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Hyperspectral and multispectral imaging of cell and tissue autofluorescence employs fluorescence imaging, without exogenous fluorophores, across multiple excitation/emission combinations (spectral channels). This produces an image stack where each pixel (matched by location) contains unique information about the sample's spectral properties. Analysis of this data enables access to a rich, molecularly specific data set from a broad range of cell-native fluorophores (autofluorophores) directly reflective of biochemical status, without use of fixation or stains. This non-invasive, non-destructive technology has great potential to spare the collection of biopsies from sensitive regions. As both staining and biopsy may be impossible, or undesirable, depending on the context, this technology great diagnostic potential for clinical decision making. The main research focus has been on the identification of neoplastic tissues. However, advances have been made in diverse applications - including ophthalmology, cardiovascular health, neurology, infection, assisted reproduction technology, and organ transplantation. This article is protected by copyright. All rights reserved.

STUDY QUESTION Can label-free, non-invasive optical imaging by hyperspectral autofluorescence microscopy discern between euploid and aneuploid cells within the inner cell mass (ICM) of the mouse preimplantation embryo? SUMMARY ANSWER Hyperspectral autofluorescence microscopy enables discrimination between euploid and aneuploid ICM in mouse embryos. WHAT IS KNOWN ALREADY Euploid/aneuploid mosaicism affects up to 17.3% of human blastocyst embryos with trophectoderm biopsy or spent media currently utilized to diagnose aneuploidy and mosaicism in clinical in vitro fertilization. Based on their design, these approaches will fail to diagnose the presence or proportion of aneuploid cells within the foetal lineage ICM of some blastocyst embryos. STUDY DESIGN, SIZE, DURATION The impact of aneuploidy on cellular autofluorescence and metabolism of primary human fibroblast cells and mouse embryos was assessed using a fluorescence microscope adapted for imaging with multiple spectral channels (hyperspectral imaging). Primary human fibroblast cells with known ploidy were subjected to hyperspectral imaging to record native cell fluorescence (4–6 independent replicates, euploid n = 467; aneuploid n = 969). For mouse embryos, blastomeres from the eight-cell stage (five independent replicates: control n = 39; reversine n = 44) and chimeric blastocysts (eight independent replicates: control n = 34; reversine n = 34; 1:1 (control:reversine) n = 30 and 1:3 (control:reversine) n = 37) were utilized for hyperspectral imaging. The ICM from control and reversine-treated embryos were mechanically dissected and their karyotype confirmed by whole genome sequencing (n = 13 euploid and n = 9 aneuploid). PARTICIPANTS/MATERIALS, SETTING, METHODS Two models were employed: (i) primary human fibroblasts with known karyotype and (ii) a mouse model of embryo aneuploidy where mouse embryos were treated with reversine, a reversible spindle assembly checkpoint inhibitor, during the four- to eight-cell division. Individual blastomeres were dissociated from control and reversine-treated eight-cell embryos and either imaged directly or used to generate chimeric blastocysts with differing ratios of control:reversine-treated cells. Individual blastomeres and embryos were interrogated by hyperspectral imaging. Changes in cellular metabolism were determined by quantification of metabolic co-factors (inferred from their autofluorescence signature): NAD(P)H and flavins with the subsequent calculation of the optical redox ratio (ORR: flavins/[NAD(P)H + flavins]). Autofluorescence signals obtained from hyperspectral imaging were examined mathematically to extract features from each cell/blastomere/ICM. This was used to discriminate between different cell populations. MAIN RESULTS AND THE ROLE OF CHANCE An increase in the relative abundance of NAD(P)H and decrease in flavins led to a significant reduction in the ORR for aneuploid cells in primary human fibroblasts and reversine-treated mouse blastomeres (P < 0.05). Mathematical analysis of endogenous cell autofluorescence achieved separation between (i) euploid and aneuploid primary human fibroblast cells, (ii) control and reversine-treated mouse blastomeres cells, (iii) control and reversine-treated chimeric blastocysts, (iv) 1:1 and 1:3 chimeric blastocysts and (v) confirmed euploid and aneuploid ICM from mouse blastocysts. The accuracy of these separations was supported by receiver operating characteristic curves with areas under the curve of 0.97, 0.99, 0.87, 0.88 and 0.93, respectively. We believe that the role of chance is low as mathematical features separated euploid from aneuploid in both human fibroblasts and ICM of mouse blastocysts. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION Although we were able to discriminate between euploid and aneuploid ICM in mouse blastocysts, confirmation of this approach in human embryos is required. While we show this approach is safe in mouse, further validation is required in large animal species prior to implementation in a clinical setting. WIDER IMPLICATIONS OF THE FINDINGS We have developed an original, accurate and non-invasive optical approach to assess aneuploidy within the ICM of mouse embryos in the absence of fluorescent tags. Hyperspectral autofluorescence imaging was able to discriminate between euploid and aneuploid human fibroblast and mouse blastocysts (ICM). This approach may potentially lead to a new diagnostic for embryo analysis. STUDY FUNDING/COMPETING INTEREST(S) K.R.D. is supported by a Mid-Career Fellowship from the Hospital Research Foundation (C-MCF-58-2019). This study was funded by the Australian Research Council Centre of Excellence for Nanoscale Biophotonics (CE140100003) and the National Health and Medical Research Council (APP2003786). The authors declare that there is no conflict of interest.

