Background: The use of antimicrobials in Thailand has been reported as one of the highest in the world in both the human and animal sectors. The objectives of this project are: (1) to improve understanding of the issue of antimicrobial resistance (AMR) among adult Thai communities and (2) to drive change through the national AMR policy to include context-specific and locally-driven solutions.Methods: The project contains two components conducted in parallel: the “AMR Dialogues” public engagement project and the embedded evaluation of the project. We will bring together AMR stakeholders and members of the public through a series of conversation events to co-create an AMR stakeholder map, engagement strategy, and context-specific solutions to reduce the burden of AMR. There will be a combination of regional in-person events  and national online events  with members of the public and AMR stakeholders. The conversations will follow this sequence: introduce and explore issues related to AMR, brainstorm solutions and finally propose promising/feasible solutions to take forward. Evaluation of the project will be conducted to assess if the AMR Dialogues objectives have been achieved using feedback forms and qualitative methods.Ethics: Approval of the evaluation component of the project has been obtained from the ethics committee of the Thailand Institute for the Development of Human Subject Protection (IHRP2021059) and the Oxford University Tropical Research Ethics Committee (OxTREC 529-21).Dissemination: The results of these conversation events will inform the next Thailand National Strategic Plan on AMR. The learning and outcomes will be disseminated to AMR policy makers, academic audiences, and participants of all the conversation events.Thaiclinicaltrials.org registration: TCTR20210528003 (28/05/2021) It has been estimated that globally there will be around 700,000 deaths each year caused by AMR bacterial infections. The human and economic cost of AMR is estimated to account for 10 million deaths a year and economic losses of US$100 trillion globally by 2050. It is projected that a disproportionate number of AMR-related deaths are likely to occur in Asia because of the high burden of infectious diseases, poor monitoring and regulation of antimicrobials, high population density and growth, and antibiotics are sold widely over-the-counter often without a prescription. A recent study estimated that there were over 97,000 deaths attributable to AMR in Southeast Asia alone. South-East Asia has been characterised as a region ‘at high risk of the emergence and spread of antibiotic resistance in humans’. In Thailand, there were an estimated 19,122 deaths in 2010 attributable to multidrug resistant hospital-acquired infections.Antimicrobial resistance (AMR) is the ability of microorganisms, including bacteria, viruses, fungi, and parasites, to stop antimicrobial drugs  from working against them. The Thai Drug Act classes the majority of antibiotics as dangerous drugs which need to be dispensed by a pharmacist but do not require a prescription. Some antimicrobials are listed prescription drugs. Nevertheless, some antibiotics are sold illegally at informal stores. Antibiotic dispensing is not currently regulated and antibiotics can often be found in village stores and other shops without a pharmacist.Thailand’s healthcare system is made up of a combination of a network of public health facilities and private healthcare providers and overseen by the Ministry of Public Health. Universal health coverage has been in place since 2002. In rural and poorer areas, primary healthcare is primarily provided by the public healthcare system, whereas in urban and more affluent areas, private providers play a larger role, which is partly attributable to the challenge of communicating technical concepts of AMR in Thai language. Antibiotics are often confused with anti-inflammatory drugs in Thailand, that has led to a misunderstanding that antibiotics can treat muscle pain and inflammation. Antibiotics have become a quick fix for care, productivity, hygiene and inequity. Thailand has one of the highest antibiotic use in both human and animal sectors among countries that have published official data on national antibiotic consumption. In 2017, Thailand used a total of 8,757 tons of antimicrobials, and in 2018, 10,133 tons.The Thai general public have a limited understanding of AMR.For decades, Thailand had taken actions to address AMR such as establishing the National AMR Surveillance Center, Thailand (NARST) in 1997, and launching the Antibiotic Smart Use programme focusing on changing prescribing practices made by healthcare providers in 2007Thailand National Strategic Plan on AMR (NSP- AMR), a 5-year plan from 2017 to 2021, was endorsed by the Cabinet as the first national plan to address the problem of AMR in Thailand. The NSP-AMR comprises of six strategies. The “AMR Dialogues” project will integrate with the NSP-AMR’s Strategy 5  and if appropriate, provide input into Strategy 6 (governance mechanisms to develop and sustain AMR-related actions). It will inform the NSP-AMR process beyond 2021.In 2016, the, which suggests a format for holding these Dialogues (see Methods). This projects builds on our previous engagement work around AMR such as “AMR Dictionary”,“antibiotic footprint”, and art and theatre projects around AMR in Thailand and Southeast Asia, and complements existing campaigns such as the annual Antimicrobial Awareness Day/Week held since 2013.The Thailand “AMR Dialogues” project uses the Wellcome Trust’s toolkit “Responsive Dialogues (RDs) on Drug Resistant Infections”. The current project focusses on engagement through a series of dialogues with different members of the community to generate solutions that are grounded in local realities and embrace ideas and views from the public. The project will bring together AMR stakeholders and members of the public to co-create an AMR stakeholder map, engagement strategy, and context-specific solutions with the aim of reducing the burden of AMR in Thailand.Previous and existing AMR campaigns have primarily focused on raising awareness through education and eventsThe main objectives of this project are:(1) to improve understanding of the issue of AMR among adult Thai communities and(2) to provide a catalyst for improving the current national AMR policy, specifically Strategy 5  and to drive change through the national AMR policy to include context-specific and locally-driven solutions.The intended long-term impacts of the project include empowerment of communities through co-creation of locally relevant solutions to AMR; and improved policies for reducing the burden of AMR across Thailand.th May 2021 (TCTR20210528003).This protocol has been registered at Thaiclinicaltrials.org on the 28There will be three phases in the project involving a series of dialogues or “conversations” held over 24 months.. MORU has dedicated public engagement team (led by author PYC) and an extensive public engagement programme that involves facilitating traditional engagement activities as well as more innovative approaches such as science theatre initiatives.Civicnet Foundation has experience facilitating workshops in communities and inspiring change. Where appropriate, we will ask participants to lead the breakout sessions. All sessions will be audio-recorded to facilitated note taking.All conversations will be led by members of the project team who have had experience and training in public engagement and facilitation, and trained using Wellcome Trust’s “Responsive Dialogues” toolkitIn all conversations, the project team will be cognizant of potential power dynamics due to age, social hierarchy and gender. Phase I: Two or three planning conversations. The planning conversations are events comprising one or two-day meetings and held in Bangkok, Thailand at a conference venue led by members of the project team . Approximately 20–25 attendees of all genders will participate in the conversations. From our experience facilitating workshops, 20–25 people are ideal to ensure that the sessions are small enough to be interactive and large enough to have a wide range of views. With this number we can also have breakout groups. The attendees will include AMR national policy makers, AMR researchers and experts, healthcare providers and non-governmental organization (NGO) representatives. The same participants will attend both meetings. Diverse stakeholders will be invited through professional networks, many of whom would have previously worked with project team members in AMR related or other healthcare projects.The aim of the planning conversations is to understand the AMR ecosystem in Thailand, narrow down AMR focus, design the structure, and identify participants for the community conversations.Phase II: Seven community conversations. There are two types of community conversations: regional conversations and national conversations that will be conducted in parallel. By holding these two types of events, we hope to be as inclusive as possible and maximise the chance of having a diverse audience. Regional conversations will be led by CT  and TP  and national conversations will be led by TP , RP  and SR .Participant selection criteria for community conversations:1.Participants who have the capacity and means to drive and engage people in the community such as youth leaders. This will be a subjective assessment based on participants involvement in other AMR or health-related projects2.Participants who have the commitment and are influential in the community such as religious leaders, teachers, village elders3.Participants who could have an impact on behaviour change in antimicrobials use such as local healthcare workers e.g. nurses, pharmacists, doctors, village health volunteers4.Participants who are familiar with the local context, lifestyles and culture of each region e.g. in the Northeastern region, we will invite people who live in slums, in the Central will invite people from labour camps, dormitory or migrant workers5.Participants who have leadership characteristics such as community leaders. This assessment will be based on their involvement in community groups and committees.6.Participants who are potential “solution experts” e.g. those who work in mass media, media influencers, science communication specialists, radio broadcasters, reporters7.Participants who are longterm or frequent users of antimicrobials e.g. for treatment of tuberculosis, acne8.Participants who are users of antimicrobials in the animal sector such as farmers9.Participants from minority groups e.g. LGBTQ , disabled, hilltribes10.Participants from different age groups, social groups, and educational levels11.Participants with different occupations12.Formal and informal prescribers/providers of antimicrobialsThe regional conversations focus on regional issues and will be attended in person by local residents, while the online national conversations focus on national issues and will be attended by people from all over the country. We hope that with a combination of these two types of conversations, we will include voices of all of the above participant groups.. Each regional conversation will follow the following sequence as detailed in the Wellcome Trust’s ‘Responsive Dialogues’ toolkit: introduce and explore issues related to AMR in the region, brainstorm local solutions and finally choose promising/feasible solutions to take forward.Regional conversations will be in-person three- or four-day sessions and held in four regions in Thailand  at conference venues/community halls. Approximately 20–25 attendees will attend the conversations from each region . From our experience facilitating workshops, 20–25 people are ideal to ensure that the sessions are small enough to be interactive and large enough to have several breakout groups in-person) and a wide range of views. The first session will introduce and explore issues related to AMR in the region, the second session will involve brainstorming locals solutions and the third