AR amplification, AR point mutations, expression of constitutively active AR splice variants, and altered intratumoral androgen biosynthesis. AR-independent resistance mechanisms include glucocorticoid receptor activation, immune-mediated resistance, and neuroendocrine differentiation. The development of novel agents, such as seviteronel, apalutamide, and EPI-001/EPI-506, as well as the identification and validation of novel predictive biomarkers of resistance, may lead to improved therapeutics for mCRPC patients.Despite the initial efficacy of androgen deprivation in prostate cancer, virtually all patients progress to castration-resistant prostate cancer (CRPC). Androgen receptor (AR) signaling is critically required for CRPC. A new generation of medications targeting AR, such as abiraterone and enzalutamide, has improved survival of metastatic CRPC (mCRPC) patients. However, a significant proportion of patients presents with primary resistance to these agents, and in the remainder, secondary resistance will invariably develop, which makes mCRPC the lethal form of the disease. Mechanisms underlying progression to mCRPC and treatment resistance are extremely complex. AR-dependent resistance mechanisms include  In the United States, prostate cancer is the most commonly diagnosed malignancy (aside from skin cancer), where approximately one out of every seven men will be diagnosed with the disease during their lifetime . It is eAR amplification, AR point mutations, expression of constitutively active AR splice variants, and altered intratumoral androgen biosynthesis. AR-independent resistance mechanisms include glucocorticoid receptor overexpression, neuroendocrine differentiation, and immune-mediated resistance mechanisms.However, prostate cancer is still the third leading cause of cancer-related death among men in the US. It is estimated that 26,730 deaths will occur in 2017 due to prostate cancer ,5. Two nUltimately, metastatic CRPC (mCRPC) remains incurable, and novel treatment resistance mechanisms continue to be identified, implicating numerous, complex dysregulated molecular signaling pathways that underlie the progression and lethality of the disease. The primary objective of this review article is to discuss the etiologies underlying clinically-relevant mechanisms that lead to drug resistance in mCRPC, and the potential treatment strategies designed to overcome resistance.AR is a protein coding gene that is located on the X chromosome at Xq11–12, is >90 kb in length, and consists of eight exons. It encodes the human AR protein, which is a member of the steroid hormone receptor superfamily, and a ligand-activated nuclear transcription factor. The AR is 110 kD, comprised of approximately 919 amino acids, and consists of four functional domains: (1) the N-terminal transactivation domain (NTD); (2) the DNA-binding domain (DBD); (3) the hinge region; and (4) the ligand-binding domain (LBD) .,20.AR) hFor over seven decades, ADT has been the cornerstone treatment for metastatic prostate cancer, and remains an indispensable treatment paradigm in mCRPC. Although ADT is initially effective in the majority of prostate cancer patients, its effects on tumor growth are transient, and most patients progress within 18–30 months . AR reacPrior to the FDA approval of abiraterone in 2011 and enzalutamide in 2012, mCRPC patients were traditionally treated with the microtubule-stabilizing taxane, docetaxel. Docetaxel was approved for the treatment of mCRPC based on two seminal phase III clinical trials (TAX 327 and SWOG 9916), both of which demonstrated a modest 2–3-month survival benefit to mCRPC patients ,23. Aften = 1195) [p < 0.001), when compared to placebo. Patients treated with abiraterone also exhibited significant improvements for all secondary endpoints such as radiographic progression free survival (PFS), time to PSA progression and PSA response rate. COU-AA-302 was a double-blinded, placebo-controlled trial that was conducted in chemotherapy-naive mCRPC patients (n = 1088) [p = 0.01), a 47% reduced risk of progression , and an increased median PFS by 8.3 months (16.5 versus 8.2 months) in abiraterone-treated patients, when compared to placebo. Again, significant improvements were observed for all secondary endpoints in patients treated with abiraterone. In both trials, excess mineralocorticoid-mediated toxicities were significantly more common among the patients treated with abiraterone. Two recently published clinical trials demonstrated that addition of abiraterone to ADT in metastatic prostate cancer patients who are initiating ADT treatment resulted in substantial benefit, including increased OS and PFS [Abiraterone blocks the production of intratumoral androgen biosynthesis by potently, selectively, and irreversibly inhibiting cytochrome P450 c17 (CYP17A1). CYP17A1 is central to androgen biosynthesis through both 17α-hydroxylase and C17,20-lyase activity . Perhaps = 1195) . COU-AA- and PFS ,29. ThesAR overexpression [n = 1199) [p < 0.001). Significant improvements in all secondary endpoints were also observed among patients in the enzalutamide arm. PREVAIL was a double-blinded, placebo-controlled trial conducted in chemotherapy-naıve mCRPC patients (n = 1717) [p < 0.001). Second, radiographic PFS was also superior for patients in the enzalutamide arm, with an 81% reduced risk of progression . Similar to AFFIRM, patients in the PREVAIL enzalutamide arm also achieved significant improvements in all secondary endpoints.Enzalutamide is a second-generation AR inhibitor that was developed to overcome resistance to first-generation agents . Enzalutamide has a tri-modal mechanism of action: (1) it potently binds to the AR LBD to prevent ligand binding and AR activation; (2) it inhibits AR translocation into the cell nucleus; and (3) it prevents binding of AR to DNA to effectively inhibit transcription of target genes . One of pression . Data fr = 1199) . AFFIRM The pharmacotherapeutic landscape for the treatment of mCRPC has been further expanded over the last decade with the FDA approval of three new agents. Options for the treatment of mCRPC now include: (1) the autologous cellular immunotherapy, sipuleucel-T, for asymptomatic or minimally symptomatic mCRPC patients (approved by the FDA in 2010) ; (2) theAlthough abiraterone and enzalutamide have advanced the treatment of mCRPC patients, approximately 20–40% of patients present with primary resistance to these agents  ,7,8,40. AR amplification, AR overexpression, AR somatic point mutations, constitutively active AR splice variants, and altered intratumoral androgen biosynthesis [Primary and secondary resistance to abiraterone and enzalutamide are extremely complex . Mechaniynthesis ,45,46,47AR amplification and overexpression are two primary etiologies for progression to the mCRPC phenotype, and are likely important to the development of treatment resistance. While not generally present in hormone-sensitive cells, up to 80% of CRPC cells exhibit AR amplification, AR mRNA overexpression, or AR protein overexpression [AR amplification, leading to AR overexpression, enables progression to CRPC even in the setting of low circulating androgens due to ADT treatment [pression ,49. AR areatment .AR amplification could also be an important resistance mechanism. Preclinical in vitro studies using enzalutamide-resistant LNCaP cells express higher levels of AR (and AR splice variants) when compared to naïve LNCaP cells [AR genomic landscape discovered that patients with AR amplification were less likely to respond to treatment. A total of 50% of patients who were pretreated with either enzalutamide or orteronel (a CYP17A1 inhibitor) prior to abiraterone treatment showed evidence of AR amplification, and only 13% of those with AR gain demonstrated a response with ≥50% PSA decline after being treated with abiraterone [AR amplification as a resistance mechanism in mCRPC patients treated with abiraterone or enzalutamide, and who had received previous docetaxel treatment. Among the patients in the study discovery cohort who had received docetaxel (n = 98), AR amplification was associated with a worse rate of PSA decline of ≥50%, shorter PFS , and shorter OS . These results were confirmed in their replication cohort of enzalutamide-treated patients from the PREMIERE trial (n = 100), where patients with AR amplification experienced shorter PSA PFS , and OS  [AR amplification in ctDNA is associated with resistance to abiraterone and enzalutamide [In addition to its role in mCRPC progression, there is mounting evidence that aP cells . One in aP cells . Finallyraterone . A separ< 0.004) . Additiolutamide ,56.AR point mutations confer resistance to enzalutamide and abiraterone, but currently there is some ambiguity as to whether the spectrum of somatic mutations that confer drug resistance are different for abiraterone and enzalutamide. The majority of clinically-relevant somatic point mutations in the AR is located in the LBD. These include four main somatic missense mutations: (1) a leucine to histidine substitution at amino acid 702 (L702H); (2) a histidine to tyrosine substitution at amino acid 875 (H875Y); (3) a phenylalanine to leucine substitution at amino acid 877 (F877L); and (4) a threonine to alanine substitution at amino acid 878 (T878A)  .AR point mutations is T878A (previously reported in the literature as T877A), which is a gain of function mutation, and can be activated by both steroid hormones  and first-generation antiandrogens . It most commonly arises after treatment with abiraterone because when CYP17A1 is effectively inhibited, intracellular progesterone levels increase, while DHEA and testosterone are suppressed. Intuitively, it would appear that this mutation would effectively limit AR activation; however, the T878A mutation broadens ligand binding specificity of the AR so that it can be activated by progesterone, glucocorticoids, and estrogen [One of the most frequently reported estrogen . Thus, testrogen . A recenestrogen .A second frequently reported somatic mutation, F877L (previously reported in the literature as F876L), arises in patients after treatment with enzalutamide or apalutamide. Apalutamide (formerly ARN-509) and darolutamide (formerly ODM-201) have a similar mechanism of action to enzalutamide ,36. TherAR who were treated with enzalutamide, only 13% experienced a ≥50% PSA decline after abiraterone treatment [p < 0.004), when compared to patients without detectable point mutations. In this study, T878A and L702H mutations were only found in patients who had received prior docetaxel treatment [Interestingly, L702H is a mutation that can result in glucocorticoid-mediated activation of the AR. In one study, the L702H mutation was associated with primary resistance to abiraterone . Anotherreatment . Anotherreatment .v567es, alternate splicing leads to skipping of exon 5, 6, and 7, and a frameshift that causes a premature stop codon in exon 8. Both splice variants cause the loss of the LBD domain, and the formation of the C-terminal truncated protein (Approximately 20 AR mRNA splice variants (AR-V) have been identified since 2008. While select AR-Vs are only conditionally active  , many ar protein  [69,70,7v567es can be induced by abiraterone. In one study that demonstrated an OS advantage in mice treated with abiraterone, AR-V7 and ARv567es expression was increased 3.1-fold and 5.2-fold, respectively [AR-V expression has been associated with both enzalutamide and abiraterone resistance. In preclinical xenograft models, it was shown that expression of AR-V7 and ARectively . Similarectively ,72.v567es and AR-V7 are likely to be the active in mCRPC, and most relevant to enzalutamide and abiraterone resistance. Early studies revealed that expression levels of ARv567es and AR-V7 were correlated with poorer survival in patients [n = 62), utilizing a CTC assay, demonstrated that AR-V7 mRNA expression is associated with enzalutamide and abiraterone secondary resistance [Clinically, ARpatients . Moreovesistance . In thissistance . Additiosistance . These dv567es and AR-V7, confer resistance, compounds that degrade the AR . Because clinically-relevant AR-Vs, such as ARlosamide ,76, or elosamide  as a prolosamide ), or