STUDY QUESTIONCan artificial intelligence distinguish between euploid and aneuploid cells within the inner cell mass of mouse embryos using brightfield images?SUMMARY ANSWERA deep morphological signature (DMS) generated by deep learning followed by swarm intelligence and discriminative analysis can identify the ploidy state of inner cell mass (ICM) in the mouse blastocyst-stage embryo.WHAT IS KNOWN ALREADYThe presence of aneuploidy – a deviation from the expected number of chromosomes – is predicted to cause early pregnancy loss or congenital disorders. To date, available techniques to detect embryo aneuploidy in IVF clinics involve an invasive biopsy of trophectoderm cells or a non-invasive analysis of cell-free DNA from spent media. These approaches, however, are not specific to the ICM and will consequently not always give an accurate indication of the presence of aneuploid cells with known ploidy therein.STUDY DESIGN, SIZE, DURATIONThe effect of aneuploidy on the morphology of ICMs from mouse embryos was studied using images taken using a standard brightfield microscope. Aneuploidy was induced using the spindle assembly checkpoint inhibitor, reversine (n = 13 euploid and n = 9 aneuploid). The morphology of primary human fibroblast cells with known ploidy was also assessed.PARTICIPANTS/MATERIALS, SETTING, METHODSTwo models were applied to investigate whether the morphological details captured by brightfield microscopy could be used to identify aneuploidy. First, primary human fibroblasts with known karyotypes (two euploid and trisomy: 21, 18, 13, 15, 22, XXX and XXY) were imaged. An advanced methodology of deep learning followed by swarm intelligence and discriminative analysis was used to train a deep morphological signature (DMS). Testing of the DMS demonstrated that there are common cellular features across different forms of aneuploidy detectable by this approach. Second, the same approach was applied to ICM images from control and reversine treated embryos. Karyotype of ICMs was confirmed by mechanical dissection and whole genome sequencing.MAIN RESULTS AND THE ROLE OF CHANCEThe DMS for discriminating euploid and aneuploid fibroblasts had an area under the receiver operator characteristic curve (AUC-ROC) of 0.89. The presence of aneuploidy also had a strong impact on ICM morphology (AUC-ROC = 0.98). Aneuploid fibroblasts treated with reversine and projected onto the DMS space mapped with untreated aneuploid fibroblasts, supported that the DMS is sensitive to aneuploidy in the ICMs, and not a non-specific effect of the reversine treatment. Consistent findings in different contexts suggests that the role of chance low.LARGE SCALE DATAN/ALIMITATIONS, REASON FOR CAUTIONConfirmation of this approach in humans is necessary for translation.WIDER IMPLICATIONS OF THE FINDINGSThe application of deep learning followed by swarm intelligence and discriminative analysis for the development of a DMS to detect euploidy and aneuploidy in the ICM has high potential for clinical implementation as the only equipment it requires is a brightfield microscope, which are already present in any embryology laboratory. This makes it a low cost, a non-invasive approach compared to other types of pre-implantation genetic testing for aneuploidy. This study gives proof of concept for a novel strategy with the potential to enhance the treatment efficacy and prognosis capability for infertility patients.STUDY FUNDING/COMPETING INTEREST(S)K.R.D. is supported by a Mid-Career Fellowship from the Hospital Research Foundation (C-MCF-58-2019). This study was funded by the Australian Research Council Centre of Excellence for Nanoscale Biophotonics (CE140100003), the National Health and Medical Research Council (APP2003786) and an ARC Discovery Project (DP210102960). The authors declare that there is no conflict of interest.