session with involve participants proposing promising/feasible solutions to take forward. We will also plan to have virtual breakout groups.National conversations will consist of three online conversations and held three hours once a month for three months consecutively. Approximately 20–25 attendees will participate in the conversations. The same participants will be asked to attend all three sessions. Similar to the regional conversations, the online national conversations will follow the following sequence as detailed in the Wellcome Trust’s ‘Responsive Dialogues’ toolkitPhase III: Two final conversations. The events will be one or two-day meetings and held in Bangkok, Thailand at a conference venue. Approximately 20–25 attendees will participate in the conversations. The attendees will include AMR national policy makers, AMR researchers and experts, healthcare providers, non-governmental organizations (NGO), and communication and “solution experts”.In these conversations, findings from the community conversations will be fed back to AMR stakeholders. Depending on what solutions have been proposed during the community conversations, we will invite the relevant “solution experts”. For example, if a social media campaign has been suggested targeting young people, we will invite social media experts and those with experience communicating with young people.Participants for all the conversations will be invited in writing by the project team with details of the project. Participants will be asked to reply in writing or by phone should they accept the invitation. Evaluation will be conducted in parallel with all ‘AMR Dialogues’ events  to assess if the AMR dialogues objectives have been achieved (led by BN).Data collection strategies for evaluation and sample size. Feedback forms will be used at the end of each conversation event. Participants will be asked to complete a short feedback either on paper or online.Daily reflections and feedback in writing will be used for events that run over multiple days . An informal dialogue session will be set up at the end of each day which will take a maximum of 30 minutes. Participants will share their active observations and feedback on key issues. The daily reflection would help the event facilitators to adjust the conversation process better the next day. Participants are requested to write their reflections on a set of questions which aim to assess 1) their understanding or increased knowledge on AMR, 2) their level of awareness of AMR, and 3) their actions or solutions they think they would and could do regarding AMR. The writing activity will take maximum 30 minutes.Focus group discussions (FGDs) will be used for events that run over multiple days . On the last day of event, participants who express their interest in joining the evaluation will be invited to share their active observations and feedbacks on key issues. We expect to run four FGDs of between 6–12 participants per FGD. This will take approximately 30 minutes to 1 hour per session.Within a month after each event of the regional conversations, the last online national conversation, and the final conversations, people who express their interest in the in-depth interview will be invited to participate in the individual in-depth interviews. The interviews will take approximately 30 minutes to 1 hour each.We anticipate that approximately 70 – 85 participants, including focus group discussions and in-depth interviews to participate in the evaluation..FGDs and in-depth interviews will be conducted using a topic guide, led by AO and BN, both of whom are experts in evaluation and are not directly involved in facilitating the conversation events. The topic guides for focus group discussions and in-depth interviews, consent form and participant information sheet can be found as extended dataParticipants and recruitment. The evaluation participants will be the attendees of any of the project’s conversation events. Participants who attend any of the AMR Dialogues public engagement events will be invited to participate in the AMR Dialogues evaluation project. As the evaluation process is embedded in the AMR Dialogues public engagement events, participants will be asked to indicate in the registration form when attending the conversation events, whether they will allow us to record and collect information of their daily reflection, feedback in writing, group discussion and follow-up in-depth interview. Information from any participants who do not wish to participate will not be collected. Informed consent. Participants for all conversations will be invited in writing with all relevant details. If they choose to participate in the conversations (either in person or online), they will attend the conversations.Participants who indicated their interest for the evaluation at time of registration will receive the participant information sheet. They will be allowed as much time as they wish to consider the information, the opportunity to question the project team and to decide whether they will be willing to allow their information to be collected and recorded. At this point, they will have the opportunity to decline. If they agree to participate, they will be asked to sign and date the latest approved version of the informed consent form before any study specific procedures are performed. Depending on the circumstances (coronavirus disease 2019 (COVID-19) restrictions and geographical location/internet access), this will be done either on paper or electronically.Each participant has the right to withdraw from the conversation events or evaluation sessions at any time. Withdrawal of consent to participate will result in exclusion of the data for that participant from analysis and withdrawn participants will not be replaced. Participants are not required to give any reason for withdrawal. The audio recording and written data will be deleted if the participant decides to withdraw during the conversation events or the evaluation interviews. For those participating in the group discussion those portions of the audio, video recordings and written data that capture his/her views will be deleted.Data analysis. For conversation events, meeting minutes will be taken during all conversations. The project team will reflect and refine a set of solutions and ideas that will be emerged and will inform the responsive dialogues process.NVivo , the software that will be used to manage the data. Codes will be established for each participant to enable appropriate collation of data sets and sub-themes and themes for qualitative data.For evaluation, the qualitative data will be translated where needed, transcribed, cleaned and exported into the latest version of, We will develop initial themes and categories through successive coding of the transcripts, and informed by the our project aims as well as issues derived from the literature. For the purpose of quality control , two researchers will independently develop their own coding tree. Frequent meetings will be held with the wider research team to discuss the findings.Qualitative data analysis will be based on thematic content analysis, particularly Framework Analysis, given the policy implications of the planned workData handling and record keeping. Direct access to the data will be granted to authorised representatives from the sponsor, ethics committees, and regulatory authorities to ensure compliance with regulations. Qualitative data includes audio recordings of focus group discussion and interviews, transcripts, written feedback, meeting minutes and field notes. Audio files will be transcribed verbatim and translated to English where necessary. Detailed summary notes will be made directly following the interview and during the focus group discussion with selected verbatim quotes being used. These audio files will be kept until they have been transcribed and the transcribed interviews will be kept securely. All audio files will be destroyed when all the transcripts have been completed and verified. data sharing policies.De-identified data will be stored digitally and indefinitely to comply with the Wellcome TrustApproval of the evaluation component of the project has been obtained from the ethics committee of the Thailand Institute for the Development of Human Subject Protection (reference IHRP2021059) and the Oxford University Tropical Research Ethics Committee (OxTREC 529-21).We will adhere to the relevant guidelines for qualitative research. All interviewers, and transcribers will be trained prior to the study. The project and its evaluation will be conducted in accordance with relevant Thai and international guidance and regulations. The protocol, informed consent form, participant information sheet and any associated material will be submitted to relevant ethics committees for written approval.This is a minimal risk and minimal harm project. The main concerns relate to privacy and confidentiality. We will make every effort to maintain privacy of participants during the audio recording of the conversations as well as evaluation interviews and FGDs. The participants will be identified only by a participant reference number on all project documents and databases. All documents will be stored securely and only accessible by authorised study personnel. We will comply with the UK General Data Protection Regulation (GDPR) and Thailand Personal Data Protection Act (PDPA).The other concern revolves around COVID-19 risks. We will comply with regional and national COVID-19 guidelines. Where in-person conversations or focus group discussions  are planned, but are not possible due to COVID-19, we will convert them to virtual sessions.There are no anticipated direct benefits to the participants apart from learning about AMR and having their views heard. New knowledge gained from this initiative is expected to inform Thailand’s National Strategic Plan on Antimicrobial Resistance committee for improving policies to reduce the burden of AMR across Thailand. Participant will receive the compensation for their time to participate in the conversations (1000 Thai baht/GBP 25 per session) and evaluation focus group discussion and in-depth interviews (300 Thai baht/GBP7.50 per session)., including the activities in the online national conversation with BHREIG.This protocol describes a public involvement project. As part of the development of our study and data collection tools, we have conducted a series of meetings with the Bangkok Health Research Ethics Interest Group (BHREIG)The learning and outcomes will be disseminated to policy makers, organisers of the Thailand AMR week, Wellcome Trust, academic audiences, as well as back to participants of all the conversation events. Some of the avenues include:•    Talks presented at conferences/meetings targeting engagement practitioners who do AMR workMESH website targeting engagement practitioners and other relevant websites•    Blogs on the.