tarlosamide  or EPI-5losamide ,39) coulPSA promoter. In addition, the combination of niclosamide and enzalutamide was shown to inhibit tumor growth in enzalutamide-resistant in vitro models, indicating that niclosamide may be a viable option to overcome secondary resistance to enzalutamide in mCRPC [Niclosamide is an FDA-approved anti-helminthic drug that was shown in preclinical models to be particularly effective at targeting AR-V7 through proteasome-dependent downregulation of AR-V7 protein expression, and inhibition of AR-V7 transcriptional activity through reduced AR-V7 recruitment to the in mCRPC . Moreovein mCRPC .v567es splice variant. These analogs of EPI-001 inhibited the growth of xenograft tumors that express AR splice variants lacking the LBD [EPI-506 is a prodrug of one of the four stereoisomers of its predecessor, EPI-001. EPI-506 binds to the AF1 region, and thereby effectively blocks the NTD, inhibits AR transcriptional activity by reducing protein–protein interactions between the AR and co-activators, and prevents NTD transactivation ,39. Thisv567es mRNA and protein expression [An alternative approach to bypass secondary resistance mechanisms involving AR splice variants is to target co-activators or co-repressors involved in AR-mediated transcription. Numerous molecules that act as either co-activators or co-repressors of the AR, to modulate its transcriptional activity, have been identified . Specifipression . Then, ipression . These dSRD5A1, HSD3β1, and AKR1C3 in CRPC tissues [HSD3B1 were resistant to ubiquitination and degradation, which led to DHT accumulation [CYP17A1 copy number variations were associated with poorer outcomes in abiraterone-treated patients [It is likely that extended treatment with either abiraterone or enzalutamide induces alterations to intratumoral androgen biosynthesis. As a result, increased circulating androgens, combined with mutations (germline and/or somatic) that affect metabolizing enzyme expression or function, promote AR reactivation and progression to mCRPC. For instance, enzalutamide-resistant cell lines were found to have upregulated androgens, and over-expressed genes involved in androgen biosynthesis . Multipl tissues ,85,86. E tissues . Abiratemulation . Finallymulation , and celpatients .In addition to AR-mediated resistance mechanisms, there are several AR-independent resistance mechanisms that lead to treatment failure, as well as progression of mCRPC. Glucocorticoid receptor overexpression, neuroendocrine differentiation, and immune-mediated resistance have also been implicated in treatment resistance in CRPC ,89,90.The role of glucocorticoids and the glucocorticoid receptor (GR) in prostate cancer is complex because glucocorticoids can be both beneficial and harmful. However, in mCRPC where ADT is used to antagonize AR signaling, GR upregulation and activation can be another clinically-relevant mechanism of resistance to therapeutics that target the AR signaling axis.The AR and GR are both members of the same class of nuclear steroid receptors, share common structures and mechanisms of action , have hiGR mRNA and GR protein expression increased in the presence of AR knockdown or AR antagonists [As patients progress to mCRPC, the reliance on direct AR signaling is bypassed as a result of potent receptor inhibition, which causes subsequent activation of the GR. Activated GR is then able to bind to nuclear AREs and regulate a subset of AR target genes that promote cell survival and tumor progression ,93. One agonists . Moreoveagonists .Data from these publications support the hypothesis that GR activation and upregulation, secondary to AR antagonism, is a potential resistance mechanism to therapies targeting the AR axis. Further investigations with analyses of pre-treatment patient samples , as well as samples at the point of treatment progression, are necessary to characterize the extent to which GR activation and upregulation contributes to secondary resistance in mCRPC.n = 209), moderate to high PD-L1 expression in prostatectomy specimens was associated with tumor progression , Gleason score (p = 0.004), AR expression (p < 0.001), and was prognostic for biochemical recurrence . In the replication cohort (n = 611), associations between PD-L1 and AR expression, and proliferation were confirmed (p < 0.001). Furthermore, the association between PD-L1 expression and biochemical recurrence was confirmed in a multivariate model  [Despite FDA approval of several immunotherapies for a variety of malignancies within the past three years, the role of checkpoint inhibitors for the treatment of mCRPC has yet to be fully elucidated. Primarily, this was based on negative results from studies involving the CTLA-4 inhibitor, ipilimumab . However= 0.007) . Recent = 0.007) . Results= 0.007) .There are two additional ongoing phase II trials exploring the role of immunotherapy in mCRPC. One of the two trials is evaluating ipilimumab in combination with abiraterone in treatment-naïve mCRPC patients (NCT01848067), and could conceivably answer important hypotheses pertaining to primary resistance. More importantly, the second trial is evaluating combination immune checkpoint blockade with ipilimumab and the PD-1 inhibitor nivolumab in mCRPC patients positive for AR-V7 (NCT02601014). This second trial has the potential to be informative from the perspective of using a predictive biomarker for the purpose of treatment selection, and also for understanding the role of immunotherapy in pre-treated mCRPC patients.n = 51 PCA, and n = 30 NEPC), whole exome sequencing showed that molecular signatures and gene copy numbers were similar between the two prostate cancer subtypes, confirming that NEPC is derived from PCA precursors [While only approximately 1% of all primary prostate cancers are diagnosed as neuroendocrine prostate cancer (NEPC), up to 30% of mCRPCs are NEPC . The proecursors . Until rTP53, which encodes the p53 tumor suppressor protein, and RB1, which encodes the retinoblastoma tumor suppressor protein, have emerged as two important factors in NEPC differentiation [RB1 deletions in 85% of cases [Rb1 loss facilitates lineage plasticity and metastasis in PCA with Pten loss, and Trp53 causes secondary resistance to therapies targeting the AR signaling axis [TP53 and RB1, and was mediated by increased expression of a transcription factor named SOX2. They also showed that inhibition of SOX2 restored TP53 and RB1 function [Loss or mutation of both ntiation ,103. In of cases . A recening axis . A seconfunction . MYCN, which encodes N-Myc, and AURKA, which encodes Aurora kinase A, are also associated with differentiation from PCA to NEPC [MYCN and AURKA occurred in between 40–86% of pretreated NEPC samples and metastases, compared to only 5% of PCAs [Genomic amplification and overexpression of  to NEPC ,107,108. of PCAs . In anot of PCAs . TP53 or RB1 genomic loss or mutations. However, a phase II trial is underway, which is evaluating the safety and effectiveness of alisertib in mCRPC and NEPC patients (NCT01799278). A second Aurora kinase A inhibitor, CD532, was shown to reduce N-Myc protein levels in preclinical models driven by MYCN, which indicates this could conceivably be a viable treatment option for NEPC patients in the future if the drug is moved into clinical trials [There are currently no therapeutics in the drug development pipeline that target l trials .AR amplification, AR point mutations, expression of constitutively active AR splice variants, and altered intratumoral androgen biosynthesis), and AR-independent mechanisms  will allow for the design and implementation of novel pharmacotherapeutic treatment paradigms in patients with mCRPC. Moreover, the development, validation and clinical implementation of assays  will be useful in identifying mechanisms of resistance, can conceivably provide clinically relevant predictive biomarkers, and will become essential tools that help clinicians identify the optimal treatment for a given patient.Nearly all patients with metastatic prostate cancer who are initially treated with ADT will progress to mCRPC, mainly due to reactivation of the AR signaling axis. Because of myriad adaptive resistance mechanisms, mCRPC remains incurable despite the development and FDA approval of novel agents that target the AR signaling axis. However, the identification and a more comprehensive understanding of AR-dependent (i.e.,


As health care practitioners, it is important to have an understanding of the common barriers to and facilitators of the rehabilitation services we provide.This article aimed to review the relevant literature regarding barriers to and facilitators of rehabilitation services for people with disabilities.Articles for the period 1990–2010 using descriptors related to rehabilitation services, barriers, facilitators and the physically disabled population were retrieved for this review.A total of 19 article titles were identified from references of other articles but following application of the inclusion criteria selected for this review, only six articles were chosen. Five of these articles were qualitative studies and one was a quantitative study. Barriers and facilitators regarding rehabilitation services highlighted by participants in the studies included a perception that health professionals have a lack of understanding of rehabilitation for people with disabilities and there was a lack of information sharing from health professionals about the rehabilitation process. On the other hand some participants reported that health professionals demonstrated confidence in the disability and rehabilitation process during consultation and highlighted that their needs were met by the rehabilitation professionals.Even though there were few studies highlighting the barriers to and facilitators of rehabilitation services, they highlighted that there are gaps in the process of rehabilitation services provided. It would be advisable for health professionals to take cognisance of the issues highlighted in this study in order to make rehabilitation services more effective. World report on disability This is also in line with the primary health care (PHC) approach to health in South Africa, which highlights that ‘specific rehabilitative services should include a basic assessment of people with disabilities, followed by an appropriate treatment programme, in consultation with the disabled person and his family’ .Articles considered for inclusion could be either qualitative or quantitative studies and had to be published in English (as interpretation of the studies would be easier for researchers) during the period 1990–2010. To be included in the review the studies had to focus on people with physical disabilities that attended rehabilitation services and were exposed to rehabilitation services, either institution based or community based.The search strategy was implemented as follows. Databases such as CINAHL with full text, ERIC, Academic search premier, MEDLINE, Health resource-consumer edition, Health source: Nursing/Academic edition, PsychARTICLES, SocIndex with full text and Ebscohost were searched for this review. The terms used to search for literature included rehabilitation service, facilitators and barriers, physically disabled, rehabilitation service providers and user satisfaction. Search terms such as positives and negatives, people with disabilities, physical therapists, occupational therapists, doctors, nurses, social workers, and client satisfaction were used alternatively to search terms such as barriers and facilitators. References used in other studies were also perused to identify articles that did not emerge in the initial database search. Studies were excluded if they did not specifically focus on rehabilitation services. Six articles meeting the criteria were found through the identified databases, and based on their titles, 19 articles were identified from the reference lists of these articles.Initially, the search was conducted by one researcher, and the abstracts and titles were screened by two reviewers. Documents for the last two decades were reviewed by applying the PIO method Moyer  – where The reviewers used a critical review form Potvin  for the Only 6 out of the 