Mammalian oocytes develop and mature in a mutually dependent relationship with surrounding cumulus cells. The oocyte actively regulates cumulus cell differentiation and function by secreting soluble paracrine oocyte-secreted factors (OSFs). We characterized the molecular mechanisms by which two model OSFs, cumulin and BMP15, regulate oocyte maturation and cumulus-oocyte cooperativity. Exposure to these OSFs during maturation altered the proteomic and multispectral autofluorescence profiles of both the oocyte and cumulus cells. In oocytes, cumulin significantly upregulated proteins involved in nuclear function. In cumulus cells, both OSFs elicited marked upregulation of a variety of metabolic processes (mostly anabolic), including lipid, nucleotide, and carbohydrate metabolism, while mitochondrial metabolic processes were downregulated. The mitochondrial changes were validated by functional assays confirming altered mitochondrial morphology, respiration, and content, whilst maintaining ATP homeostasis. Collectively, these data demonstrate that OSFs remodel cumulus cell metabolism during oocyte maturation in preparation for ensuing fertilization and embryonic development.HIGHLIGHTSDuring oocyte maturation, oocyte-secreted factors promote cell cooperativity between the oocyte and cumulus cells by altering the molecular composition of both cell types.Oocyte-secreted factors downregulate protein catabolic processes, and upregulate DNA binding, translation, and ribosome assembly in oocytes.Oocyte-secreted factors alter mitochondrial number, morphology, and function in cumulus cells.Oocyte-secreted factors further enhance metabolic plasticity in cumulus cells by upregulating anabolic pathways for macromolecules and small molecule organics.The oocyte, via oocyte-secreted factors, instructs cumulus cells to increase metabolic workload on its behalf, thereby subduing oocyte metabolism.

Stem cell exhaustion plays a major role in the ageing of different tissues. Similarly, in vitro cell ageing during expansion prior to their use in regenerative medicine can severely compromise stem cell quality through progressive declines in differentiation and growth capacity. We utilized non-destructive multispectral assessment of native cell autofluorescence to investigate the metabolic mechanisms of in vitro mesenchymal stem cell (MSC) ageing in human bone marrow MSCs over serial passages (P2–P10). The spectral signals for NAD(P)H, flavins and protein-bound NAD(P)H were successfully isolated using Robust Dependent Component Analysis (RoDECA). NAD(P)H decreased over the course of hMSC ageing in absolute terms as well as relative to flavins (optical redox ratio). Relative changes in other fluorophore levels (flavins, protein-bound NAD(P)H) suggested that this reduction was due to nicotinamide adenine dinucleotide depletion rather than a metabolic shift from glycolysis to oxidative phosphorylation. Using multispectral features, which are determined without cell fixation or fluorescent labelling, we developed and externally validated a reliable, linear model which could accurately categorize the age of culture-expanded hMSCs. The largest shift in spectral characteristics occurs early in hMSC ageing. These findings demonstrate the feasibility of applying multispectral technology for the non-invasive monitoring of MSC health in vitro. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11357-020-00250-9) contains supplementary material, which is available to authorized users.

The preservation of cognitive ability by increasing nicotinamide adenine dinucleotide (NAD

Chronic kidney disease (CKD) is characterised by progressive loss of kidney function leading to kidney failure. Significant kidney damage can occur before symptoms are detected. Currently, kidney tissue biopsy is the gold standard for evaluation of renal damage and CKD severity. This study explores how to precisely quantify morphology characteristics of kidney cells exfoliated into urine, with a view to establish a future urine-based non-invasive diagnostic for CKD. We report the development of a novel deep learning method, which was able to discover a RELIC (moRphology dEep Learning Imaging Cells) signature that can differentiate between kidney cells exfoliated in human urine of and CKD patients with varying degree of kidney damage and non-CKD controls. Exfoliated proximal tubule cells (PTCs) originating from kidneys were isolated from the urine of patients with different levels of kidney damage using previously published methods. An advanced combination of artificial intelligence techniques, deep learning, swarm intelligence, and discriminative analysis was used to discover a RELIC signature in brightfield microscopy images of exfoliated PTCs. Kidney damage in the study subjects was characterised by assessing kidney tissues obtained through a nephrectomy or kidney biopsy. A special deep learning algorithm was developed and trained to create a predictive tool. The algorithm was then used to analyse data from patients with normal and fibrotic kidneys. Data were then classified according to different groups (healthy or fibrosis) and clustering of the training and validation cells was determined for model validation. We developed a novel deep learning method, to obtain RELIC signatures and identify specific deep morphological features which can be used to differentiate urinary PTC cells shed by people with CKD (confirmed by tissue histology obtained from an invasive kidney biopsy) from those without CKD, with a discriminatory accuracy of 82%. We identified a RELIC signature which can be used on a collection of bright field images of exfoliated urinary PTCs to create a predictive tool and differentiate between normal and pathological kidney cells. This study, for the first time, provides a proof of concept that urinary exfoliated tubule cells in patients with kidney fibrosis and healthy controls differ in appearance (morphology) as observed under a basic brightfield microscope. The results suggest that morphological signatures of exfoliated PTCs have the potential to serve as a non-invasive marker of kidney fibrosis.