•    Public talks and panel discussions conducted through MORU’s and its partners’ existing engagement channels e.g. BHREIG, science cafes, and Pint of Science events•    Dialogues with professional groups e.g. pharmacists in Thailand and beyond, focusing on the co-created AMR solutions. •    The final AMR stakeholder map, an interim project report and final project report of the project will be provided to the Thailand’s National Strategic Plan on Antimicrobial Resistance committee.Strengths: This is the first time Thailand’s National Strategic Plan on Antimicrobial Resistance will have direct input from members of the public and other stakeholders previously not consulted. It is envisaged that embedding voices from the public will make the AMR policy more context-specific and realistic.Limitation: We plan to invite participants from minority groups, from different age groups, social groups, and educational levels to attend the conversations. We recognize there may be power dynamics and other such challenges that may hinder some participants from making their voices heard. There may be also challenges due to the team’s positionality as some of the members have been involved in current and previous Thailand’s National Strategic Plans on Antimicrobial Resistance which may deter some participants from giving us honest opinions during the conversations. In facilitating the conversations, we will pay extra attention to group dynamics and encourage those who are less vocal to speak. Our facilitation team members are experienced in conducting workshops with members of the public and communities with a wide range of backgrounds. We also plan to have breakout groups as some participants may feel more comfortable speaking up in a smaller group. Protocol approvals have been obtained and conversations have commenced.No data are associated with this article.http://doi.org/10.5281/zenodo.5115834.Zenodo: Extended data for "AMR Dialogues": a public engagement initiative to shape policies and solutions on antimicrobial resistance (AMR) in Thailand.This project contains the following extended data:-AMR Dialogues evaluation PISICF_V3.0 21Jun2021.docx -AMR Dialogues evaluation_Question guides_v3.0 21Jun2021.docx Creative Commons Attribution 4.0 International license (CC-BY 4.0).Data are available under the terms of the I have no further comments to make.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?PartlyAre the datasets clearly presented in a useable and accessible format?YesReviewer Expertise:Antimicrobial Resistance, Infertility, Neglected Tropical Diseases, Non-communicable diseaseI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This protocol paper presents the public engagement initiative on AMR in Thailand. AMR is a global public health threat that requires a local solution. This protocol provides a timely and appropriate example of such a local initiative. Public engagement is the core element of the co-creation of public health interventions and this protocol provides an organized and very systematic approach for public engagement in Thailand to find out context-specific solutions. The protocol takes a ‘dialogue’ approach to engage the community and the researchers also propose to involve a range of very relevant stakeholders who can play a role in mitigating ARM in Thailand. The sequence of the engagement is also appropriate, which begins with exploring the issue and then brainstorming for solutions. It is good that the protocol includes an evaluation element as well. It is also appreciable that the team considered both in-person and virtual public engagement events keeping the pandemic situation in mind.It is good that the research team has suggested several diverse groups with whom they intend to have the conversation. However, the group's compositions seem too generalized in some cases. Although the groups have been categorised through different attributes, there might be heterogenicity within the group. For example, there could be huge diversity between users of antibiotics for humans or animals in terms of economic status, education, gender. Among the ‘solution experts’, there might be a difference in terms of status and experience. All these differences might influence the conversation if done as a group. I would recommend paying attention to this particular aspect of group dynamics.The protocol proposes seven community conversation, however, eleven categories of community has been listed. Not clear how this will be resolved.Informal providers are major health care providers, who dispense and prescribes antibiotics in most of the global south countries. Although the protocol acknowledges their role in Thailand, the team does not include them in the conversation. I think this needs attention.Some clarification is needed regarding the evaluation. It has been proposed that an evaluation of the public engagement will be done in two stages one right after the conversation and the other after one month on the following issues 1) their understanding or increased knowledge on AMR, 2) their level of awareness of AMR, and 3) their actions or solutions they think they would and could do regarding AMR. It is understandable that the response just after the dialogue will be influenced by the close time immediacy of the dialogue. It is not clear whether the same set of questions will be used during evaluation after one month. Also, it is not clear whether the individual impact of the dialogue could be evaluated in Focus Group Discussion.  However, I have the following queries and clarifications:Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?PartlyAre the datasets clearly presented in a useable and accessible format?YesReviewer Expertise:Antimicrobial Resistance, Infertility, Neglected Tropical Diseases, Non-communicable diseaseI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Many thanks for your valued comments. Here is our point by point response.  This protocol paper presents the public engagement initiative on AMR in Thailand. AMR is a global public health threat that requires a local solution. This protocol provides a timely and appropriate example of such a local initiative. Public engagement is the core element of the co-creation of public health interventions and this protocol provides an organized and very systematic approach for public engagement in Thailand to find out context-specific solutions. The protocol takes a ‘dialogue’ approach to engage the community and the researchers also propose to involve a range of very relevant stakeholders who can play a role in mitigating ARM in Thailand. The sequence of the engagement is also appropriate, which begins with exploring the issue and then brainstorming for solutions. It is good that the protocol includes an evaluation element as well. It is also appreciable that the team considered both in-person and virtual public engagement events keeping the pandemic situation in mind. However, I have the following queries and clarifications: It is good that the research team has suggested several diverse groups with whom they intend to have the conversation. However, the group's compositions seem too generalized in some cases. Although the groups have been categorised through different attributes, there might be heterogenicity within the group. For example, there could be huge diversity between users of antibiotics for humans or animals in terms of economic status, education, gender. Among the ‘solution experts’, there might be a difference in terms of status and experience. All these differences might influence the conversation if done as a group. I would recommend paying attention to this particular aspect of group dynamics.Response: We agree with your comments.  We recognize that this is a potential limitation to get all voices heard. We have included a new section “Limitations” to acknowledge this explained that we will pay attention to group dynamics as well as power dynamics. The protocol proposes seven community conversation, however, eleven categories of community has been listed. Not clear how this will be resolved.Response: Most of the conversations will have a mixture of groups from these 11 categories (now 12 – see next response) Informal providers are major health care providers, who dispense and prescribes antibiotics in most of the global south countries. Although the protocol acknowledges their role in Thailand, the team does not include them in the conversation. I think this needs attention.Response: We agree. We have now included this group in “Participant selection criteria for community conversations”. Some clarification is needed regarding the evaluation. It has been proposed that an evaluation of the public engagement will be done in two stages one right after the conversation and the other after one month on the following issues 1) their understanding or increased knowledge on AMR, 2) their level of awareness of AMR, and 3) their actions or solutions they think they would and could do regarding AMR. It is understandable that the response just after the dialogue will be influenced by the close time immediacy of the dialogue. It is not clear whether the same set of questions will be used during evaluation after one month.Response: The questions are not the same. We have updated paragraph 7 in Part 2. Please see question guide herehttps://zenodo.org/record/5115834#.YkMSuzfMLeo. We have included this in the reference. Also, it is not clear whether the individual impact of the dialogue could be evaluated in Focus Group Discussion. Response: Thank you for the comment. It is true that individual impact cannot be evaluated in focus group discussions. We will include individual interviews as well. Thank you for all your comments. This protocol seeks to utilise an community engagement model  to influence policy making for controlling AMR in Thailand. It adopts a 'bottom-up' approach to ensure that stakeholders, particularly community members exposed to the problem participate in developing policy towards their wellbeing. It is an important contribution to the evidence on how to engage communities in solving their problems and improving their wellbeing. Specifically, for contemporary social problems like the growing epidemics of AMR, infectious disease outbreaks and other humanitarian emergencies, it is now clear that the role of non-biomedical interventions is as important in combating them, as has been the case with biomedical technology. Therefore, the authors propose a much-needed protocol to try and understand how concerned communities can be engaged and participate in shaping policies and solutions for antimicrobial resistance in Thailand. The background, including literature on the problem of AMR in Thailand is well stated. Perhaps there may be need to expound a little more on how antibiotics and anti-inflammatory drugs are perceived or conflated in the local context. What examples of language illustrate this conflation? Expounding, with one example will enhance the background. It was also not clear what the following statement means: “In Thailand, by law, most antimicrobials can be dispensed by licensed pharmacists at pharmacies without a prescription.” - Do you imply that it is not illegal to dispense antimicrobials without prescription? Or that the law is not followed concerning dispensing antimicrobials but when the law could be that they shouldn’t be dispensed without a prescription? It may be helpful to cite the law in this case. Objective 2 is quite important as there is a need to provide a catalyst to AMR policy while recognizing that change or improvement should be context specific and locally-driven. As such I would think that rather than ‘drive change’ the team wishes to ‘provide a catalyst for improving current AMR policy’. The protocol is well planned. However, there are a series of activities being planned which may require a bit more elaboration on how they are tied to the or would contribute to ‘catalyzing’ change in policy. Perhaps a matrix or chart may help to tag or identify what planned meetings or sessions lie under the respective policy areas being targeted. For instance, given that there are different levels of actors whose contribution/participation is being sought, then perhaps stratifying the meetings or sessions by target populations would help the reader chart the flow of how these meetings may enhance or contribute to policy change. Similarly there were several formats of the meetings that need some clarification . That is an example where it is not clear if the virtual breakout session is part of an in-person meeting such that as the in-person meeting is ongoing, there is an opportunity for the same teams to break out into sub groups but virtually? Part 1: AMR Dialogues: Should all conversations be led by the research team? Is it possible to consider if some of the communities of participants being involved can lead some conversations – in a systematic way – without compromising on the design? Since the protocol is premised on the concept of community engagement – should the engagement entail the community leading in some of the sessions? The study proposes sessions of 20-25 persons. Given