25 article titles identified during the literature review met the inclusion criteria. The omitted articles (19) were mostly excluded as they did not address the aim of this review or did not include the identified population based on the CASP form. A flowchart of the process followed to identify the articles used in this study is presented in A self-developed data extraction form was used to extract the data from the studies, using criteria that were determined prior to the data extraction. The data extraction form was designed to extract information such as author, date of publication, country, population including sample size, gender, educational level and type of disability see . Out of The World Health Organization’s  Internatet al.  and one from a developing country (China). These studies are reported on individually based on the aim of the study, population and outcome of the study. Contextual factors include environmental and personal factors. Environmental factors are classified as the physical, social or attitudinal world and may be facilitating or hindering. Personal factors may include socio-demographic data , co-morbidities, fitness, lifestyle, coping mechanisms and psychological status. The studies included focused on different aspects of personal factors. Williams and Bowie  focused et al.  focused  (et al.  focused et al. (facilitators related to the rehabilitation process: being treated with humanity by health professionals, being acknowledged as individuals, having their autonomy respected, having confidence and trust in health professionals, and exchange of information.In addition, with regard to the contextual factors, barriers to as well as facilitators of rehabilitation services are found in the physical, social and attitudinal environment in which people live and conduct their lives. Mangset et al.  used sembarriers to rehabilitation included that their needs were not met by health professionals in terms of activities of daily living, lack of communication, lack of resources in the areas of psychology, speech therapy and neuropsychology, lack of education given to the disabled, and lack of community awareness regarding disability.Williams and Bowie  used intet al. (facilitators identified by the participants in this study included provision of information, doctors having good skills, easy access to doctors, good understanding of rehabilitation services, confidence in the value of rehabilitation services, and easily accessible rehabilitation services.Zongjie et al.  used a set al. (barriers to rehabilitation as being that rehabilitation was not personalised to the needs of the patient and there was not enough support for patients.Vincent et al.  used focet al. (barriers: poor facilities, equipment and procedural accessibility issues, poor transportation, poor appointment scheduling, poor patient-provider communication, professional manner, disability-specific knowledge, personal motivation, cognitive issues, information and self-education, and lack of a personal doctor or usual source of care.Kroll et al.  used focBarriers to rehabilitation included the following: ineffective health and rehabilitation professionals, family members as part of rehabilitation process were devaluing the clients, rehabilitation was associated with unwanted dependency and social discomfort, and dissatisfaction with the help received. Facilitators included meaningful assistance from health and rehabilitation professionals, having therapeutic relationships with health and rehabilitation professionals, and being assertive and independent in rehabilitation.Lastly, Crisp  used intThe services utilised by participants included rehabilitation medical services, psychological services and social services. Rehabilitation education was provided as part of the rehabilitation process.The aim of the current study was to explore the literature on rehabilitation services for people with physical disabilities, in order to identify the barriers to and facilitators of accessing such services. Within the context of the ICF it is important to consider various factors that influence an individual’s reason to access health services, such as policies, individual and contextual factors.The PHC approach includes five types of care, namely promotive, preventive, curative, rehabilitative and palliative. Within this approach health care must be accessible, affordable, appropriate and accountable. Five of the studies included in the review were from developed countries that adopt a health care system similar to the PHC approach. et al.et al. (It is evident from the studies that patients with varying conditions access rehabilitation services and that they have positive and negative experiences regarding the service. Participants’ service-related expectations were the same; they both complimented and were dissatisfied with rehabilitation service received. Although four of the six studies reported on the education level of participants, conclusions cannot be drawn to how this has influenced experience with rehabilitation services. Literature indicates, however, that receiving health information from health professionals such as physicians is an important measure for increasing knowledge amongst users of the service as they are perceived to have clear knowledge about conditions (Tian .et al.  highlighet al.et al.et al.One of the main outcomes of the review was that clients with physical disabilities identified health professionals’ attitude towards them as both a facilitator and a barrier. Respect and empathy were highlighted as facilitators. On the other hand, people with disabilities were concerned about health professionals who focused on their disabilities and not their health. A client-centred approach is favoured in the literature, which emphasise that clients regard respect, autonomy and acknowledgement as individuals as important aspects (Mangset It is evident from the review that there are mixed emotions about rehabilitation services. This review therefore highlights for rehabilitation practitioners the gaps that need to be addressed to make this service a comprehensive one. It is also evident from the review that contextual factors play a major role in understanding the impact of disability and the need for rehabilitation services. The factors highlighted in this review allow the consideration of patient-centred service provision models to be explored further.This review has several limitations. Because only English language articles were included, it is possible that this review is a not complete representation of the available evidence. In addition, the databases accessed was limited to those available at a single institution and thus could present a publication bias. As both qualitative and quantitative articles were included it was difficult to compare the results of the studies.


In the 1940s Charles Huggins reported remarkable palliative benefits following surgical castration in men with advanced prostate cancer, and since then the androgen receptor (AR) has remained the main therapeutic target in this disease. Over the past couple of decades, our understanding of AR-signaling biology has dramatically improved, and it has become apparent that the AR can modulate a number of other well-described oncogenic signaling pathways. Not surprisingly, mounting preclinical and epidemiologic data now supports a role for AR-signaling in promoting the growth and progression of several cancers other than prostate, and early phase clinical trials have documented preliminary signs of efficacy when AR-signaling inhibitors are used in several of these malignancies. In this article, we provide an overview of the evidence supporting the use of AR-directed therapies in prostate as well as other cancers, with an emphasis on the rationale for targeting AR-signaling across tumor types. Androgens, or male sex hormones, have a wide range of functions, including promoting the development of male secondary sexual characteristics, stimulating erythropoiesis, increasing metabolic rate, increasing bone density and stimulating libido . In men,The AR is a member of the nuclear hormone receptor family of transcription factors, which also includes the estrogen receptor (ER), glucocorticoid receptor (GR), progesterone receptor (PR) and others ,3. Like PSA) are usually expressed even in men progressing on androgen deprivation therapy (ADT), with AR pathway alterations commonly observed in late stage disease   . In vitrosamine] ,95.Kawahara and colleagues recently published a paper describing a series of in vitro and in vivo experiments in AR-positive and AR-null bladder cancer models . They foAndrogen receptor is expressed in the distal and proximal tubules of normal kidneys and is expressed in approximately 15% to 42% of renal cell carcinomas (RCC) ,98,99. IIn a study evaluating AR transcript levels using real-time PCR, it was found that AR mRNA expression levels correlated with pathologic T stage and cancer specific survival. Multivariate regression analysis found AR transcript levels were independently associated with cancer specific survival. Of note, AR mRNA levels did not differ between sexes.A more recent analysis of the TCGA data revealed that high AR protein and transcript levels was associated with improved overall survival in patients with clear cell RCC (the most common pathologic subtype), but not other histologic subtypes of RCC  . InteresIn vitro experiments have reported that exposure to DHT causes proliferation in AR-positive RCC cells, while enzalutamide can reduce cell viability . Other gAlthough the incidence of AR expression is not well defined in pancreatic cancer, AR does appear to be expressed . A numben = 49) in patients with both localized and metastatic pancreatic cancer [p = 0.079, Wilcoxon; p = 0.01, log-rank). Several other studies in patients with pancreatic cancer have not shown hormonal therapies to be beneficial, however [Greenway reported the results of a randomized trial comparing flutamide  vs. placebo , although, like pancreatic cancer, the incidence has not been well defined ,125,126.In 1998, Risch hypothesized that epithelial ovarian cancers may develop as a result of androgens stimulating epithelial cell proliferation, and as it stands, a number of lines of evidence support the role for AR-signaling in the pathogenesis of the disease ,138. AR A handful of clinical trials testing AR-signaling inhibitors in women with ovarian cancer have been completed, with no clear signs of activity. A single-arm Phase II study testing flutamide in ovarian cancer patients progressing on platinum chemotherapy has previously been reported . Out of Similar to prostate and breast cancer, endometrial cancers are hormonally dependent, and hormonal agents targeting ER-/PR-signaling are options for select patients . Given tAR appears to be hypomethylated in mantle cell lymphoma—indicating that epigenetic silencing of AR gene expression may not be present in mantle cell lymphoma [Mantle cell lymphoma shows a male predominance, and interestingly, male sex appears to associate with higher mortality based on a retrospective SEER analysis . While ilymphoma ,159. To n = 10) reported a clinical benefit when ADT—most often single agent bicalutamide—was given to patients with salivary ductal carcinoma, with 50% of patients experiencing clinical benefit  [AR is expressed in the majority of lacrimal gland ductal carcinomas, and as a result AR staining is often used as part of the workup to confirm the diagnosis ,165,166., n = 2) . A case , n = 2) . A singlAR signaling is involved in a number of normal physiologic processes, and there is varying levels of evidence for its role in promoting cancer growth and progression across an array of malignancies. To date, prostate cancer remains the only malignancy with Level 1 evidence supporting the use of AR-directed therapies as an integral part of its treatment paradigm. However, mounting preclinical, epidemiologic and early phase clinical trial data support the further exploration of these drugs in diseases as varied as breast and salivary gland cancers, and it is likely that in the ensuing decade next generation AR-directed drugs will extend their reach beyond prostate cancer.