One of the earliest physiological consequences of advancing age is the loss of female reproductive potential. This is primarily due to oocyte quality and developmental competence, which is highly sensitive to biological age. We applied deep learning, swarm intelligence and discriminative analysis to images of mouse oocytes taken by common bright field microscopy and were successfully able to identify a highly informative deep radiomic signature (DRS) of oocyte age. This signature distinguished morphological changes in oocytes associated with maternal age with 92% accuracy (AUC~1), reflecting this decline in oocyte quality. We then employed the DRS to evaluate the impact of the treatment of reproductively aged mice with the NAD+ precursor nicotinamide mononucleotide (NMN). The DRS signature classified 60% of oocytes from NMN-treated aged mice as having a 'young' morphology, suggesting that NMN was able to rejuvenate the morphological changes identified by the DRS. These findings indicate that NMN therapy may be able to restore the quality of a sizable subset of oocytes affected by reproductive ageing, and that these oocytes will be able to be distinguished and selected by DRS.

Background Cell cycle analysis is important for cancer research. However, available methodologies have drawbacks including limited categorisation and reliance on fixation, staining or transformation. Multispectral analysis of endogenous cell autofluorescence has been shown to be sensitive to changes in cell status and could be applied to the discrimination of cell cycle without these steps. Methods Cells from the MIA-PaCa-2, PANC-1, and HeLa cell lines were plated on gridded dishes and imaged using a multispectral fluorescence microscope. They were then stained for proliferating cell nuclear antigen (PCNA) and DNA intensity as a reference standard for their cell cycle position (G1, S, G2, M). The multispectral data was split into training and testing datasets and models were generated to discriminate between G1, S, and G2 + M phase cells. A standard decision tree classification approach was taken, and a two-step system was generated for each line. Results Across cancer cell lines accuracy ranged from 68.3% (MIA-PaCa-2) to 73.3% (HeLa) for distinguishing G1 from S and G2 + M, and 69.0% (MIA-PaCa-2) to 78.0% (PANC1) for distinguishing S from G2 + M. Unmixing the multispectral data showed that the autofluorophores NADH, FAD, and PPIX had significant differences between phases. Similarly, the redox ratio and the ratio of protein bound to free NADH were significantly affected. Conclusions These results demonstrate that multispectral microscopy could be used for the non-destructive, label free discrimination of cell cycle phase in cancer cells. They provide novel information on the mechanisms of cell-cycle progression and control, and have practical implications for oncology research.

Damage and degradation of articular cartilage leads to severe pain and loss of mobility. The development of new therapies for cartilage regeneration for monitoring their effect requires further study of cartilage, ideally at a molecular level and in a minimally invasive way. Hyperspectral microscopy is a novel technology which utilises endogenous fluorophores to non-invasively assess the molecular composition of cells and tissue. In this study, we applied hyperspectral microscopy to healthy bovine articular cartilage and osteoarthritic human articular cartilage to investigate its capacity to generate informative molecular data and characterise disease state and treatment effects. We successfully demonstrated label-free fluorescence identification of collagen type I and II – isolated in cartilage here for the first time and the co-enzymes free NADH and FAD which together give the optical redox ratio that is an important measure of metabolic activity. The intracellular composition of chondrocytes was also examined. Differences were observed in the molecular ratios within the superficial and transitional zones of the articular cartilage which appeared to be influenced by disease state and treatment. These findings show that hyperspectral microscopy could be useful for investigating the molecular underpinnings of articular cartilage degradation and repair. As it is non-invasive and non-destructive, samples can be repeatedly assessed over time, enabling true time-course experiments with in-depth molecular data. Additionally, there is potential for the hyperspectral approach to be adapted for patient examination to allow the investigation of cartilage state. This could be of advantage for assessment and diagnosis as well as treatment monitoring.

Radiodynamic therapy (RDT) is a recent extension of conventional photodynamic therapy, in which visible/near infrared light irradiation is replaced by a well-tolerated dose of high-energy X-rays. This enables greater tissue penetration to allow non-invasive treatment of large, deep-seated tumors. We report here the design and testing of a drug delivery system for RDT that is intended to enhance intra- or peri-nuclear localization of the photosensitizer, leading to DNA damage and resulting clonogenic cell kill. This comprises a photosensitizer (Verteporfin, VP) incorporated into poly (lactic-co-glycolic acid) nanoparticles (PLGA NPs) that are surface-functionalized with a cell-penetrating HIV trans-activator of transcription (TAT) peptide. In addition to a series of physical and photophysical characterization studies, cytotoxicity tests in pancreatic (PANC-1) cancer cells in vitro under 4 Gy X-ray exposure from a clinical 6 MV linear accelerator (LINAC) showed that TAT targeting of the nanoparticles markedly enhances the effectiveness of RDT treatment, particularly when assessed by a clonogenic, i.e., DNA damage-mediated, cell kill.