the large numbers in the context of COVID-19, it would be good to have a note on what risk mitigation measures are in place or how those would influence/impact the method of conversation. See also the suggestion to have up to 12 participants in an FGD. What are the implications if there was COVID-19 restrictions in Thailand and how would it influence the protocol? A short note on the situation of the pandemic and how it is affecting research may help clear this. It could be elaborated under the section “risks and benefits”. Similarly, the protocol indicates that attendees of all gender are welcome. Will age be a variable to consider and if so will it be varied or grouped and by what criteria? If not, a note on that is helpful for the reader to determine the justification or possible limitation. This comment is inspired by knowing that in some societies age determines whose opinion counts during conversations/meetings or planning for social issues. The team plans to invite diverse stakeholders through their professional networks of previous engagement in AMR related or other health projects. Would the team comment about the issue of positionality and whether it is a potential limitation to the study? The sample size estimation/description is not clearly stated. Are the approximately 70-85 participants for FGDs only? It may be best to simply state the number of FGDs estimated, then separately assign the number of In-depth interviews planned.Is the rationale for, and objectives of the study clearly stated? Partly. See further comments above under background. Objective 2 is quite important as there is a need to provide a catalyst to AMR policy while recognizing that change or improvement should be context specific and locally-driven. As such I would think that rather than ‘drive change’ the team wishes to ‘provide a catalyst for improving current AMR policy’.Is the study design appropriate for the research question? YesAre sufficient details of the methods provided to allow replication by others? YesAre the datasets clearly presented in a usable and accessible format? Yes Mandatory questions:Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?PartlyAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?YesReviewer Expertise:Medical Anthropology, infectious disease control, community based interventionsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Many thanks for your valued comments. We appreciate it very much. Here is our point by point response. This protocol seeks to utilise an community engagement model  to influence policy making for controlling AMR in Thailand. It adopts a 'bottom-up' approach to ensure that stakeholders, particularly community members exposed to the problem participate in developing policy towards their wellbeing. It is an important contribution to the evidence on how to engage communities in solving their problems and improving their wellbeing. Specifically, for contemporary social problems like the growing epidemics of AMR, infectious disease outbreaks and other humanitarian emergencies, it is now clear that the role of non-biomedical interventions is as important in combating them, as has been the case with biomedical technology. Therefore, the authors propose a much-needed protocol to try and understand how concerned communities can be engaged and participate in shaping policies and solutions for antimicrobial resistance in Thailand.Response: Thank you. The background, including literature on the problem of AMR in Thailand is well stated. Perhaps there may be need to expound a little more on how antibiotics and anti-inflammatory drugs are perceived or conflated in the local context. What examples of language illustrate this conflation? Expounding, with one example will enhance the background.Response: We have now included a sentence in paragraph 3. It was also not clear what the following statement means: “In Thailand, by law, most antimicrobials can be dispensed by licensed pharmacists at pharmacies without a prescription.” - Do you imply that it is not illegal to dispense antimicrobials without prescription? Or that the law is not followed concerning dispensing antimicrobials but when the law could be that they shouldn’t be dispensed without a prescription? It may be helpful to cite the law in this case.Response: We have now cited the law. See paragraph 2. Objective 2 is quite important as there is a need to provide a catalyst to AMR policy while recognizing that change or improvement should be context specific and locally-driven. As such I would think that rather than ‘drive change’ the team wishes to ‘provide a catalyst for improving current AMR policy’.Response: We have now changed the text as advised. The protocol is well planned. However, there are a series of activities being planned which may require a bit more elaboration on how they are tied to the or would contribute to ‘catalyzing’ change in policy. Perhaps a matrix or chart may help to tag or identify what planned meetings or sessions lie under the respective policy areas being targeted. For instance, given that there are different levels of actors whose contribution/participation is being sought, then perhaps stratifying the meetings or sessions by target populations would help the reader chart the flow of how these meetings may enhance or contribute to policy change.Response: Our project is specifically aimed at only one strategy of the National Action Plan. All the activities are targeting this strategy which is Strategy 5 . We have made it clearer in the text. See objective 2. Similarly there were several formats of the meetings that need some clarification . That is an example where it is not clear if the virtual breakout session is part of an in-person meeting such that as the in-person meeting is ongoing, there is an opportunity for the same teams to break out into sub groups but virtually?Response: That was an error. Where there are in-person meetings, the breakout rooms will be in-person. Similarly, where there are virtual meetings, all breakout rooms will be virtual. We have clarified this. See Phase II. Community Conversations. Part 1: AMR Dialogues: Should all conversations be led by the research team? Is it possible to consider if some of the communities of participants being involved can lead some conversations – in a systematic way – without compromising on the design? Since the protocol is premised on the concept of community engagement – should the engagement entail the community leading in some of the sessions?Response: Thank you for the suggestion. The Wellcome Responsive Dialogues toolkit is very specific and the project team are following the guide closely. Hence, we feel that we should not ask community participants who have no training using Wellcome’s toolkit to lead the main sessions. We have also described the project team’s background. We have vast experience in engagement and facilitation. However, we think it is a good idea to involve community members to lead the discussions. We will ask some of them to lead the breakout group discussions. See Part 1 paragraph 2. The study proposes sessions of 20-25 persons. Given the large numbers in the context of COVID-19, it would be good to have a note on what risk mitigation measures are in place or how those would influence/impact the method of conversation. See also the suggestion to have up to 12 participants in an FGD. What are the implications if there was COVID-19 restrictions in Thailand and how would it influence the protocol? A short note on the situation of the pandemic and how it is affecting research may help clear this. It could be elaborated under the section “risks and benefits”.Response: Thank you for the suggestion. We have now included a paragraph on COVID-19 mitigation plans. Similarly, the protocol indicates that attendees of all genders are welcome. Will age be a variable to consider and if so will it be varied or grouped and by what criteria? If not, a note on that is helpful for the reader to determine the justification or possible limitation. This comment is inspired by knowing that in some societies age determines whose opinion counts during conversations/meetings or planning for social issues.Response: This is indeed a good point. We intend to invite all age groups but we recognize that there may be challenges in mixing age groups. In Thailand, opinions of older people are respected. See paragraph 3 in Part 1, and the new section on Strengths and Limitations. The team plans to invite diverse stakeholders through their professional networks of previous engagement in AMR related or other health projects. Would the team comment about the issue of positionality and whether it is a potential limitation to the study?Response: Thank you. We have added a section on Limitation to address this point. The sample size estimation/description is not clearly stated. Are the approximately 70-85 participants for FGDs only? It may be best to simply state the number of FGDs estimated, then separately assign the number of In-depth interviews planned.Response: We expect to run four FGDs of between 6–12 participants per FGD. See Evaluation (paragraph 4). We have included the number (70-85) at the request of our ethics committee. We have also updated some text for clarity. Please also see our response to the other reviewer.  Thank you,.


The neurotransmitter dopamine is a key factor in central nervous system (CNS) function, regulating many processes including reward, movement, and cognition. Dopamine also regulates critical functions in peripheral organs, such as blood pressure, renal activity, and intestinal motility. Beyond these functions, a growing body of evidence indicates that dopamine is an important immunoregulatory factor. Most types of immune cells express dopamine receptors and other dopaminergic proteins, and many immune cells take up, produce, store, and/or release dopamine, suggesting that dopaminergic immunomodulation is important for immune function. Targeting these pathways could be a promising avenue for the treatment of inflammation and disease, but despite increasing research in this area, data on the specific effects of dopamine on many immune cells and disease processes remain inconsistent and poorly understood. Therefore, this review integrates the current knowledge of the role of dopamine in immune cell function and inflammatory signaling across systems. We also discuss the current understanding of dopaminergic regulation of immune signaling in the CNS and peripheral tissues, highlighting the role of dopaminergic immunomodulation in diseases such as Parkinson’s disease, several neuropsychiatric conditions, neurologic human immunodeficiency virus, inflammatory bowel disease, rheumatoid arthritis, and others. Careful consideration is given to the influence of experimental design on results, and we note a number of areas in need of further research. Overall, this review integrates our knowledge of dopaminergic immunology at the cellular, tissue, and disease level and prompts the development of therapeutics and strategies targeted toward ameliorating disease through dopaminergic regulation of immunity.Canonically, dopamine is recognized as a neurotransmitter involved in the regulation of movement, cognition, and reward. However, dopamine also acts as an immune modulator in the central nervous system and periphery. This review comprehensively assesses the current knowledge of dopaminergic immunomodulation and the role of dopamine in disease pathogenesis at the cellular and tissue level. This will provide broad access to this information across fields, identify areas in need of further investigation, and drive the development of dopaminergic therapeutic strategies. I.A.Dopamine, or 3-hydroxytyramine, is an endogenous catecholamine that is important to both neuronal and nonneuronal processes. Dopamine was first synthesized in 1910, and initial studies examined its biologic effect as a weak sympathomimetic,although the mechanism of action was not clear . NeurotrThe biosynthetic pathways associated with