . The benTancheva et al.  tested t35–55 showed the ability of EA (50 mg/kg/day), a pomegranate peel extract (PEm) rich in EA and punicalagin [MS is characterized by inflammatory cell infiltration and demyelination in the CNS . Two stuicalagin , and of icalagin , respecticalagin . UA signicalagin . These sEA (100 mg/kg)  and coriOenothein B, a dimeric ET widely distributed in various medicinal plants, has a hydrophilic structure and may not have been able to pass through the BBB. Okuyama et al.  found thToxoplasma gondii (T. gondii) characterized by the persistence of parasite cysts in the brain, is associated with high mortality in immunocompromised patients and with poor tolerability of the current therapy, which is not effective against parasite cysts. UA was tested and has been shown to be effective in the treatment of mice chronically infected with T. gondii, reducing the parasite cyst formation and significantly prolonging survival. Thus, UA is a promising natural bioactive compound that can be used in the treatment of neurotoxoplasmosis [Neurotoxoplasmosis, a chronic infection with lasmosis .Oxidative stress and inflammatory conditions play a major role in the pathogenesis of irritable bowel syndrome (IBS). In a double-blind, placebo, parallel randomized clinical trial (RCT) in patients with IBS (22 EA vs. 22 placebo), the intake of 180 mg of EA per day for 8 weeks reduced abdominal pain and distention, flatulence, and rumbling . MoreoveIn a double-blind, randomized, placebo-controlled trial conducted in middle-aged and older adults (98 PJ vs. 102 placebo), daily consumption of PJ (236.5 mL) for 1 year kept stable the ability to learn visual information vs. the significant decline observed in the placebo group .Shigella and Catenibacterium, negatively correlated with plasma IPA levels. These outcomes were also confirmed in vivo. Thus, the microbial Trp metabolism could contribute to the health benefits of ETs [In another double-blind, parallel, placebo-controlled trial (11 PJ vs. 9 placebo), stool and plasma were collected at baseline and after 1 year of PJ consumption and analyzed to investigate the tryptophan (Trp) metabolism. Plasma level of indole propionate (IPA), a microbial metabolite of Trp, was significantly decreased in the placebo group and it was kept stable in the PJ-treated group at the end of the study vs. baseline. Other major metabolites of Trp , as well as the Trp levels, did not change significantly in either group. PJ consumption was associated with a reduction of the abundance of two genera, s of ETs . Aging is associated with a decline in mitochondrial function. Several recent clinical trials have looked at the effects of long-term high-dose UA supplementation on mitochondrial and cellular health in middle-aged and older adults ,201,202.Andreux et al.  conducteIn an RCT by Liu et al. , 66 adulTherefore, these studies certify that UA supplementation is safe and it generates increased circulating levels of UA. UA is a promising therapeutic agent with real anti-aging potential and could be used in the prevention of age-related muscle decline. Furthermore, oral administration of chemically synthesized UA is safe in humans, and 1000 mg/serving could be used as a functional food ingredient . MoreoveETs and EA are bioactive polyphenols that are found in several plant-source foods, including walnuts, berries, and pomegranates. Urolithins, their gut microbiota-derived metabolites, are better absorbed and might be responsible for the beneficial effects ascribed to ETs and EA.In this review, we analyzed the last recent-published findings on ETs, EA, urolithins and the intestinal and brain effects, the potential mechanisms of action and the connection between the ET microbiota metabolism and the consequences detected on the gut–brain axis.Our review highlights much preclinical and clinical evidence indicate that attests that ET-rich foods associated with individual gut microbiome or certain urolithins, especially UA and UB, could promote beneficial health impact. Their biological actions are complex, including the modulation of many important signaling pathways involved, particularly in inflammation and aging, as well as the function stabilization of the intestinal barrier and BBB. A better understanding of the role of these metabolites in the disease pathogenesis may assist in the prevention or treatment of pathologies targeting the gut–brain axis. Based on our knowledge, this review is the first one to focus on the impact ETs, EA, and urolithins could have on the gut–brain axis.However, future preclinical detailed toxicological evaluations and clinical investigations of individual gut microbiota composition and health status in different age groups should be conducted before the therapeutic application of EA-enriched foods in human population.