we developed mitochondrially targeted biodegradable polymerpoly(lactic-co-glycolic acid) nanocarriers incorporating a photosensitiser verteporfin, ultrasmall (2-5 nm) gold nanoparticles as radiation enhancers and triphenylphosphonium acting as the mitochondrial targeting moiety. Upon X-ray radiation our nanocarriers generated cytotoxic amounts of singlet oxygen within the mitochondria, triggering the loss of membrane potential and mitochondria-related apoptosis of cancer cells. Our X-PDT strategy effectively controlled tumour growth with only a fraction of radiotherapy dose (4 Gy) and improved the survival rate of a mouse model bearing colorectal cancer cells. It may offer a paradigm-shifting treatment alternative for patients who need neoadjuvant radiotherapy but wish to avoid long term detrimental effect on functional outcome by undergoing X-PDT using only a fraction of the conventional radiotherapy.

Pain is currently assessed using subjective measurements, often not aligning with clinical symptoms. Therefore, objective pain level assessments, using minimally-invasive and molecular methods, are needed to assess disease activity and response to treatment in osteoarthritis and rheumatoid arthritis. We report sophisticated quantitative biochemical “signatures” from the label-free hyperspectral imaging (HSI) of cartilage tissue for the characterization of molecular composition, structure and functional status. Further study on sinuvium tissue provides evidence that HSI could be used as a novel technique to delineate disease state. Additionally, HSI could be used to objectively separate individuals based on pain severity providing molecular correlates of pain.

Our approach to multispectral fluorescence microscopy can non-invasively identify the biomolecular composition of cells and capture complex biological heterogeneity which is fundamentally important for biological research and medical diagnostics. We have applied this technology to demonstrate the embryo quality for chromosomal abnormalities (containing euploid and aneuploidy cells) and understanding the biochemical signatures of polycystic ovarian syndrome (PCOS) oocytes. We then explored oocyte quality following treatment with the NAD+ precursor NMN. These findings demonstrate the utility of our approach to the multispectral assessment of autofluorescence for the non-destructive, label-free assessment of clinically relevant problems.

Study questionCan label-free, non-invasive optical imaging by hyperspectral microscopy discern between euploid and aneuploid cells within the inner cell mass of the mouse preimplantation embryo?Summary answerHyperspectral microscopy shows a variance in metabolic activity which enables discrimination between euploid and aneuploid cells.What is known alreadyEuploid/aneuploid mosaicism affects up to 17.3% of human blastocyst embryos with trophectoderm biopsy or spent media currently utilised to diagnose aneuploidy and mosaicism in clinical in vitro fertilisation. Based on their design, these approaches will fail to diagnose the presence or proportion of aneuploid cells within the fetal lineage (inner cell mass (ICM)) of some blastocyst embryos.Study design, size, durationThe impact of aneuploidy on cellular metabolism of primary human fibroblast cells and mouse embryos was assessed by a fluorescence microscope adapted for imaging with multiple spectral channels (hyperspectral imaging). Primary human fibroblast cells with known ploidy were subjected to hyperspectral imaging to record native cell fluorescence (euploid n= 467; aneuploid n= 969). For mouse embryos, 50-70 individual euploid and aneuploid blastomeres (8-cell stage embryo) and chimeric blastocysts (40-50 per group: euploid; aneuploid; or 1:1 and 1:3 ratio of euploid:aneuploid) were utilised for hyperspectral imaging.Participants/materials, setting, methodsTwo models were employed: (i) Primary human fibroblasts with known karyotype and (ii) a mouse model of embryo aneuploidy where mouse embryos were treated with reversine, a reversible spindle assembly checkpoint inhibitor, during the 4-to 8-cell division. Individual blastomeres were dissociated from reversine treated (aneuploid) and control (euploid) 8-cell embryos and either imaged directly or used to generate chimeric blastocysts with differing ratios of euploid:aneuploid cells. Individual blastomeres and embryos were subjected to hyperspectral imaging. Changes in cellular metabolism were determined by quantification of metabolic cofactors (inferred from their autofluorescence signature): reduced nicotinamide adenine dinucleotide (NAD(P)H), flavins with the subsequent calculation of the optical redox ratio (ORR: Flavins/[NAD(P)H + Flavins]). Mathematical algorithms were applied to extract features from the autofluorescence signals of each cell/blastomere/inner cell mass to discriminate between euploid and aneuploid.Main results and the role of chanceAn increase in the relative abundance of NAD(P)H with a decrease in flavins led to a significant reduction in the ORR for aneuploid cells in both primary human fibroblasts and individual mouse blastomeres (P < 0.05). Mathematical algorithms were able to achieve good separation between (i) euploid and aneuploid primary human fibroblast cells, (ii) euploid and aneuploid mouse blastomeres cells and (iii) euploid and aneuploid chimeric blastocysts and (iv) 1:1 and 1:3 chimeric blastocysts. The accuracy of these separations was supported by receiver operating characteristic curves with areas under the curve of 0.85, 0.99, 0.87 and 0.88, respectively. We believe that the role of chance is low as multiple cellular models (human somatic cells and mouse embryos) demonstrated a consistent shift in cellular metabolism in response to aneuploidy as well as the robust capacity of mathematical features to separate euploid and aneuploid cells in a statistically significant manner.Limitations, reasons for cautionThere would be added value in determining the degree of embryo mosaicism by sequencing the inner cell mass (ICM) of individual blastocysts to correlate with metabolic profile and level of discrimination achieved using the mathematical features approach.Wider implications of the findingsHyperspectral imaging was able to discriminate between euploid and aneuploid human fibroblasts and mouse embryos. This may lead to the development of an accurate and non-invasive optical approach to assess mosaicism within the ICM of human embryos in the absence of fluorescent tags.Study funding/competing interest(s)K.R.D. is supported by a Mid-Career Fellowship from the Hospital Research Foundation (C-MCF-58-2019). This study was funded by the Australian Research Council Centre of Excellence for Nanoscale Biophotonics (CEI40100003). The authors declare that there is no conflict of interest.