the synthesis of dopamine were first hypothesized by Hermann Blaschko , and witIn addition, research over the past few decades has shown that dopamine can have a substantial impact on immune cell function in both the CNS and periphery. Dopaminergic immunomodulation affects both innate and adaptive immunity and has become increasingly important as a possible target for drug discovery and disease management. While there have been numerous reviews that detail individual parts of these topics , this fiB.Dopamine primarily mediates its effects on different cell types by signaling through dopamine receptors, which are G-protein coupled receptors (GPCRs). An overview of these signaling cascades, delineating the pathways described in this section, is shown in α subunit of the heterotrimeric G-protein. This releases the coupled G-protein and facilitates its dissociation into α and βγ subunits. The α subunit then acts on adenylate cyclase, an enzyme that catalyzes the conversion of ATP into cAMP. The specific effect on adenylate cyclase depends on the released G-protein. D1-like receptor activation releases Gs alpha subunits of the Gs heterotrimeric G protein (Gαs), which activate adenylate cyclase, increasing intracellular concentrations of cAMP . D2-like receptor activation inhibits the activity of adenylate cyclase, reducing cAMP production and decreasing the downstream activity induced by D1-like receptors , but studies have shown that cAMP can also activate exchange factor directly activated by cAMP (EPAC) and protein kinase C (PKC). PKA activation leads to the transcription of cAMP response element binding protein (CREB), which triggers the transcription of a variety of genes , althougβ (PLCβ) to induce inositol triphosphate (IP3)-mediated intracellular calcium flux. Unlike the effect on cAMP signaling, both dopamine receptor subtypes mediate similar effects on IP3-mediated calcium flux despite different signaling cascades  and D2-like receptors as inhibitory (Gαi) is only partially accurate, as D1- and D2-like receptors can stimulate both opposing and overlapping signaling mechanisms through non-cAMP pathways.Dopamine signaling can also be mediated through G-protein-independent pathways, such as the activation of tivities . In addieceptors , triggereceptors  which reeceptors . These a2+, and PLCβ, as dopamine receptors can activate a wide range of additional proteins and effectors, including the MAPKs extracellular signal-regulated kinase 1/2 (ERK1/2), p38 MAPK, and c-Jun N-terminal kinase (JNK)/stress-activated protein kinase, L-type calcium channels, Akt, and AMP-activated protein kinase , but in brain regions with low DAT expression, dopamine is taken up by the norepinephrine transporter . Once dopamine is taken back up, it can be repackaged into VMAT2-expressing vesicles, which are then re-released, recycling the neurotransmitter. Alternatively, in both neurons and other cell types, dopamine can be metabolized to form homovanillic acid (HVA). The two major degradation pathways that generate HVA begin with oxidative deamination by monoamine oxidases (MAOs), or O-methylation by catechol-O-methyltransferase (COMT). These pathways generate a variety of intermediate metabolites, including dihydroxyphenylacetaldehyde, 3,4 dihydroxyphenylacetic acid (DOPAC), and 3-methoxytyramine, which are ultimately metabolized to HVA . These rD.Classically, dopaminergic neurons release dopamine when an action potential reaches the axon terminal, inducing dopamine-containing vesicles to fuse with the cell membrane and release dopamine via exocytosis . Within Extracellular dopamine mediates communication by binding to dopamine receptors on neighboring cells. Classic neurotransmission refers to dopamine receptors on the postsynaptic neuron and point-to-point transfer of dopamine in the synaptic cleft. This type of direct interaction within well-defined physical boundaries, such as axons and their synapses, represents a discrete type of transmission known as wired transmission. This type of communication was long considered to be the primary form of dopaminergic neurotransmission . HoweverBecause dopaminergic neurons have broad arbors, dopamine released via spillover and extrasynaptic release increase dopamine concentrations in a large area of surrounding tissue. This can activate extrasynaptic dopamine receptors on neighboring neurons, as well as other nearby cells, such as immune cells, that may be a considerable distance away from the synapse . BecauseThe function of DAT is particularly important for the regulation of dopaminergic signaling, as this transporter is a critical regulator of extracellular dopamine concentrations. DAT dysregulation or neuronal death/dysfunction that reduces the amount of functional DAT in a specific area could expose larger brain areas and the immune cells in those regions to increased concentrations of dopamine. Indeed, DAT dysregulation is implicated in several distinct pathologies, including ADHD, PD, and bipolar disorder . Most stE.α-synuclein aggregation, glial cell activation, alterations in calcium signaling, mitochondrial dysfunction, and excess free iron . Dopamine and its metabolites contain 2-hydroxyl residues, which generate highly reactive dopamine and DOPA quinones (3+) or by cyclooxygenases, tyrosinases, or other enzymes but can also occur spontaneously. These reactions can then generate superoxide radical anions by donating electrons to oxygen , ventral tegmental area (VTA), and arcuate nucleus of the hypothalamus . Their e−8M to 10−4M in both the hypothalamus and pituitary, and immune cells could be exposed to significant dopamine fluctuations due to diet  have considerable associated errors . More prConsideration must also be given to the relationship between the amount of dopamine measured in a particular tissue and the amount of dopamine to which immune cells in that compartment are exposed. In the brain and likely other compartments, biogenic amines and their metabolites are generally found in three regions: the extracellular space, cytoplasmic vesicles, and the cytoplasm itself , 2010. PB.−5M to 10−11M, although the utility of higher and lower levels of dopamine should be determined based on the experimental question. While the higher end of dopamine concentrations are >10−5M in some brain regions and peripheral compartments such as the adrenal gland, gut, and carotid body, most immune cells will generally encounter lower concentrations of dopamine during homeostatic conditions  is that it may create confounding results by initiating immune functions that do not occur in vivo. One mechanism by which this could occur is through the activation of lower affinity dopamine receptors that would not be activated when an immune cell encounters lower dopamine levels. Different dopamine receptors, as well as nondopamine receptors, also have discrete affinities for dopamine  increased phagocytosis, while higher dopamine levels (10−7–10−5M) decreased phagocytosis , interleukin (IL)-6, and IL-8 and blocked dopamine-mediated IL-12p40 suppression in human keratinocytes and rodent macrophages -induced NO production, suggesting that dopamine may act through adrenergic receptors in this system  for 24 hours attenuated LPS-induced expression of IL-6, tumor necrosis factor alpha (TNF-α), and IL-1β by inhibiting NF-κB  in response to high dopamine concentrations (10−5–5 × 10−4M) (−5M) from reactivating latent human immunodeficiency virus (HIV) in a chronically infected T-cell line  , 1997. Iell line , indicatC.Cell type- and species-specific differences in dopamine receptor expression and signaling have important implications in the effects of dopamine on immune cell function and regulation. As has been reviewed recently  and willDopamine receptor expression levels are typically analyzed at the mRNA level using in situ hybridization and reverse-transcription polymerase chain reaction or at the protein level by Western blotting, immunohistochemistry, or immunofluorescent staining. While mRNA expression does not equate to protein expression and cannot reveal the receptor expression levels in the plasma membrane, the absolute specificity of the probe/primer sequences can indicate expression, enable precise subtype differentiation, and suggest the relative ratios between the different subtypes. In contrast, protein analysis can theoretically demonstrate surface expression and be used to quantify receptor density. However, dopamine receptor antibodies often lack specificity , likely These technical issues, as well as differences in the information provided by these methodologies, creates difficulties when trying to make comparisons across the literature. For instance, mRNA and protein expression levels of dopamine receptors vary greatly among human and rodent immune cell types, making comparisons across species complicated . Even wiThese differences are especially important when considering the impact of dopamine on cells isolated during different disease states or in activated and resting cells. Diverse stimuli, as well as many pathologies, can alter both dopamine concentrations and dopamine receptor expression levels, which could potentially activate different dopamine receptors than would normally respond to dopamine and promote important homeostatic activity. Changes in the expression of some dopamine receptors and not others could also affect function by altering the ratios of different dopamine receptors. As changes in dopamine receptors may be critical for determining the effects of dopamine on distinct cell types, it is important to define baseline expression levels, how those levels compare with other systems, and how those levels change throughout experiments. Moving forward, examining dopamine receptor ratios may be more relevant than measuring individual receptor expression. Further, examining receptor ratios in relation to other receptors that modulate dopamine signaling  may be a better strategy for understanding dopamine-mediated patterns in immune function and disease.D.Classically, dopamine signaling has been defined in neurons, but several studies have shown dopamine signaling differs between neurons and immune cells, as well as other nonneuronal cell types , and betα- and β-cells express dopamine and adrenergic receptors, but there are large, species-specific differences in the ratios of dopamine receptors to adrenergic receptors. Further, dopamine induces dose-dependent changes in glucagon in human islets, but low levels decrease glucagon, while higher levels increase glucagon. In contrast, dopamine only dose-dependently increases glucagon in mouse islets. This may be due to variations in the ratios of receptors with different dopamine affinities , D1-like receptor activation does not stimulate cAMP production  and primfinities . These tfinities  or betwe+ T-cells and that these D5R:CCR9 complexes are increased during gut inflammation and drive colonic homing of these T-cells . Because it is often not clear how the pharmacologic agent is acting on the dopamine receptor being studied or what is the appropriate concentration of agonist/antagonist to use, extrapolations about the effects of dopamine based on pharmacologic drugs could be misleading.Another similar issue occurs in studies evaluating the immunomodulatory effects of addictive drugs. As previously noted, all addictive substances, including stimulants such as cocaine and methamphetamine , alcoholIII.A.A growing body of evidence has shown that dopamine can modulate a variety of immune functions, including proliferation, chemotaxis, antigen presentation, phagocytosis, cytokine secretion, and cell adhesion . Much ofβ and IL-10 production or B-cell activation , are among the highest in the body. Therefore, CNS immune cells, particularly in these regions, are likely to frequently encounter immunomodulatory levels of dopamine, and dopamine-mediated effects may be associated with homeostatic function in these regions . The mosammation .All five dopamine receptor subtypes have been identified on human microglia , human