There are few studies of careful examination of wildlife casualties in Wildlife Rehabilitation Centers. These studies are essential for detecting menaces to wild species and providing objective criteria about cost-benefit of treatments in those centers. The release rate is considered the main outcome indicator, but other parameters such as length of stay at the center and a cost-benefit index expressed as number of released animals per euro and day, could be used as reliable estimators of the rehabilitation costs.A retrospective study based on 54772 admissions recorded from 1995–2013 in the database of the Wildlife Rehabilitation Center of Torreferrussa  assessed the morbidity, outcomes and cost-benefits of the rehabilitation practices.Three hundred and two species were included: 232 birds (n = 48633), 37 mammals (n = 3293), 20 reptiles (n = 2705) and 13 amphibians (n = 141). The most frequent causes of admission were: 39.8% confiscation of protected species (89.4% passerines), 31.8% orphaned young animals  and 17.4% trauma casualties (46.7% raptors and owls). The highest proportion of releases was found in the captivity confiscation category [87.4% passerines (median time of stay: 12 days)], followed by the orphaned category . For the trauma group, 46.8% of releases were hedgehogs (44 days) and 25.6% owls (103 days). As regards the cost-benefit index, the trauma casualties and infectious diseases had the worse values with 1.3 and 1.4 released animals/euro/day respectively, and were particularly low in raptors, waders, marine birds and chiroptera. On the contrary, captivity (4.6) and misplacement (4.1) had the best index, particulary in amphibian, reptiles and passerines.Cost-benefit studies including the release rate, the time of stay at the center and the cost-benefit index should be implemented for improving management efficiency of the Wildlife Rehabilitation Centers. Wildlife Rehabilitation is defined as the treatment and temporary care of injured, diseased and displaced indigenous animals, and the subsequent release of healthy animals to appropriate habitats in the wild . BenefitThe information recorded in the WRC can become a material of great value for conservation, providing evidence of the natural or anthropogenic menaces for the species. Although there are many morbidity studies in wildlife ,6,7,8, mIn the present study, we analyze 54772 cases attended at the WRC of Torreferrussa, comprising 302 different wild species in a 19-year-long period, including primary causes of admission (morbidity), release and death rates (as main outcome indicators), the rehabilitation stay period in the center and a cost-benefit index as an approach to calculate the rehabilitation costs. In order to improve our understanding and the efficiency of the rehabilitation process, our objective was to evaluate the relative importance and temporal variation of different primary causes of admission during the study period, as well as to evaluate the effectiveness of the rehabilitation in different taxa and in relation to these primary causes.A retrospective study was performed using the original medical records of the animals admitted at the WRC of Torreferrussa . The center receives animals from Catalonia, mainly from the North and Central areas. Catalonia is a state of Spain located at the Mediterranean subregion of the western Palearctic (3°19’-0°9’ E and 42°51’-40°31 N). Wild animals admitted alive from 1995 to 2013 were included in the analyses. Any domestic or exotic species, non-wild born individuals or captive born cases, as well as any case with a total lack of information about the patient were excluded from the analysis.The rehabilitation center is under the direction of the Catalan Wildlife-Service, who stipulates the management protocols and Ethical Principles according to the Catalan  and SpanFor each individual admitted to the center we recorded species, sex and age. For statistical analysis, species were grouped in the following broader taxonomic categories: Amphibians (including Anura and Caudata), Reptiles (including Testudines and Squamata), Mammals , Diurnal birds of prey (Accipitriformes), Owls (Strigiformes), Marine Birds , Herons and allies , Waders (Charadrifomes), Other Aquatic birds , Swifts (Apodiformes), Passerines (Passeriformes) and Other birds . Sex was determined when possible by inspection in dimorphic species or by gonadal examination at necropsy. The age was categorized as “first calendar year” and “>1 year calendar” for all the animal groups .The categories and subcategories of the causes of admission were based on the primary diagnoses ,18. BrieA prognostic scoring was defined according to the severity of the illness or injury at the moment of the admission, including the following categories: 1, apparently healthy; 2, mild weakness or thinning, uncomplicated fractures; 3, severe  and 4, very severe .r: number of animals released to the wild/total number of animals admitted), 2) Euthanasia rate , 3) Mortality rate , and 4) Captivity rate .After admission a bird could follow four different outcomes: 1) Euthanasia, which was humanely assisted death applied to animals with low prognosis or low quality of life, 2) Unassisted death, which occurred during treatment of some animals, 3) Release to the wild, of successfully healed individuals with good perspectives to adapt in the wild, and 4) Captivity, for non-releasable animals that were kept permanently captive, due to their poor prognosis of survivability in the wild. According to these categories, four outcome indicators of the final dispositions of the rehabilitation process were considered and expressed as a rate between the number of cases of each category by the total number of admissions in a given period of time : 1) Reles) in the center was used as the basic estimator or approach for assessing the cost of the rehabilitation process. This parameter (Ts) was defined as the length of time that the animal was retained in the center, that is, the period in days from the date of admittance to the date of release or death of the animal. In order to study the Ts, the percentiles 10 (P10) and 90 (P90) of this variable were selected as cut-off points.The time of the rehabilitation stay  * number of animals) for each taxonomic group and cause of admission and prognostic category. The daily cost per animal was assumed the same for all species along the rehabilitation process. In order to estimate the daily cost per animal, we selected data from 2008 to 2012. Thus, the average expenses of the WRC , were divided by the product [(number of cases/year)* 365 days)], obtaining a value of 0.19 euros/animal/day. Therefore, this estimator expresses the number of released animals per euro of expenses per day of stay, along the period of the study.The variable “People that brought the animal” included: Rangers, Others Police Authorities, Private individuals, Others and Unknown.50) and Percentiles 10 and 90  were provided for the descriptive analysis of the cost-benefit of the rehabilitation process.Descriptive statistics, normality test and inferential analyses were done using 95% of confidence intervals (95%CI) with SPSS Advanced Models ™ 15.0 . Morbidity and outcome studies were analyzed for variation among the different groups of animals, seasons or among years of the study. Comparisons of the median were evaluated using the U-Mann-Whitney and Kruskal-Wallis test. Chi-square or Fisher exact tests were used for comparisons between the causes of admission, outcomes rates, sex, age and taxonomical categories. Linear regression model was used to estimate the trend of the causes of admission and final dispositions during the period of study. Mean, Confidence Intervals of 95% (CI95%), Median  of the total cases admitted for rehabilitation.The revision process was done in 65335 admission reports. Most of the animals were brought to the WRC by the competent authorities, such as the Rangers (75%), other police authority’s (9%) and by private citizen (12%). The final sample for the study included 54772 cases . The final study population included 302 different species : most ofBirds accounted for 48633 (89%) admissions, followed by 3293 (6%) Mammals, 2705 (5%) Reptiles and 141 (0.3%) Amphibians. As regards to the sex, 16926 (31%) animals were males, 7865 (14%) females, and 29981 (55%) were undetermined. Within the male group, 10661 animals were finches, representing 63% of the males included in the study. As regards to age, 29549 (54%) of admissions were first calendar year animals, 16376 (30%) were >1 calendar year animals and 8874 (16%) were of undetermined age.Anthropogenic interferences were involved in 64% of the admissions . “CaptivFurther analysis of the trauma category showed that 73% of the trauma were classified as of unknown origin (lack of information about the circumstances of the trauma or accident). Twenty-percent of traumas were due to gunshot (10%) and collision with vehicles (10%) . DiurnalMisplacement is an important reason of bringing to the Wildlife Rehabilitation Centers in reptiles  and hedgehogs (31%). Finally, note that in the miscellanea "Other" has been included causes with a very small number of cases, but relevant from the point of view of the impact of human activity, such as poisoning (25 cases), bycatch (37 cases) and oiled birds (54 cases).Primary infectious and parasitic diseases included a wide variety of conditions. Thus, aspergillosis, trichomoniasis, coccidiosis and other endoparasites, avian poxvirus, and E. coli and Salmonella spp infections were the most common diseases diagnosed in birds. In mammals, the most prevalent diseases were myxomatosis in rabbits, sarcoptic mange in carnivores and parasitic pneumonia and abscesses in hedgehogs.As regards to the distribution of cases along the calendar year, 48% were admitted in summer, 26% in spring, 15% in autumn and 11% in winter. The increase of cases during the spring and summer seasons was consequence of the onset of reports of orphaned animals which represented 38% and 48% of the admissions respectively. In autumn and winter, illegal captures (54–56%) and traumas (30–27%) were the most common causes of admission.2 = 0.82; b = 271.55; p<0.001). Among them, orphaned , and animals suffering from trauma , metabolic/nutritional  or infectious/parasitic diseases  had a significant increase. By contrast, in the trauma category, a slight decrease was observed in the collision with vehicles ; on the other hand, the slopes of regression for collision with buildings  and electrocution  were very close to 1. No trend was observed in gunshot reports .Year regression analyses showed a significant rise of the total number of attended animals along the years of study (Rr = 13%), 12280 animals died during the rehabilitation process (Mr = 22%), 493 were kept in captivity (Cr = 1%), and 34722 animals were released (Rr = 63%).Overall, 7277 animals were euthanized  was reported in the orphaned waders (56.7%), herons (45.3%), passerines (29.3%) and swifts (27.8%) , waders (24.7%) and artiodactyla (16.6%) had the lowest release ratebove 75% . By cont (27.8%) .r . The median days of stay at the centre was 17 days  for released animals, 3 days for natural death  and 0 days for euthanized .Overall, the median Ts were observed in diurnal birds of prey and owls with around two months of hospitalization  and by contrast, misplacement had the shorter time (3 days). Trauma has the higher Ts (P90 = 284), independent of the zoological group. Importantly, hand-rearing orphans had median Ts between 20–60 days, with values around 20 days in swifts and other bird categories, which represent the largest number of chicks. On the other hand, both infectious diseases and metabolic and nutritional were associated with high recovery times, especially in hedgehogs, carnivore, owls and birds of prey. Finally, it was noteworthy the high Ts of birds of prey that have been kept illegally in captivity.In the group of released animals, the longest Tlization . In mammAs regards of the cost-benefit index, the best values were observed in amphibian, reptiles and passerines, with values ranging from 4 to 5 released animals per euro and day . On the It is important to take into consideration that the purpose of the Wildlife Rehabilitation Centers (WRC) is the release of healthy animals to the appropriate habitats in the wild after a temporary care in captivity. For this reason, the evaluation of data about the rehabilitation practice is essential to have reference values for comparison purposes among different WRC in order to critically analyze the protocols and improve efficiency if necessary in each center. To our knowledge, the present epidemiological study is one of the largest and long-term studies conducted in a WRC. Data reported in this study should have a significant impact in the morbidity analysis as regards the large number of animals (>55000) and diversity of species (>300) included. Moreover, it provides new information about outcomes and the cost-benefit estimators of the rehabilitation process that can be useful as a reference for professionals involved in wildlife medicine and management.It is well documented that anthropogenic factors are the most prevalent cause of admission in the WRC worldwide, representing up to 31% of the total admissions . In thisTestudo in the Mediterranean and Asia Minor regions [Illegal possession of reptiles, principally of tortoises for pet trade, is an important threat for species of the genus  regions ,25. In S regions . Moreove regions .The second leading cause of admission in this study was the orphaned young, representing a 32% of the cases. This percentage of orphaned was very similar to the 28% reported in United Kingdom  and the Trauma related with anthropogenic activities represented another important cause of morbidity. In our study, the trauma of unknown origin represents the largest