Background Metformin, a first line antihyperglycemic medication, is an AMPK activator and has been hypothesized to act as a geroprotective agent. Studies on its association with various classifications of age-related cognitive decline have shown mixed results with positive and negative findings. Objective To synthesize the best available evidence on the association of metformin-use with risk, progression, and severity of dementia. Method Eligible research investigated the effect of metformin on dementia, Alzheimer's disease, or any measure of cognitive impairment compared to any control group who were not receiving metformin. The initial search resulted in 862 citations from which 14 studies (seven cohort, four cross-sectional, two RCTs, and one case control) were included. Results Meta-analysis of three studies showed that cognitive impairment was significantly less prevalent in diabetic metformin (Odds ratio = 0.55, 95% CI 0.38 to 0.78), while six studies showed that dementia incidence was also significantly reduced (Hazard ratio = 0.76, 95% CI 0.39 to 0.88). Mini-Mental State Examination scores were not significantly affected by metformin-use, although both RCTs showed that metformin had a neuroprotective effect compared to placebo. Some studies found negative or neutral effects for metformin use by people with diabetes; the potential mechanism of metformin-induced vitamin B12 deficiency is discussed. Conclusions Metformin should continue to be used as a first line therapy for diabetes in patients at risk of developing dementia or Alzheimer's disease. The use of metformin by individuals without diabetes for the prevention of dementia is not supported by the available evidence.

Pain catastrophizing (PC), defined as an exaggerated negative cognitive-affective orientation toward pain, is one of the strongest psychological predictors of pain outcomes. Although regularly included as a process variable in clinical trials, there have been no comprehensive reviews of how it can be modified. Using a registered protocol (PROSPERO 2016 CRD42016042761), we searched MEDLINE, PsychINFO, EMBASE, CINAHL, and CENTRAL up to November 2016 for all randomized controlled trials measuring PC in adults with chronic noncancer pain. Two authors independently screened studies and assessed bias risk using the Cochrane tool. Quality of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation criteria. We included 79 studies (n = 9,914), which mostly recruited participants with musculoskeletal pain and had low risk of bias. Meta-analyses (standardized mean difference) showed 9 interventions had efficacy compared with waitlist/usual care or active control, although evidence quality was often low. The best evidence (moderate-high quality) was found for cognitive-behavioral therapy, multimodal treatment, and acceptance and commitment therapy. Effects were generally of medium strength and had questionable clinical significance. When only the 8 studies targeting people with high PC were included, effects were larger and more consistent. Multimodal treatment showed the strongest effects when all studies were considered, whereas cognitive-behavioral therapy had the best evidence among targeted studies. Perspective PC is a modifiable characteristic but most interventions produce only modest benefit unless targeted to people with high PC. More research into theory-driven interventions matched to specific patient profiles is required to improve treatment efficacy and efficiency.

REVIEW QUESTION The review question is: what is the effectiveness of primary surgery versus primary radiotherapy on disease-free survival and quality of life in adults with an unknown primary, head and neck squamous cell carcinoma?