mDopamine has several effects on microglia, many pertaining to neuroinflammation and the activation state of these cells. In wild-type mice, no D2 expression was detected in Iba-1+ microglia, but cerebral ischemia and the associated inflammation induced high levels of D2 expression in these cells . In a se−6M) induced the formation of extracellular traps. Although extracellular traps are normally generated in granulocytes, dopamine has not been shown to affect trap formation in that cell type. The novelty of this process was increased by the finding that these extracellular traps were formed independent of ROS production, actin polymerization, or cell death  to various stimuli associated with pathogens or other insults. The four main families of PRRs are toll-like receptors (TLRs), nucleotide-binding oligomerization domain-like receptors (NLRs), C-type lectin receptors, and RIG-1 like receptors . TLRs arβ-glucans, which are components of fungal cell walls; and immunostimulants, such as polyinosinic:polycytidylic acid, which mimics activation caused by viral RNA. The expression and activation of PRRs on innate immune cells mediates coordinated effector responses upon contact with an invading pathogen (PRRs act primarily by recognizing a variety of molecules known as pathogen-associated molecular patterns (PAMPs) or damage-associated molecular patterns (DAMPs), which signal the presence of danger. Examples of PAMPs and DAMPs include LPS, which is a component of Gram-negative bacterial cell walls; single- or double stranded RNA, which is associated with viral infection; pathogen . Dopaminpathogen .a.Chilo suppressalis) hemocytes, blood cells that are analogous to macrophages in vertebrates , alveolar macrophages (lung), Kupffer cells (liver), adipose-associated macrophages (adipose tissue), Langerhans cells (skin), osteoclasts and bone marrow macrophages (bone), and intestinal macrophages (gut). There is very little specific data on the effect of dopamine on tissue-specific macrophages other than microglia, although recent studies have identified DAT on a subset of gut macrophages in the lamina propria . This lab.There has been relatively little research on the impact of dopamine on the four types of granulocytes: neutrophils, basophils, eosinophils, and mast cells. Dopamine has been shown to mediate functional changes in neutrophils, eosinophils, and mast cells  with lit−7 M) attenuated the expression of CD62l (L-selectin) and CD11b in neutrophils stimulated with N-formyl-methionyl-leucyl-phenylalanine, a potent neutrophil activator that mimics the actions of factors released by bacteria. This effect was not seen in resting neutrophils or in response to lower dopamine concentrations (2.61 × 10−10M) (−4M–10−5M) increased apoptosis in human neutrophils  . The dowtrophils , and thetrophils , suggestEosinophils are another granulocyte subset that are much less common than neutrophils (2%–3% of blood leukocytes) that have a key role in defense against helminth infection, injured tissue repair, and allergic diseases. These cells are released into the circulation like neutrophils but generally reside in tissues, mediating their effects through the release of cytoplasmic granules, cytokines, chemokines, and growth factors . Very feα; growth factors such as TGF-β and vascular endothelial growth factor; proteoglycans, proteases, and other enzymes; and biogenic amines such as histamine, serotonin, and dopamine . Other studies have confirmed dopamine storage in murine , C-C motif chemokine ligand 5, and TNF-dopamine . Mast cedopamine . mRNA fodopamine . Bone man murine  and bovin murine .−9M–10−7M) activation of D1-like receptors dose-dependently increased murine mast cell degranulation. Antagonizing D1-like receptors with SCH23390 also reduced ear swelling caused by passive cutaneous anaphylaxis, which is a mast cell–mediated process  on target cells. Indeed, one of the primary functions of these cells is to recognize and eliminate other cells that lack MHC class I molecules. NK cells act by producing and secreting cytokines and chemokines that can influence the immune response and/or induce death pathways in infected cells  to inhibit cellular proliferation and reduce the synthesis of IFN-γ  are professional antigen-presenting cells derived from both myeloid and lymphoid progenitors. The primary function of these cells is to migrate to secondary lymphoid organs and interact with T-cells to promote the differentiation of various effector T-cell subsets . Both huar space . Human Dar space , increasar space . Once pr+ T-cells, dopamine is released and activates D1-like receptors to increase cAMP signaling, which regulates T-helper (Th)1–Th2 polarization . Blocking D2-like receptors also increased Th2 cytokine (IL-10) production and reduced Th1 polarization in cocultured T-cells  subset primarily prevents a response to self-antigens and suppresses detrimental immune responses. CD8+ cells, also called cytotoxic T-cells or cytotoxic T lymphocytes, are activated by CD4+ T-cells or antigen-presenting cells, producing cytotoxins such as perforin and granzyme, Fas ligand, and various cytokines that destroy target cells such as virus-infected cells or tumor cells.The primary cells that mediate adaptive immunity are T- and B-lymphocytes, which interact with the innate immune system to generate specific responses to invading pathogens, killing infected cells and generating specific antibodies against pathogens. A critical feature of adaptive immunity is immune memory, which enables the body to rapidly respond to repeat insults using factors that specifically target those pathogens. Lymphocytes, particularly T-cells, can differentiate into numerous subpopulations that have a wide variety of functions depending on the maturation process and stimuli to which they are exposed. The major T-cell subsets are classified by surface expression of CD4 or CD8. The CD4The other major lymphocyte that mediates adaptive immunity is the B-cell, which primarily produces antibodies, although B-cells can also act as antigen-presenting cells and produce cytokines. Naïve or memory B-cells express B-cell receptors on the plasma membrane, and when this receptor is activated by a specific antigen, the B-cell proliferates and differentiates into a plasma cell, producing large quantities of specific antibodies to fight invading pathogens. Both T-cells and B-cells can develop into memory cells that can persist in a quiescent state for long periods of time until activated by the specific antigen to which they respond. Once the memory cell is activated, it generates a rapid adaptive immune response. Lymphocyte differentiation, the specific roles of lymphocytes subsets, and the formation of immune memory are central to the adaptive immune response, and this topic is an extraordinarily expansive and well-researched field, with numerous excellent reviews . The rola.+CD25+ Tregs contained significantly higher dopamine levels than CD4+CD25− T-cells (fh) stored much higher concentrations of dopamine than naïve T-cells , or the PKC activator phorbol myristate acetate increased the production and release of dopamine and other catecholamines  downregulates the suppressive activity of Tregs but does not affect the D1-mediated response of T-effector cells to regulatory cell suppression, which may be mediated by ERK signaling (reg function in human CD4+ Tregs (regs in vivo and increased the expression of glucocorticoid-induced tumor necrosis factor receptor-related protein (GITR)  . Thus, breg suppressive functions, in naïve CD4+ T-cells, D5 signaling increased proliferation and increased the differentiation of the Th17 inflammatory phenotype in the early stages of EAE , also blocked Th1 and Th17 polarization, and this effect was blocked by D2 antagonism with L-741,626 , SKF-38393 (D1-agonist), and LY171555 (D2-agonist) all increased LPS-induced murine splenocyte proliferation  was increased in the CNS due to increases CNS tropism mediated by upregulation of CXC chemokine receptor 3 (CXCR3). Further, this subset of cells seems important to the onset of EAE, because knocking out Drd3 in B-cells completely abrogated disease symptoms. Expression of CXCR3 is increased in the CNS of patients with MS, and natalizumab, which blocks lymphocyte entry into the CNS, reduces CXCR3+ B-cells in MS brains. However, in a separate EAE model that does not require antigen-presentation, Drd3 knockout in B-cells exacerbated disease progression and increased the number of inflammatory CD4+ T-cells in the CNS. This suggested that D3 activation had discrete effects on antigen presenting versus nonantigen-presenting, anti-inflammatory B-cell subsets, demonstrating the importance of dopamine in regulating the function of several types of B-cells  hemocytes, exposure to LPS stimulates dopamine synthesis  signaling activates NF-κB and inflammasomes during bacterial and antifungal infections, respectively. Antiviral immunity is most often mediated by the upregulation of type I interferons via cytoplasmic RIG-I/MDA5, which is a cytoplasmic caspase-recruiting domain helicase  reduced both LPS-induced expression of NO synthase and the expression of the NLRP3 inflammasome components NLRP3 and caspase-1  also decreased inflammatory cytokine production and NLRP3 activity in murine lung tissue in ventilator-induced lung injury models  cells  cells . These sM) cells . The conM) cells .κB and NLRP3 activity (−8–10−6M) increased the production of the inflammatory mediators CCL2, IL-6, C-X-C motif chemokine ligand (CXCL) 8, IL-1β, CXCL9, and CXCL10 (−6M–10−5M) increased IL-6 and IL-1β production in activated primary murine microglia, NK cells, and BV-2 murine microglial cells  increased the production of IL-5, IL-17, IL-1β, and IL-6 and the dopamine-mediated changes in IL-5 and IL-17 were blocked by the presence of SCH23390 (D1-like receptor antagonist)  . The sectivation . Activath2 cells . In a mope cells . In an M T-cells . In addi T-cells , and in  T-cells .+ and IL-17+ T-cells  increased the anti-inflammatory mediator IL-10 in LPS-induced hMDMs  inhibited NLRP3 activation in mouse lung , brain , and kidof NF-κB . D2 actiof NF-κB  and humaof NF-κB .α in the same population , this seems unlikely, as both D1  and D5  have beepulation . This bi3.Litopenaeus vannamei, a species of white prawn, dopamine (10−7M–10−6 M) significantly decreased gene expression of Drd4, Gi heterotrimeric G protein, and exocytosis-related proteins, while phagocytosis-related proteins and Gs heterotrimeric G protein were increased , dopamine (10−5M) increased hemocyte phagocytosis via a D1-like receptor. This effect appeared to involve ERK1/2 activation  could decrease phagocytosis, while very low dopamine concentrations (10−11–10−15M) could increase phagocytosis (−8–10−7M) increased the phagocytic activity of murine BMDMs in the presence of IFN-γ, as well as in neutrophils (−7M) reduced neutrophil phagocytosis (−6M) and guinea pig macrophages treated with bromocriptine (D2 receptor agonist) and pergolide (D2 receptor agonist) both showed an enhanced binding and phagocytosis of IgG-sensitive red blood cells  receptors, which are critical regulators of the immune response that mediate a number of factors including antigen uptake  treatment of LPS-activated BV2 microglia, but no effect on the phagocytic activity of resting cells was observed, suggesting autocrine control of phagocytosis by dopamine signaling in activated myeloid cells  and D2 activation increased phagocytosis  increased the production of CCL2, CXCL8, CXCL9, and CXCL10 (−5–10−6M) increased CXCL1 production  inhibited IL-8 mediated transendothelial migration  and SKF38393 (D1-like agonist) increased chemokinesis and transmigration across a model of the blood–brain barrier  potentiated homing to CCL19, CCL21, and CXCL12 through D3 and Gαi-mediated Ca2+ mobilization (−8M) increased spontaneous migration and migration toward CXCL12  mediated a chemotactic response to IL-8 that required the activation of Gαi and Gβγ activity, while Gαs and Gαq receptors did