number of admissions and shows an increasing trend, compared to other causes of injury. Unfortunately, this result can be explained by errors in the identification and classification of the origin of trauma, which are intrinsic to the collection of information in the Wildlife Rehabilitation Centers. A more detailed analysis of the trauma category has confirmed that collisions with vehicles are the second leading cause of injury, especially in mammals and birds, as in other reports . GunshotMisplacement was especially important in amphibians, reptiles and Insectivora (mainly hedgehogs). In most of these cases, those animals are found in the proximity of human settlements or buildings. Similar to the young category, living near humans, increases the possibility of contact of these animals with the public, especially in densely populated areas .Finally, the positive increase of the admissions due to primary infectious and metabolic diseases along the years of study might be consequence of the improvement in diagnostic and health protocols. In this kind of studies it is worthy to remark that mortality rates attributed to infectious or parasitic diseases or chronic poisoning may be underestimated, being a possible bias of the study. However, due to financial constraints at the WRC, we must assume such kind of bias since it is economically unaffordable a thorough analysis in all admitted cases.r) over 50% of the admissions, higher than previously reported outcomes in other generalistic Wildlife Rehabilitation Centers. In a recent review, an overall Rr = 40% has been published in the centres of the RSPCA in UK [r found in the “Captivity” and “Misplacement”, could be mostly explained by the large proportion of healthy animals, especially the recently captured birds. In fact, the severity of the clinical condition has been reported as the best predictor for the individual survival and release of wildlife casualties despite the species [In our study, the analysis of the rehabilitation outcomes showed an overall release rate  between 0–5 days and 7% stay more than 100 days [s is 9 days and the P90 is 69 days for the overall cohort. Due to the non normal distribution of this variable, this variable should be presented as median and percentiles.Importantly, the early assessment of prognosis and suitability for release is crucial in order to avoid unnecessary suffering of wildlife attended in Wildlife Rehabilitation Centers . For thi100 days . In our s was introduced as an estimator of the cost of the rehabilitation process, since each day of hospitalization in the center represents a cost in staff, food and medicines. Although this is not a complete measure of the real cost, this parameter can be an indication of resource usage, and be useful as a rough approach to efficiency [s of 12 days). By contrast, poached birds of prey had the longest stay (128 days), mostly due to plumage and behavior abnormalities. Orphaned young passerines and swifts had also shorter stays than birds of prey and owls. Indeed, swifts represented 20% of the admitted hand-reared birds with a median stay of 19 days and a P90 of 40 days. Within the overall group of the orphaned young, the P90 was higher than 5 months as a result of the management policies of the center which does not allow releasing young animals during the winter months, especially mammals as bats and hedgehogs. Finally, trauma-related casualties were in general time-consuming, with long Ts and in consequence less efficient saving costs; in birds of prey were especially long (Ts = 114 days of median) because of the muscle-skeletal and nervous system injuries requires long clinical healing and rehabilitation. Similarly, conditions as infectious or metabolic diseases are also associated to long recovery times.Moreover, in our study, the Tficiency . Taken iEconomic evaluation (EA) is a quantitative technique developed by economists to promote the most efficient use of the resources. In human medicine, there are different studies of EA, as cost-effectivity, cost-utility or cost-benefit . The cosOne of the most important limitations in this study was to assume that the daily cost was the same for the different species, clinical conditions and husbandry protocols. Although this approach is not accurate, allows an overall success estimation of the rehabilitation process and the detection of differences between zoological groups and admission categories. Nevertheless, our analyses must be considered partial because we did not perform comparisons among different alternatives of health or rehabilitation protocols, according to the specificities of the causes of admission and the diversity of species. A correction factor for the cost-benefit parameter should be introduced in further studies to compensate for cost differences depending on the species or taxonomic categories.Finally, in Catalonia, the Wildlife Service is the only one that has competence in the care of wild species that are found injured or orphaned. For this reason most of the animals have been collected by the competent authorities from the wild or most of the time they picked up from citizens home. It should be noted that private citizens are the following group bringing animals directly to the WRC, as expected in an area so populated as the area of influence of the our center.In our opinion, the cost-benefit analysis of wildlife rehabilitation based on the admission causes and the prognostic category are complementary and useful for the detection of critical points in the clinical and husbandry protocols and the management of WRC. In conclusion, we suggest that an initial approach to cost-effectiveness studies of Wildlife Rehabilitation Centers should include both the outcomes indicators, the stay at the center and a cost-benefit index in the different zoological groups and primary cause of admission. In the future, it would be desirable to conduct more specific cost-effectiveness analysis to improve the overall performance of rehabilitation, both for economic reasons and in order to improve the animal welfare.


In silico docking studies for aPPD binding to AR, alongside transactivation bioassays and in vivo efficacy studies were carried out in the castration-resistant C4-2 xenograft model. Immunohistochemical (IHC) and Western blot analyses followed by evaluation of AR, apoptotic, cell cycle and proliferative markers in excised tumors was performed. The growth of established CRPC tumors was inhibited by 53% with aPPD and a corresponding decrease in serum PSA was seen compared to controls. The IHC data revealed that Ki-67 was significantly lower for aPPD treated tumors and was associated with elevated p21 and cleaved caspase-3 expression, compared to vehicle treatment. Furthermore, aPPD decreased AR protein expression in xenograft tumors, while significantly upregulating p27 and Bax protein levels. In vitro data supporting this suggests that aPPD binds to and significantly inhibits the N-terminal or the DNA binding domains of AR. The AR androgen binding site docking score for androgen (dihydrotestosterone) was −11.1, while that of aPPD was −7.1. The novel findings described herein indicate aPPD potently inhibits PCa in vivo partly via inhibition of a site on the AR N-terminal domain. This manifested as cell cycle arrest and concurrent induction of apoptosis via an increase in Bax, cleaved-caspase-3, p27 and p21 expression.We have explored the effects of 20(S)-protopanaxadiol (aPPD), a naturally derived ginsenoside, against androgen receptor (AR) positive castration resistant prostate cancer (CRPC) xenograft tumors and have examined its interactions with AR.  Despite the substantial progress made during the past two decades, PCa remains the third leading cause of cancer death among men in North America and accounts for about 10% of all lethal cancers  was employed for the in silico docking [To gain insight of into why aPPD cannot compete with DHT for ABS in spite of its structural similarity, we performed  docking . The pro docking . The cenH-tetrazolium (MTS) assay.PC-3 cells lacking the AR and authenticated by IDEXX Laboratories  were maintained in RPMI 1640 media (Life Technologies) and 5% FBS (Hyclone Thermo Fisher Scientific) at 37 °C and 5% CO2. Cultures were routinely monitored for mycoplasma contamination. Cells were seeded in 96-well plates  in RPMI 1640 medium with 5% charcoal-stripped serum (CSS) (Hyclone). After 24 h, cells were co-transfected with both NTD and pG5luc (10 ng each) or NTD-DBD and pARR3-tk-luciferase (5 ng each) using TransIT20/20 transfection reagent (3 μL/μg of DNA)  in Optimem serum-free media (Life Technologies) for 24 h according to the manufacturer's suggested protocol. At 24 h after transfection, cells were treated with either 0.1% DMSO (solvent control) or serial dilutions of increasing concentrations of aPPD. Enzalutamide (C-terminus inhibitors) and EPI-001 (N-terminus inhibitor), were used as positive controls. At 24 h after treatment, the medium was aspirated off and the cells were lysed by adding 60 μL of 1× passive lysis buffer (Promega) followed by shaking at room temperature for 15 min and two freeze/thaw cycles at −80 °C. Twenty microliters of lysate from each well were transferred onto a 96-well white flat bottom plate (Corning) and the luminescence signal was measured after adding 50 μL of luciferase assay reagent (Promega). The chemical oxidation of luciferin into oxyluciferin by the luciferase is accompanied by light production that can be quantified as luminescence by a TECAN M200Pro instrument. Each concentration was assayed in replicates n = 6, with a biological replicate of n = 3. The toxicity of aPPD (6.25-50 μM) was assessed in the same experimental conditions on non-transfected PC-3 cells using the 3--5-(3-carboxymethoxyphenyl)-2-(4-sulphophenyl)-2t-test (parametric). The level of significance was set prior at a P value of < 0.05.For each studied variable, mean and standard error of the mean (SEM) were calculated. Differences between the mean values of two treatment groups were analyzed using the Student


These latter outcomes are at the core of rehabilitation, yet rehabilitation services are often underdeveloped, underresourced, and undervalued.The world faces new challenges in light of health and demographic trends, populations are ageing, and the number of people living with noncommunicable diseases and the consequences of injuries is increasing.4 The prevalence of health conditions associated with severe levels of disability has increased by nearly 23% since 2005.5 However, in many parts of the world, the size of the rehabilitation workforce is insufficient. For example, in the World Health Organization African and Eastern Mediterranean Regions, the number of trained professionals required to meet the demand for rehabilitation services  is estimated to be a tenth of that required.4A dramatic increase in the absolute number of years lived with disability combined with a rising prevalence of severely disabling conditions has led to a demand for rehabilitation that is largely going unmet. Seventy-four percent of years lived with disability are the result of health conditions for which rehabilitation may be beneficial.7 An additional factor is a lack of awareness of the need for rehabilitation—what it is, what it does, and whom it may benefit. Rehabilitation comprises a set of interventions designed to reduce disability and to optimize functioning in individuals with health conditions in interaction with their environment. As such, it is not restricted to a minority group of persons with disabilities or those with significant long-term impairments. Rehabilitation is also relevant to people experiencing limitations in functioning associated with ageing, an injury, or other conditions. For example, evidence indicates that rehabilitation improves functioning for those who have had acute myocardial infarction or strokes, while it can also have positive results for those with musculoskeletal or mental health conditions.11Factors contributing to the unmet need for rehabilitation services include poor accessibility, transport barriers, high out-of-pocket expenses, and long waiting times.12 For example, rehabilitation has been found to be beneficial in reducing length of stay in hospitals and decreasing readmissions, thus mitigating the negative social and health risks associated with prolonged hospitalizations. In the context of complex conditions that require intensive and highly specialized rehabilitation, cost savings to both the individual and the health sector may be realized. By improving a person's ability to participate more fully in everyday life, rehabilitation reduces the costs related to ongoing care and support and may accelerate the ability to return to education or employment.The role that rehabilitation plays in maximizing the impact of other health services—such as surgical interventions, trauma care, and management of noncommunicable diseases—and its potential for significant cost savings are also frequently misunderstood and underestimated.4 These actions include the following: improving rehabilitation governance and investment, expanding a high-quality rehabilitation workforce, and enhancing rehabilitation data collection. The commitment to strengthen health systems to provide rehabilitation services should make it possible for millions of people not only to live longer but also to live well.Rehabilitation is part of universal health coverage and should be incorporated into the package of essential services, along with prevention, promotion, treatment, and palliation. To this end, on February 7, 2017, World Health Organization, Member States, international and professional organizations, nongovernmental organizations. and rehabilitation experts issued “Rehabilitation 2030: a call for action,” a commitment to key actions to strengthen rehabilitation services in Member States.