REVIEW QUESTION The objective of this review is to investigate the association between paternal body mass index (BMI) (particularly elevated paternal BMI) and complications of conception and pregnancy as well as neonatal and childhood health.

This systematic review investigated whether the insulin sensitiser metformin has a geroprotective effect in humans. Pubmed and Embase were searched along with databases of unpublished studies. Eligible research investigated the effect of metformin on all-cause mortality or diseases of ageing relative to non-diabetic populations or diabetics receiving other therapies with adjustment for disease control achieved. Overall, 260 full-texts were reviewed and 53 met the inclusion criteria. Diabetics taking metformin had significantly lower all-cause mortality than non-diabetics (hazard ratio (HR) = 0.93, 95%CI 0.88–0.99), as did diabetics taking metformin compared to diabetics receiving non-metformin therapies (HR = 0.72, 95%CI 0.65–0.80), insulin (HR = 0.68, 95%CI 0.63–0.75) or sulphonylurea (HR = 0.80, 95%CI 0.66–0.97). Metformin users also had reduced cancer compared to non-diabetics (rate ratio = 0.94, 95%CI 0.92–0.97) and cardiovascular disease (CVD) compared to diabetics receiving non-metformin therapies (HR = 0.76, 95%CI 0.66–0.87) or insulin (HR = 0.78, 95%CI 0.73–0.83). Differences in baseline characteristics were observed which had the potential to bias findings, although statistical adjustments were made. The apparent reductions in all-cause mortality and diseases of ageing associated with metformin use suggest that metformin could be extending life and healthspans by acting as a geroprotective agent.

Integrated care is the combination of different healthcare services with the goal to provide comprehensive, seamless, effective and efficient patient care. Assessing the experiences of healthcare professionals (HCPs) is an important aspect when evaluating integrated care strategies.The aim of this rapid review was to investigate if quantitative surveys used to assess HCPs' experiences with integrated care capture all the aspects highlighted as being important in qualitative research, with a view to informing future survey development.The review considered all types of health professionals in primary care, and hospital and specialist services, with a specific focus on the provision of integrated care aimed at improving the patient journey. PubMed, CINAHL and grey literature sources were searched for relevant surveys/program evaluations and qualitative research studies. Full text articles deemed to be of relevance to the review were appraised for methodological quality using abridged critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from included studies using standardized data extraction templates. Findings from included studies were grouped into domains based on similarity of meaning. Similarities and differences in the domains covered in quantitative surveys and those identified as being important in qualitative research were explored.A total of 37 studies (19 quantitative surveys, 14 qualitative studies and four mixed-method studies) were included in the review. A range of healthcare professions participated in the included studies, the majority being primary care providers. Common domains identified from quantitative surveys and qualitative studies included Communication, Agreement on Clear Roles and Responsibilities, Facilities, Information Systems, and Coordination of Care and Access. Qualitative research highlighted domains identified by HCPs as being relevant to their experiences with integrated care that have not routinely being surveyed, including Workload, Clear Leadership/Decision-Making, Management, Flexibility of Integrated Care Model, Engagement, Usefulness of Integrated Care and Collaboration, and Positive Impact/Clinical Benefits/Practice Level Benefits.There were several domains identified from qualitative research that are not routinely included in quantitative surveys to assess health professionals' experiences of integrated care. In addition, the qualitative findings suggest that the experiences of HCPs are often impacted by deeper aspects than those measured by existing surveys. Incorporation of targeted items within these domains in the design of surveys should enhance the capture of data that are relevant to the experiences of HCPs with integrated care, which may assist in more comprehensive evaluation and subsequent improvement of integrated care programs.

Review question/objective:The objective of the review is to assess the effect of metformin on the risk, progression and severity of Alzheimer's disease and other forms of dementia, as well as any measures of cognitive performance or impairment.

REVIEW OBJECTIVE The objective of this review is to systematically identify, review and synthesize relevant qualitative research on end user and implementer experiences of mobile health (mHealth) technologies developed for noncommunicable chronic disease management in young adults. "End users" are defined as young people aged 15-24 years, and "implementers" are defined as health service providers, clinicians, policy makers and administrators.The two key questions we wish to systematically explore from identified relevant qualitative studies or studies with qualitative components are.