not mediate these effects  larva chemotaxis into the bile duct, indicating that dopamine plays a role in the development of clonorchiasis (−5M) also increased the expression of flagellar motility-related genes and the swimming motility of the aquatic bacterium Vibrio harveyi, a Gram-negative bacterium that is a major pathogen of all aquatic organisms. This effect was blocked by chlorpromazine, suggesting that this effect was driven by D2-like receptors, although the effect could be influenced by the many effects of chlorpromazine on nondopaminergic receptors  and superoxide anion, which can be formed by the activity of superoxide dismutase. This process is common in phagocytes, such as myeloid cells and granulocytes, to degrade internalized bacteria and other particles as part of the immune response. These bursts can also affect cell signaling (−7M) of human neutrophils reduced ROS production (−4 and 10−5 M) inhibited superoxide anion production in response to N-formylated N-formyl-methionyl-leucyl-phenylalanine stimulation (−4M) and fenoldopam (D1-like agonist) reduced respiratory bursts in neutrophils isolated from the blood of patients with systemic inflammatory response syndrome (−7M or 2.61 × 10−10M) had no effect on the formation of H2O2-mediated oxidative bursts in human neutrophils  of hemocytes from the white shrimp Litopenaeus vannamei significantly reduced respiratory bursts and superoxide dismutase activity (−6–10−9M) broadly inhibited neutrophil activity in a D1-dependent manner  increased NO synthase (−5M) and to a much lesser extent than other catecholamines  kinase, which phosphorylates IκB to release and activate NF-κB  and potential cell type– and species-specific differences in dopamine receptor expression and signaling bias. Thus, there is no clear consensus on the roles of distinct dopamine receptor subtypes in mediating these effects. The hypothesis that D1-like receptors are inflammatory while D2-like are anti-inflammatory is not broadly supported by the data, although there are certainly specific cell types or diseases, which will be discussed in depth in the following sections, in which this may be the case. Evidence suggests that dopamine may be more anti-inflammatory in stimulated cells and inflammatory in resting cells, and studies in human cells generally show an inflammatory effect of dopamine, although this may be due to the smaller numbers of studies done in humans relative to other systems. Data also suggest that the effects of specific dopamine receptors may differ between cell types and among the same cell type in different species. Signaling pathways activated by dopamine receptors are also likely to overlap, and the activation of multiple dopamine receptor subtypes could interact and result in opposing, additive, or novel outcomes.Moving forward, careful evaluation of dopamine receptor expression in each model system, defining both raw receptor expression and the ratios of different dopamine receptors, is important in precisely defining the receptors and signaling mechanisms that mediate a particular effect. Many areas warrant further investigation, including the understanding of dopamine release in immune cells, examination of cell type–specific dopamine receptor signaling and specific immune activity, and delineation of dopamine-mediated inflammation from inflammation mediated by pharmacologic drugs that modify dopamine signaling. Broadly, these data show the importance of dopamine in the regulation of immune function and the need for further studies with carefully considered experimental designs to better understand and leverage dopaminergic immunomodulation for disease treatment. In the subsequent sections, we will discuss how the immunomodulatory effects discussed here impact different organs and diseases, highlighting the potential for dopaminergic immunomodulation in the treatment of a wide array of pathogenic conditions.IV.A.1.While further research on the signaling processes and cell type–specific effects induced by dopamine is important for understanding the basic processes that mediate dopaminergic immunomodulation, it is also important to consider the application of this research to specific pathologies. Fluctuations in dopamine and the dopaminergic system influence a wide variety of organ systems and diseases. Prominent among these are numerous neurologic conditions including PD and neuroHIV, neuropsychiatric conditions such as schizophrenia and depression, and developmental neurologic disorders such as ADHD and epilepsy. Many of the studies evaluating the impact of dopamine on these diseases can be found in Anatomic changes in dopaminergic brain regions, the dysregulation of dopamine transmission, and aberrant dopamine receptor activity are key aspects in the development or progression of these diseases . Changes2.α-synuclein protein aggregates known as Lewy bodies , and serum in PD patients , negative symptoms , and cognitive deficits involving executive functioning and memory. Schizophrenia has a complex etiology but is thought to involve genetic and environmental factors that promote alterations in the dopaminergic system . The dopNeuroinflammation and abnormal immune responses, particular changes in the activity of T-cells, microglial cells, and peripheral monocytes, may also drive the pathogenesis of schizophrenia . These cAs both schizophrenia and its therapeutic agents target the dopaminergic system, dopaminergic changes in immune activity could drive disease progression . ExpressStudies of D3 expression have shown increases , decreasThe expression of D1-like receptors and their involvement in schizophrenia is less well-studied, and D1 expression was no different in PBLs from healthy controls, treated patients, and drug-naïve patients . However+ memory T-cells and reduced percentages of DCs, CD4+ memory T-cells, and HLA-DR+ regulatory T-cells have been found in the blood of patients who are resistant to clozapine treatment. These CD4+ T-cells showed significantly increased D3 expression, which correlated with a reduced frequency of Tregs  mRNA in the schizophrenic midbrain  model of schizophrenia. This model shows an elevated risk of schizophrenia following prenatal exposure to maternal infection and subsequent immune-mediated disruption of early brain development . Animal While the immune dysregulation associated with schizophrenia seems to be both a cause and consequence of disease progression, it is not clear whether correlations with inflammatory markers following treatment are mediated by the drugs or the psychiatric symptoms. In vivo and in vitro studies show that antipsychotics can be both inflammatory and anti-inflammatory , but stuIn the context of schizophrenia, it has been hypothesized that lower dopamine levels may selectively stimulate high-affinity dopamine receptors (D3 and D5), triggering inflammation, while higher dopamine levels could also stimulate low-affinity dopamine receptors (D1 and D2), inducing an anti-inflammatory effect . Thus, ib.Bipolar disorder is a chronic, recurring psychiatric disorder characterized by mood shifts from acute depression to mania and hypomania, with intermittent periods of stable mood states (euthymia) . ClinicaThere is relatively little literature on dopamine and immune function in bipolar individuals, but studies examining patients diagnosed with schizophrenia, bipolar , and psyWhile bipolar disorder has not been specifically studied in animal models of MIA, some of the experimentally induced phenotypes, such as deficits in sensorimotor gating  and deprDopamine antagonists and partial agonists are widely used in the pharmacological treatment of bipolar disorder , as is lc.Depression is a psychiatric disorder characterized by low mood, anhedonia, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and suicidal ideation. It is a major cause of disability worldwide with over 322 million people living with depression . Standard pharmacological treatments for depression include antidepressants that predominantly act on serotonin but also other monoamines. These include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors, as well as typical and atypical antipsychotics for more treatment-resistant patients. Antidepressant therapies are effective for many patients with major depression, especially when paired with evidence-based psychotherapy such as cognitive-behavior therapy. However, even with initial treatment, over two-thirds of patients continue to have significant depressive symptoms . Furtherα, and C-reactive protein (CRP) in blood and CSF , an essential enzyme cofactor that is required to produce tyrosine and dopamine, that has been discussed as a potential treatment target . In acutα, has been shown to reduce depressive symptoms including anhedonia and psychomotor slowing in patients with inflammatory disorders and in depressed patients with increased inflammation . Anxiety is a complex feeling of uneasiness, fear, and worry, and in individuals with anxiety disorders, anxiety is more frequent, intense, and persistent. These disorders include but are not limited to generalized anxiety disorder (GAD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), panic disorder, and phobias. First-line treatment of anxiety disorders consists of SSRIs, serotonin, norepinephrine reuptake inhibitors (SNRIs), and pregabalin, with benzodiazepines such as diazepam as second-line options. Many patients do not respond to first-line treatments, or they continue to have residual symptoms, putting them at high risk of experiencing disorder chronicity and a lower quality of life. New and repurposed pharmacological agents, such as mood stabilizers and atypical antipsychotics , have been introduced as monotherapies or combined with SSRIs/SNRIs, but these treatments are not recommended as first-line options .Anxiety research has been somewhat confounded by its high comorbidity with depression and SUDs. However, data show that dopaminergic signaling plays a critical role in the regulation of anxiety behaviors , and botα  may be relevant and should be considered.4.a.ADHD is a neurologic disorder that typically manifests early in development and is characterized by a persistent pattern of inattention, disorganization, and/or hyperactivity-impulsivity. While ADHD is usually thought of as a childhood disorder, it is now considered a chronic condition. Around 50% of children with ADHD have continued impairment into adolescence, with 30% to 60% of those continuing into adulthood , substanRecent research shows a clear role for inflammation in ADHD pathophysiology . ADHD isAccumulating evidence from human studies and animal models supports a role for crosstalk between dopamine and inflammation in ADHD pathophysiology. In humans, increased levels of antibodies against the basal ganglia  and DAT regs in the thymus and spleen, reduced cyclo-oxygenase 2, TNF-α, and Irf7 expression in microglia, and decreased monocyte infiltration into the brain. DAT hypofunction was associated with weaker choroid plexus activation, which was attributed to increased expression of IκBα and reduced nuclear translocation of NF-κB p65, and was associated with decreased mRNA expression of proinflammatory markers in the choroid plexus. Amphetamine reversed and stimulated p65 nuclear translocation in the choroid plexus in DAT-deficient mice. This study highlights the potential importance of the choroid plexus in neurologic disorders  or spread to entire cerebral hemispheres . The development of epilepsy, epileptogenesis, derives from a diverse array of factors, including genetic predisposition, developmental dysfunction, and neurologic insult, which contribute to synaptic changes and hyperexcitable neurotransmission . SeizureWhile clinical and experimental studies implicate many neurotransmitters in epileptogenesis, the dopaminergic system plays a prominent role in the modulation of seizures. Drugs that increase dopamine, such as apomorphine, amphetamines, L-DOPA, and anti-parkinsonian drugs (pergolide and bromocriptine), have antiepileptic