Hyperglycemia is common in extremely low gestational age newborns (ELGAN) and is associated with increased mortality and morbidity, including abnormal neurodevelopment. Hippocampus-mediated cognitive deficits are common in this population, but the specific effects of hyperglycemia on the developing hippocampus are not known.The objective of this study was to determine the acute and long-term effects of hyperglycemia on the developing hippocampus in neonatal rats using a streptozotocin (STZ)-induced model of hyperglycemia. STZ was injected on postnatal day (P) 2, and littermates in the control group were injected with an equivalent volume of citrate buffer. The acute effects of hyperglycemia on markers of oxidative stress, inflammatory cytokines, microglial activation, and reactive astrocytosis in the hippocampus were determined in the brain tissue collected on P6. The long-term effects on hippocampus-mediated behavior and hippocampal dendrite structure were determined on P90.On P6, the transcript and protein expression of markers of oxidative stress and inflammatory cytokines, including the CXCL10/CXCR3 pathway, were upregulated in the hyperglycemia group. Histological evaluation revealed microglial activation and astrocytosis. The long-term assessment on P90 demonstrated abnormal performance in Barnes maze neurobehavioral testing and altered dendrite structure in the hippocampus of formerly hyperglycemic rats.Neonatal hyperglycemia induces CXCL10/CXCR3 signaling, microglial activation, and astrocytosis in the rat hippocampus and alters long-term synaptogenesis and behavior. These results may explain the hippocampus-specific cognitive deficits common in ELGAN who experience neonatal hyperglycemia. Hyperglycemia (blood glucose concentration > 150 mg/dL [> 8 mmol/L]) is seen during the first 1 to 2 weeks after birth in 30–80% of extremely low gestational age newborns  . HyperglThe effects of hyperglycemia on the developing hippocampus are relatively unknown. The hippocampus is central to recognition memory and is vulnerable to injury during a variety of perinatal conditions . HippocaIn a previous study, using a neonatal rat model, we have demonstrated that recurrent episodes of hypoinsulinemic hyperglycemia upregulate poly(ADP-ribose) polymerase-1 (PARP-1) expression in the cerebral cortex , likely Among the chemokines in the brain, C-X-C motif chemokine ligand 10 (CXCL10) and its cognate receptor C-X-C motif chemokine receptor 3 (CXCR3) are important because of the role of CXCL10/CXCR3 signaling in neuronal function and synaptic activity . Both thCXCL10/CXCR3 signaling has been implicated in the pathogenesis of T1D, including pancreatic β cell destruction –24. SeruThe objective of our study was to determine the acute and long-term effects of hyperglycemia on the developing hippocampus in neonatal rats. The acute effects were determined by measuring the expression of CXCL10/CXCR3, PARP-1, and NF-κB, and their downstream targets, including apoptosis-inducing factor (AIF) and B cell lymphoma 2 (Bcl-2), and NMDA receptor (NR2B) expression. The long-term effects were determined by evaluating hippocampal dendritic architecture using microtubule-associated protein (MAP-2) immunohistochemistry, postsynaptic density protein (PSD) 95 protein expression, and performance in a hippocampus-mediated behavioral test (Barnes maze) at adulthood.Experiments were performed with the approval of the Institutional Animal Care and Use Committee of the University of Minnesota. Male and female Wistar rats were studied from postnatal day 1 (P1) to P90 (adulthood). Pregnant dams were purchased  and housed under standard laboratory conditions on ad lib diet and 12:12 h light and dark cycles.Hyperglycemia was induced using streptozotocin (STZ) , a model that was adapted from previous studies –31. STZ To confirm that the effects are due to hyperglycemia and not the administered STZ, a separate set of rats was subjected to recurrent hypoinsulinemic hyperglycemia twice daily from P3 to P12 using a previously described model from our lab . BrieflyRats subjected to STZ-induced hyperglycemia and control rats were killed on P6 or P90 using sodium pentobarbital . Animals subjected to the recurrent hyperglycemia were killed on P13. The brain was removed, and the hippocampus was dissected on ice, then flash-frozen using liquid nitrogen, and stored at − 80 °C until analysis. Rats used for histochemical analysis underwent in situ transcardial perfusion-fixation with paraformaldehyde before brain removal as in our previous studies .n = 6–12/group) were assayed in duplicate using ribosomal protein s18 as control. Some experiments were repeated using GAPDH as control to confirm the observed results.Transcript expression in the hippocampus was determined using commercial primers  and a gene expression kit  as previously described from our lab . Samplesn = 4–6/group) [Protein concentrations of CXCR3 and PSD95 in the hippocampus were determined using 20 μg of hippocampal homogenate and primary antibodies against CXCR3 and PSD95  and β-actin  using previously published methods (6/group) . Followihttps://imagej.nih.gov/ij/) and the total number of cells/mm2 was determined . Anti-S100β protein  was used to quantify immunoreactive astrocytes in the hippocampus, which were counted in a similar manner at × 20 magnification  as the microglia.The coronal brain sections (20 μm) corresponding to 0.8 to 2.6 mm anterior to the interaural line in an age-appropriate rat brain atlas  were obtThe cellular origin of CXCL10 (Bioss 1:100) was determined by colocalizing with GFAP, NeuN, and Iba1. The cellular origin of CXCR3 (Novus 1:100) was determined by colocalizing with NeuN , Iba1 , and GFAP  using previously described methods .On P90, the dendritic structure of the hippocampus was determined by staining for microtubule-associated protein-2 (MAP-2) as previously described . The mean = 18) and control (n = 21) rats were tested for hippocampal function on P90 for a total of 7 days during the light phase (6 am to 6 pm) on the Barnes maze [STZ . Then they were trained for an additional 2 days followed by probe 2. The rats in both groups were trained for three trials per day with an inter-trial period of 5 min. The maze and goal location chamber were cleaned with 70% ethanol between each trial to eliminate odor cues. Each trial began with the lights off in the room and the animal placed in the center of the maze beneath an opaque container.To begin the trial, bright overhead lights were turned on to serve as an aversive stimulus, the opaque container was removed, and the rat was given 3 min to explore the maze and find the goal location . If the t tests . Barnes maze data were analyzed using mixed-model multifactorial ANOVA with day and treatment as independent factors and rats as a random event variable. Statistical significance was set at alpha < 0.05.All data are reported as mean ± SEM. The control and hyperglycemia groups were compared using two-tailed unpaired p < 0.01. By P14, the difference between STZ and control animals’ blood glucose values were less pronounced but still significant .Hyperglycemia was observed by 24 h after the STZ injection with a mean blood glucose concentration of 265.4 ± 14.5 mg/dL on P3. Hyperglycemia was sustained until P6, at which time the mean glucose value was 267.1 ± 27.6 mg/dL. The mean blood glucose concentration from P3 to P6 was 144.1 ± 2.5 mg/dL in the control group. All these intergroup differences were statistically significant, p < 0.05). Subsequently, the animals in the STZ group continued to remain 20–24% lighter until P6 . However, the STZ group had higher blood glucose levels compared with the control group in the fed state . Male rats in the STZ group had a lower body weight on P90 compared with the control group . This difference was not present for female rats .On P90, there was no difference between the control and STZ groups in blood glucose levels after overnight fasting .The mean blood glucose concentration in the recurrent hypoinsulinemic hyperglycemia model was 217 ± 17 mg/dL . Transcript expression of AIF was not altered, while Bcl2 was upregulated 60% and NR2B mRNA expression was downregulated 40% in the STZ group (Table The transcript expression of PARP-1 was upregulated by 58% and that of NF-κB was upregulated by 276% in the STZ group relative to the control group (p < 0.05). CXCR3 protein expression was 10% higher in the STZ group  and 442% , respectively, in the recurrent hyperglycemia group compared with the control group.CXCL10 and CXCR3 transcript expression were upregulated by 97%  = 163.92, p < 0.0001) after collapsing across both probe sessions. While there was no significant main effect of hyperglycemia on guess rate  = 0.49, p = 0.48), there was a significant interaction between hyperglycemia and guess type  = 9.31, p < 0.01). Rats in the STZ group made fewer “good guesses” and more “bad guesses”  (es” Fig. .Fig. 5Thp < 0.05; Fig. p < 0.05; Fig. The effect of neonatal hyperglycemia on the dendritic structure in the CA1 region of the adult hippocampus is shown in Fig. Understanding how high glucose levels affect the developing brain is important because it impacts clinical decision-making. Currently, treatment of hyperglycemia in preterm infants is highly variable and controversial and involves restricting glucose infusion and/or insulin therapy . Better Our study demonstrates that hyperglycemia comparable in severity to that experienced by the ELGAN is associated with growth deceleration and evidence of oxidative stress and inflammation in the hippocampus in the neonatal period, as well as long-term negative effects on hippocampal dendrite development and function in adulthood in rats. These findings are consistent with clinical data reporting restriction of somatic and brain growth  and impaWe sought to use an animal model of hyperglycemia that was similar in etiology, severity, and duration to that seen in the ELGAN population. Although hyperglycemia experienced by these extremely preterm infants is multifactorial in nature , our STZOur previous study demonstrated that hyperglycemia is associated with PARP-1 and NF-κB upregulation and microgliosis in the cerebral cortex , likely Abnormal CXCL10/CXCR3 signaling may be responsible for the decreased synaptic density and abnormal performance in Barnes maze at adulthood, likely by altering NMDA receptor expression  and glutAnimals in the STZ group had higher blood glucose concentration in the fed state at adulthood. This is consistent with previous data in this model . While hAlthough our model was well suited for assessing the effects of hyperglycemia, it did not account for the other components of neonatal hyperglycemia in human preterm infants, including dextrose infusion and treatment with insulin. In adults with diabetes, glucose fluctuations have a greater triggering effect on oxidative stress than chronic sustained hyperglycemia , althougFinally, this study focused on the hippocampus and hippocampus-mediated learning. However, other functional deficits are also common in extremely preterm infants, for example, deficits in executive function , 59. As In summary, we found that hyperglycemia in newborn rats induces CXCL10/CXCR3 signaling, microglial activation, and astrocytosis, and alters long-term synaptogenesis and function in the hippocampus. Therefore, efforts at minimizing neonatal hyperglycemia should be considered in the ELGAN, so as to reduce the risk of adverse neurodevelopment, in a patient population that is already vulnerable to brain injury from additional comorbidities.


Wedelia chinensis herbal extract, and act synergistically to inhibit the AR activity in PCa. Here, we further demonstrated that an herbal extract of W. chinensis (WCE) effectively disrupted the AR, HER2/3, and AKT signaling networks and therefore enhanced the therapeutic efficacy of androgen ablation in PCa. Furthermore, WCE remained effective in suppressing AR and HER2/3 signaling in an in vivo adapted castration-resistant PCa (CRPC) LNCaP cell model that was insensitive to androgen withdrawal and second-line antiandrogen, enzalutamide. This study provides preclinical evidence that the use of a defined, single plant-derived extract can augment the therapeutic efficacy of castration with significantly prolonged progression-free survival. These data also establish a solid basis for using WCE as a candidate agent in clinical studies.Crosstalk between the androgen receptor (AR) and other signaling pathways in prostate cancer (PCa) severely affects the therapeutic outcome of hormonal therapy. Although anti-androgen therapy prolongs overall survival in PCa patients, resistance rapidly develops and is often associated with increased AR expression and upregulation of the HER2/3-AKT signaling pathway. However, single agent therapy targeting AR, HER2/3 or AKT usually fails due to the reciprocal feedback loop. Previously, we reported that wedelolactone, apigenin, and luteolin are the active compounds in  Androgen receptor plays a critical role in the development and progression of PCa, and therefore androgen-deprivation therapy (ADT) is usually the first-line treatment for metastatic disease. Androgens bind and activate AR transcription factor to regulate many signaling pathways for PCa cell viability, proliferation and invasion . AlthougAltered PI3K signaling including PTEN loss is well characterized in PCa with 42% in primary tumors and 100% in metastases . ActivatWedelia chinensis and exhibit anti-tumor function by inhibiting AR activity and clonogenic growth in PCa cells   . In addict (WCE) , 2015. Pct (WCE) . And, wect (WCE) . HoweverAntibodies to HER2, HER3, AKT1, phospho-AKT1 (S473) and PARP1 were purchased from Cell Signaling . Antibodies to cytokeratin-18, phosphor HER3, Ki-67 and GADPH were purchased from Abcam . Anti-pAKT (S473) for IHC staining was from GeneTex . AR antibody was from Santa Cruz Biotechnology . Antibodies to phoso-HER2 and cleaved caspase 3 came from Merck Millipore .in vivo measurement of tumor growth, the cell lines were stably transfected with firefly luciferase luc2 of pGL4  driven by a hybrid EF1α/eIF4g promoter through lentivirus infection . All cell lines were authenticated by comparing them with the ATCC database of short tandem repeat DNA profiles. For nfection . All celW. chinensis plant was performed based on sequencing results of the internal transcribed spacer DNA sequence (ITS) analysis compared with the reference in NCBI databank (Accession: AY947415.1). The whole fresh plants were air-dried, ground and extracted by immersion with ethanol. After condensing, the ethanolic extract was acid-hydrolyzed with HCl at pH 2.0, at 80°C for 30 min to increase aglycone flavonoid content, then neutralized with NaOH and applied to flash LC with a C18 column  to separate the extract into fractions. To assure consistent WCE quality, the chemical profiles of all WCE lots were analyzed by HPLC-CAD, quantified by triple quadruple LC-MS for contents of wedelolactone, apigenin and luteolin, and analyzed by PSA reporter assay for AR-inhibitory activity.The plant materials are cultivated in a greenhouse in Annan District, Tainan City, Taiwan and authentication of the Wedelia chinensis was dissolved in DMSO for in vitro studies. For in vitro mimic of the castration effect, cells were incubated in medium containing 10% CD-FBS with indicated treatments of vehicle control, 5α-dihydrotestosterone (DHT), or WCE for 2 days. After treatment, cell lysates were prepared by lysis with RIPA buffer supplemented with protease and phosphatase inhibitor cocktails (Thermo Fisher Scientific) for immunoblotting. A quantitative polymerase chain reaction (qPCR) analysis was conducted using a Thermo Fisher scientific SYBR Master Mix and an ABI 7500 real-time PCR system. Raw counts were normalized to GAPDH (ΔCt) and values are presented as fold change relative to vehicle-treated control (2-ΔΔCt). For cell growth assay, 5000 cells were seeded in 96-well plates overnight and treated with different concentrations of WCE for 4 days. The readout of cell number was measured by CyQUANT Direct Cell Proliferation Assay (Thermo Fisher Scientific).4) that were stable clone transfected with PSA promoter-Luciferase gene were grown on 96-well plates with RPMI-1640 medium containing 10% CD-FBS for 18 h. The culture was refreshed with the same medium containing treatments as indicated in the figures and grown for another 18 h. Cells were lysed by passive lysis buffer (Promega) and luciferase assay was performed by luciferase assay system (Promega). Luciferase activity was measured by VICTOR3 counter  and data were normalized to lysate protein as measured by Coomassie (Bradford) Protein Assay Kit (Thermo Fisher Scientific). Inhibition of AR by each treatment was calculated by relative luciferase activity induced by 10 nM DHT as 0% inhibition and vehicle as 100% inhibition.For luciferase activity, 22Rv1/103E cells  of tumors, mice received D-luciferin at 150 mg/kg by intraperitoneal injection at 10 min prior to imaging and tumor growth was monitored once per week. For ex vivo BLI of lung tissues, mice were sacrificed by CO2 overdose and lung tissues were removed, immersed in DPBS and imaged for 10 s. The images were acquired with a Xenogen IVIS 50 Imaging System and quantitatively analyzed with Living Image 2.50 software (PerkinElmer).Athymic nude mice (6 weeks old) were obtained from the National Laboratory Animal Center (Taiwan) and all animal work was conducted in accordance with a protocol approved by the Institutional Animal Care and Use Committee, Academia Sinica. For orthotopic implantation, male mice were anesthetized by 2.5% isoflurane and 2 × 10n = 6) were examined following staining.The formalin-fixed, paraffin-embedded tissue sections were deparaffinized and hydrated in a series of graded alcohol to water. After antigen retrieval, tissue sections were incubated with specific antibodies for 1 h at room temperature. PromARK micro-polymer detection systems  were used to detect the primary antibodies. All images were captured with a Zeiss AxioCam HRc camera attached to a Zeiss AxioImager.Z1 microscope . For determination of positive cells, the random five fields per tumor sections (50) values of PSA reporter assay were calculated using GraphPad Prism 6.0  using non-linear regression. The significant differences between the groups were compared with Student’s t-test (two-tailed) by the same software. A P-value of less than 0.05 was considered statistically significant. All values presented in the study were expressed as means with standard error (SEM).The median inhibition concentration . Furthermore, high-dose of WCE (50 μg/mL) induced a 64 and 39% increase, respectively, in the sub-G1 fraction in LNCaP and 22Rv1cells. In apoptotic cells, caspases cleave PARP1 (110-kDa) into 86- and 24-kDa fragments. Immunoblotting of PARP1 showed that the WCE treatment caused a dose-dependent rise and fall of the cleaved 86-kDa fragment and intact PARP1 in 22Rv1 and LNCaP, not PC-3 or DU145 cells . These results suggest that WCE induced caspase-dependent apoptosis in AR-positive PCa cells, not in AR-negative PCa cells. Due to the promising suppression in AR-positive PCa cells, we next determined the WCE effect on AR expression in LNCaP and 22Rv1 cells and found that WCE significantly inhibited the AR expression in PCa cells . As determined by qRT-PCR analysis, the WCE effect on AR was at least in part due to a decrease in AR expression at the transcript and protein levels in PCa cells . Our analysis of WCE responsive genes in 22Rv1 cells using microarray and Gene Set Enrichment Analysis (GSEA) identified a group of androgen responsive genes . Genes of FKBP5, STEAP1 and TMPRSS2 are AR target genes with functional androgen-responsive elements in their promoters. As analyzed by qRT-PCR, these AR-responsive genes were dose-dependently downregulated by WCE in both 22Rv1 and LNCaP cells . EZH2 and monoamine oxidase A (MAOA) were correlated with worse clinical outcomes in PCa patients . Interestingly, the WCE regulated genes are also downregulated in AR-negative PCa cells except MAOA and TMPRSS2 did not reach statistical significance. It is worth noting that the truncated AR arising from alternative splicing in 22Rv1 was also downregulated by WCE treatment . The C-terminally truncated AR protein lacking the ligand-binding domain (ΔLBD) was constitutively nuclear and actively bound to DNA independent of androgens, resulting in androgen-independent expression of AR target genes and PCa growth  induced apoptosis in LNCaP and 22Rv1 cells with 12% and 13% increases, respectively, in the sub-G1 population, while causing cell cycle arrest in the G2/M phase in PC-3 cells . Downstream of HER2/3, AKT phosphorylation at S473 was