and anticonvulsant effects. Seizures involving the limbic system are most affected by modulating dopaminergic signaling . SeizureIn contrast, D2-like receptor signaling is generally considered to have antiepileptogenic effects, and antagonizing D2-like receptor signaling reduces seizure thresholds . PatientInflammatory processes arising from neuronal damage, gliosis, and microgliosis are also a likely common mechanism in the pathophysiology of seizures and epilepsy . SteroidMost studies examining inflammation in epilepsy focus on neuroinflammatory pathways, but peripheral immune cells, and the effects of dopamine on those cells, may also contribute to epilepsy pathophysiology . SeizureCurrently, dopaminergic drugs are not used to treat epilepsy, but antiepileptic effects of dopaminergic agents have been reported in epileptic patients . Bromocr5.HIV is a retrovirus that attacks the immune system and causes AIDS. While HIV was initially a terminal diagnosis for the majority of infected individuals, the development of effective antiretroviral therapy (ART) has revolutionized HIV treatment and significantly improved the lifespan and quality of life of people living with HIV (PLWH). Today, more than 37 million people are living with HIV globally . Importa+/CD16+ monocytes -infected rhesus macaques, treatment with selegiline (monoamine oxidase inhibitor) and L-DOPA during peak viremia significantly enhanced viral infection and neuropathology in the basal ganglia, frontal cortex, and hippocampus at 6 to 8 weeks postinfection , 2004. I−6–10−8M) significantly increased viral replication in primary hMDMs  significantly increased HIV replication by activating NF-κB and Sp1 binding sites in the HIV long terminal repeat  is an umbrella term for Crohn’s disease (CD) and ulcerative colitis, which are two distinct disorders that are characterized by chronic, progressive inflammation in the GI tract. Inflammation in ulcerative colitis is localized to the mucosal and submucosal layers of the colon and rectum, whereas inflammation in CD can be found throughout the GI tract and affects all layers of the intestinal wall . The etiology of IBD is not well understood and is thought to involve multiple mechanisms that initiate and support an inflammatory phenotype, including microbiome dysregulation, neuroimmune signal dysregulation, and immune cell overactivation . As noteβ, IL-6, and TNF-α, increased the anti-inflammatory cytokine IL-10 and increased the ratio of M1 and M2 macrophages to levels seen in healthy rodents. However, berberine also reduced IL-17 expression, increased IL-22 expression and suppressed Th1 and Th17 cell expansion  are being affected by signaling through those receptors. These studies will be critical in effectively leveraging the dopaminergic pathway to treat IBD, as they define the diverse impacts of dopamine receptor and transporter activity on different immune cell populations. Despite the gaps in knowledge, the effects of dopamine signaling on gut inflammation and pathologies make it a strong target for new IBD therapeutics, as well for studies examining the specific receptors and cell types that drive the immunomodulatory properties of this neurotransmitter.These data indicate that different dopamine receptor subtypes mediate both pro-and anti-inflammatory activity in the gut and may act differently on discrete types of immune cells, as D5 activation was shown to both decrease colitis by altering M1/M2 ratios and increase T3.The skin plays a vital role in regulating a homeostatic environment and has innate and adaptive immune roles that are still being defined. The skin consists of three main layers—the epidermis, dermis, and hypodermis—and contains numerous cell types throughout these layers that contribute to homeostatic maintenance and immune regulation . KeratinOne such pathway may be mediated by cytochrome P450 2D6 (CYP2D6), which can metabolize both p- and m-tyramine to dopamine in the brain and liver . ExpressWhile melanocytes can produce L-DOPA, their capacity to generate dopamine has not been directly shown, and the expression of AADC or CYP2D6 have not been observed in these cells . Howevera.h17 cells, which are implicated in both psoriasis and schizophrenia  cells in vitiligo. These are resident populations of T-cells that establish themselves in a specific site, such as the skin, and are removed from circulation, proliferating and expanding within the site and have extended lifespans, on the magnitude of years in humans. Selective elimination of the CD69+CD103+CD8+ T-cells (markers for Trm cells) within the epidermis in vitiliginous mice durably reverse vitiligo  and integrin α4β1 (very late antigen 5), cellular adhesion molecules  (−8M–10−10M) (−9–10−6M) (−4M–10−5M)  , rodent –10−10M) , primary9–10−6M) , and theM–10−5M) . TreatmeM–10−5M) . The dopM–10−5M) . In contM–10−5M) .In all these studies, the reduction in osteoclastogenesis was accompanied by a dopamine-mediated reduction in osteoclastic markers  that was generally found to be mediated through D2-like receptor signaling. The effects of dopamine could be replicated with D2-like receptor agonists, such as pramipexole, and blocked with D2-like receptor antagonists, such as haloperidol. Treatment with D1-like agonists and antagonists had no effect on osteoclastogenesis. Analysis of the D2-like receptor signaling mediating this process showed that activation of D2 downregulated cAMP and PKA activity, inhibiting CREB phosphorylation and subsequent transcription . These d−5M) increased the proliferation of the immature murine osteoblast cell line MC3T3-E1 , although in another study using this cell line, dopamine suppressed osteoblast mineralization and osteoblast marker expression that was not seen in primary murine osteoblasts . These data indicate important roles for dopamine in bone homeostasis, with D2-like receptor activation reducing bone loss by diminishing osteoclast activity and D1-like receptor activation promoting osteogenesis by promoting osteoblast differentiation and activity.While D2-like dopamine receptor signaling seems to primarily regulate osteoclastogenesis and subsequent bone resorption, signaling via D1-like receptors was found to influence osteoblast activity. Treatment with dopamine , an effect that was blocked by activating D1-like receptors with A68,930 , which was partially due to inhibition of the NLRP3 inflammasome  increased cardiac output and mean arterial pressure, while lower doses (1–2 μg/kg/min) decreased mean arterial pressure  and increase production of IL-10, although, as previously noted, these effects are complex and vary with cell type, dopamine concentration, dopamine receptor ratio, and species. Increased dopamine output from the adrenal glands attenuated the increase in serum TNF-α levels in a mouse model of endotoxemia (−4M) prevent Staphylococcus aureus–induced sepsis in mice through activation of D5 on macrophages, inhibiting TLR2-induced inflammation and NF-κB activation (However, these studies did not consider differences in dopamine dose or any potential age-related effects, so it is possible that these effects are confounders. There may also be age-related differences in how immune cells and the cardiovascular system respond to dopamine, which need to be further explored. In addition, a number of studies show that dopamine treatment is as safe and effective as other treatments, and randomized trials in neonates and pediatric patients who were septic and treated with dopamine or epinephrine showed no difference in long-term mortality and comparable efficacy and safety . In patiotoxemia , and in otoxemia . In anototoxemia , as patiotoxemia . A separtivation .These data suggest that dopamine may be as safe as other vasopressors in some populations and that the beneficial effects may be mediated by activation of D1-like receptors, which are important in the regulation of inflammation during sepsis. This correlates well with many studies discussed earlier, showing that activation of D1-like receptors in rodents and in cells treated with LPS was anti-inflammatory and supports the concept that dopamine has distinct effects in inflammatory and noninflammatory environments. Defining the mechanisms by which specific dopamine receptors affect inflammation in sepsis will be useful in the management of this condition, enabling development or repurposing of targeted agonists that leverage anti-inflammatory activity. However, until these mechanisms and the way they affect distinct populations are better understood, norepinephrine will remain the first-line vasopressor because of its more consistent effects and better safety profile across all populations.V.The data discussed in this review clearly show that dopaminergic immunomodulation has substantial impacts across both the CNS and periphery, broadly affecting homeostatic function and disease pathogenesis. Although spread across a wide array of cell types, systems, and diseases, and despite very limited data in some contexts, there are clear immunoregulatory roles of dopamine in different organs and diseases, highlighting the potential for dopaminergic immunomodulation in the treatment of a wide array of pathogenic conditions. Many of the studies discussed highlight the interconnected nature of the impact of dopamine, showing, for example, that alterations in dopamine levels during neurologic diseases that can influence CNS immune functions can also drive immunologic changes in bone or gut health. Thus, dopamine, and the therapeutics that modulate dopamine signaling, facilitate bidirectional communication between the immune system and many other organ systems and cell types. This means that consideration of the immunologic effects of dopamine is a critical aspect in the studies of many different systems and diseases.However, information about dopaminergic immunomodulation, intersystem crosstalk via dopamine and dopamine signaling, and peripheral dopamine in general can be difficult to access, making it challenging to plan and analyze these types of studies. The primary purpose of this review is to ameliorate those issues by examining and synthesizing ideas regarding dopaminergic immunomodulation across these research areas, as well as discussing the problems and considerations that are important to the execution and evaluation of this type of research. This will hopefully facilitate the identification of common underlying pathways upon which dopamine and immunomodulation converge in different contexts. For example, data that show changes in cytokines that are similar across psychiatric disorders and are similarly reduced by the same medication. More careful analyses of these overlaps could lead to considerations in the effects of prescribed dopaminergic and immune therapeutics on other diseases, as well as comorbidities within a particular individual. Indeed, the synergistic effect of immune activation and increased dopamine levels due to therapeutics could have important implications in the treatment of immune-compromised individuals and populations with dysfunctional dopamine signaling.Overall, these data demonstrate the importance of further expanding our understanding of dopaminergic immunoregulation in the CNS and, especially, in the periphery. This is critically important for the treatment of diseases with both CNS and peripheral symptoms that may have a common, dopaminergic basis, such as GI symptomology in PD or depression in PLWH. Research that further defines and validates the crosstalk between the immune system and CNS in the development of disease is also needed. Development of this research will require collaborative efforts using a broad array of research modalities: from human trials, imaging studies, and in vivo animal systems to multiple preclinical models, including human in vitro models such as induced pluripotent stem cell mono- and coculture systems and organoids, ex vivo primary cells/tissues, and postmortem human samples, as we recently suggested in the context of neuroHIV and neuropsychiatric diseases . The int