suppressed after WCE treatment in all four cell lines . Next, we determined whether the effect is regulated at the transcriptional level. In 22Rv1 cells, HER2 mRNA was dose-dependently upregulated by WCE treatment . This is consistent with previous reports that inhibition of AR transcriptional activity in 22Rv1 cells induced HER2 expression . WCE-mediated transcription of HER3 in PCa cells is not fully constant with respective HER3 protein level, especially at low dose of WCE treatment, suggesting that posttranslational regulation may also be involved in WCE-mediated HER3 degradation . Although WCE treatment raised HER2 expression in 22Rv1 cells, WCE also reduced the AKT expression to impair HER2/3 signaling . The mRNA level of AKT was unaffected by WCE, suggesting translational or posttranslational regulation of WCE-mediated AKT expression was involved . WCE decreased the expression of HER2 and HER3 at the protein and mRNA levels in PCa cell lines except HER2 expression in 22Rv1 cells. Consistently, AR-expressing PCa cell lines were more sensitive to WCE than AR-negative cell lines. Of note, WCE effectively disrupted the crosstalk between the HER2/3-AKT pathway and AR signaling in LNCaP and 22Rv1 cells.Previous study has indicated that suppression of AR signaling leads to upregulation of HER2/3 signaling and AKT reactivation, which can stabilize the AR and contribute to the eventual failure of ADT . To detepression . However-9 mol/L DHT). In androgen-dependent LNCaP cells, lack of androgen significantly decreased the expression of AR protein but increased the expression of HER2, HER3 and downstream AKT phosphorylation without induction of apoptosis, . Unlike ADT, WCE in the presence of androgen concurrently abolished both AR and HER2/3 signaling and induced apoptosis ; WCE combined with ADT further augmented PARP1 cleavage over WCE or ADT alone . In castration-resistant 22Rv1 cells, ADT slightly decreased AR expression and resulted in activated HER2-AKT signaling . Despite the HER2 upregulation by WCE in 22Rv1, WCE decreased the expression of AKT and AR proteins, still leading to cell apoptosis . Moreover, WCE combined with ADT decreased the expression of AR, HER2 and HER3, enhancing the cell apoptosis . These effects were next examined in vivo using a 22Rv1 orthotopic xenograft model. The anti-androgen drug Casodex moderately delayed the tumor growth leading to 30% lower tumor weight compared to the vehicle control; however, WCE treatment significantly inhibited tumor growth and caused 60% lower tumor weight at end-point .To determine the effect of WCE combined with ADT, cells were grown in a medium stripped by charcoal to mimic ADT, and treated with WCE in the presence or absence of androgen . WCE or castration monotherapy markedly reduced tumor growth compared with the vehicle control; and a combination of both therapies further reduced tumor growth . Consistent with the tumor growth result, immunohistochemical staining of Ki-67 and cleaved caspase 3 showed that castration or WCE alone inhibited the cell proliferation and induced apoptosis, and combination therapy further enhanced the therapeutic effect . While either monotherapy markedly decreased lung metastasis compared with vehicle treatment, combination therapy was also more effective in inhibiting metastasis than either castration or WCE monotherapy . Only a few micrometastatic PCa foci were detected in the lungs of the WCE or castration monotherapy groups, and none were detected in the combination group .To consider the clinical feasibility of WCE, we investigated the effect of castration in combination with oral WCE treatment in an LNCaP orthotopic xenograft in a nude mouse model . To further understand the anti-androgenic activity of WCE in the treated mice, mouse serum containing testosterone, DHT, and WCE compounds was harvested 2 h following the last WCE dose and analyzed by PSA-reporter assay. The active compounds in sera from WCE-treated mice remained functional and inhibited both the physiological and DHT-replaced levels of androgen activity .To understand whether WCE might affect tumor growth through regulating the physiological levels of androgens, we studied the WCE function under DHT replacement using 12.5 mg of DHT pellet with 60 days release . Despite being used alongside ectopic hormone replacement, WCE remained effective in attenuating tumor growth and metastasis, suggesting that WCE regulated the AR and downstream activities rather than the physiological levels of androgens . This alteration reflects the transition of androgen-dependent PCa to CRPC and enhancement of cancer survival during ADT by upregulating the AR and HER3 signaling pathways . Compared to monotherapy, combination therapy of WCE and ADT showed a more potent therapeutic outcome by suppressing HER3 activation and AR expression. Overall, in contrast with castration, which has unfavorable side effects, WCE treatment decreased the levels of AR, HER2/HER3, and AKT phosphorylation in PCa .Castration treatment for 12 weeks upregulated HER3 phosphorylation (Y1289), AKT phosphorylation (S473) and AR expression in tumors . After LNCaP PCa relapsed from castration in mice, we performed necropsies on the mice and cultured the relapsed LNCaP tumor cells, named LNCaP-CR cells. The same procedure was repeated four times and LNCaP-CR4 cells were derived. In vitro, growth of LNCaP-CR4 was not affected by ADT in the medium, whereas growth of the parental LNCaP cells was inhibited by ADT . Upon treatment with enzalutamide, a second-line anti-androgen, LNCaP-CR4 cells were ∼10-fold more resistant than the parental LNCaP cells . Therefore, LNCaP-CR4 cells represented a state of CRPC. To this end, WCE elicited the same concentration-effect relationship on the cell growth of LNCaP and LNCaP-CR4 cells . In addition, LNCaP-CR4 expressed higher levels of HER2, HER3, and AKT phosphorylation compared with parental LNCaP cells . Upon ADT, LNCaP-CR4 cells still expressed a high level of AR , while ADT significantly decreased AR expression in LNCaP cells, . Activation of HER2, HER3 signaling in LNCaP-CR4 might arise from upregulation of gene transcription while the increased AR expression may be influenced by HER2/3 activation . Even following the failure of ADT, WCE treatment in PCa cells still effectively inhibited the expression of AR, HER2, and HER3 at the protein and mRNA levels, which also resulted in a decrease in AKT phosphorylation and promotion of apoptosis . In conclusion, the data suggest that exposure to effective doses of WCE can completely inhibit the cell growth in LNCaP and LNCaP-CR4 cells at least in part due to effective simultaneous suppression of AR and HER2/3.Our previous study determined that the major active compounds in WCE are wedelolactone, luteolin and apigenin. Wedelolactone is an IKKα/β inhibitor which has been shown to reduce viability of PCa cells via down-regulation of PKCε . ApigeniFigure 1B). On the other hand, suppression of AR signaling may activate the PI3K/AKT pathway because loss of AR-mediated FKBP5 expression which in turn assists the folding of AKT phosphatase PHLPP would promote AKT activation and the eventual failure of castration therapy . Furthermore, in vitro growth assay showed WCE has better efficacy than androgen ablation, and WCE treatment significantly induced apoptosis in LNCaP, LNCaP-CR4, and 22Rv1 cells . LNCaP cells express full-length AR, whereas 22Rv1 cells express both full-length AR and truncated AR variants encoded by mRNA lacking exons 5–7 (At early-stage PCa, ADT is effective in hormone-dependent PCa but ADT elicits a marked increase in HER3 protein and activation of downstream signaling, which may be responsible for the oncogenic cell survival and the promotion of CRPC . This inxons 5–7 . The C-txons 5–7 . WCE redThe most effective therapy is to apply combination therapy at the early stage of PCa to prolong the progression-free survival of ADT. Here, we showed that WCE can concomitantly target HER2/3, AR and AKT to maximize the therapeutic effects of ADT in treating AR-positive PCa without activating the feedback pathways. WCE might inhibit AR gene transcription and thus effectively downregulate full-length and truncated AR. Furthermore, we established castration-resistant LNCaP cells and demonstrated their clinical pathological characteristics, i.e., high levels of AR, HER3 and AKT activities. A further novel finding is that WCE significantly inhibited expression of EZH2 and MAOA. Aberrant overexpression of EZH2 and MAOA correlated with poor prognosis in PCa patients. MAOA has been demonstrated to promote prostate tumorigenesis and cancer metastasis, and this study revealed that WCE inhibited MAOA expression, a promising therapeutic effect . A previOur data also showed that the defined herbal extract WCE can improve the therapeutic outcome of PCa as an add-on to hormonal therapy for androgen-dependent disease and may be effective for use in AR-positive CRPC.C-HT, S-FT, S-CH, C-JT, M-HT, and Y-CY participated in data collection and analysis. C-HT and P-WH participated in the design of the study, data interpretation and the writing of the manuscript.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.