Multispectral assessment of cell autofluorescence gives a direct window into the molecular processes occurring within those cells. This can be used to non-invasively characterise and classify various cellular properties without requiring fixation, dyes or transformation. Human mesenchymal stem/ stromal cells (MSCs) have great potential to contribute to regenerative medicine, especially with regards to autologous transplantation. However, this capacity is often limited by inherent properties of cell lines, which prevent their being sufficiently expanded after derivation for effective clinical application. The investigation of these properties requires numerous, time and labour-intensive assays. In this study we have used correlative microscopy based on multispectral images of cell autofluorescence then correlated to functional assays in order to construct multispectral signatures of numerous inherent cell characteristics. These included cell cycle status (indicating the proportion of cells undergoing cell division at a given time), cell ‘age’ (number of passages undergone, indicating capacity for further expansion), and β- galactosidase (a marker of senescence, indicating cells which can no longer divide). This study has established a single protocol, in place of multi-functional assays, to characterize the growth and differentiation capacity of hMSC lines using a non-invasive approach.

Detecting reactive oxygen species (ROS) that play a critical role as redox modulators and signalling molecules in biological systems currently requires invasive methods such as ROS - specific indicators for imaging and quantification. We developed a non-invasive, real-time, label-free imaging technique for assessing the level of ROS in live cells and thawed cryopreserved tissues that is compatible with in-vivo imaging. The technique is based on autofluorescence multispectral imaging (AFMI) carried out in an adapted fluorescence microscope with an expanded number of spectral channels spanning specific excitation (365 nm-495 nm) and emission (420 nm-700 nm) wavelength ranges. We established a strong quantitative correlation between the spectral information obtained from AFMI and the level of ROS obtained from CellROX staining. The results were obtained in several cell types (HeLa, PANC1 and mesenchymal stem cells) and in live kidney tissue. Additioanly, two spectral regimes were considered: with and without UV excitation (wavelengths > 400 nm); the latter being suitable for UV-sensitive systems such as the eye. Data were analyzed by linear regression combined with an optimization method of swarm intelligence. This allowed the calibration of AFMI signals to the level of ROS with excellent correlation (R= 0.84, p=0.00) in the entire spectral range and very good correlation (R= 0.78, p=0.00) in the limited, UV-free spectral range. We also developed a strong classifier which allowed us to distinguish moderate and high levels of ROS in these two regimes (AUC= 0.91 in the entire spectral range and AUC = 0.78 for UV-free imaging). These results indicate that ROS in cells and tissues can be imaged non-invasively, which opens the way to future clinical applications in conditions where reactive oxygen species are known to contribute to progressive disease such as in ophthalmology, diabetes, kidney disease, cancer and neurodegenerative diseases.

In this work, we brought together two existing clinical techniques used in cancer treatment—X-ray radiation and photodynamic therapy (PDT), whose combination termed X-PDT uniquely allows PDT to be therapeutically effective in deep tissue. To this end, we developed mitochondrially targeted biodegradable polymer poly(lactic-co-glycolic acid) nanocarriers incorporating a photosensitizer verteporfin, ultrasmall (2–5 nm) gold nanoparticles as radiation enhancers, and triphenylphosphonium acting as the mitochondrial targeting moiety. The average size of the nanocarriers was about 160 nm. Upon X-ray radiation our nanocarriers generated cytotoxic amounts of singlet oxygen within the mitochondria, triggering the loss of membrane potential and mitochondria-related apoptosis of cancer cells. Our X-PDT strategy effectively controlled tumor growth with only a fraction of radiotherapy dose (4 Gy) and improved the survival rate of a mouse model bearing colorectal cancer cells. In vivo data indicate that our X-PDT treatment is cytoreductive, antiproliferative, and profibrotic. The nanocarriers induce radiosensitization effectively, which makes it possible to amplify the effects of radiation. A radiation dose of 4 Gy combined with our nanocarriers allows equivalent control of tumor growth as 12 Gy of radiation, but with greatly reduced radiation side effects (significant weight loss and resultant death)., We developed a novel strategy named X-ray-induced photodynamic therapy (X-PDT) which enables chemotherapy-free treatment of deep cancer with a low dose of X-ray radiation.

Female infertility is a common and devastating condition with life-long health, emotional and social consequences. There is currently no pharmacological therapy for preserving oocyte quality during aging, which is the strongest risk factor for infertility. This leads to an age dependent decline in natural conception and IVF success rates (1). Here, we show that this is due in part to declining levels of the metabolic cofactor nicotinamide adenine dinucleotide (NAD+), and that restoring NAD+levels with its metabolic precursor nicotinamide mononucleotide (NMN) rejuvenates oocyte quality and quantity in aged animals, leading to improved fertility. These benefits extend to the developing embryo, where NMN supplementation in embryo culture media following IVF enhances blastocyst formation in older mice. The NAD+dependent deacylase SIRT2 is sufficient, but not essential, to recapitulate the benefits ofin vivoNMN treatment, and transgenic overexpression of SIRT2 maintains oocyte spindle assembly, accurate chromosome segregation, decreased oxidative stress and overall fertility with ageing. Pharmacological elevation of NAD+may be an effective, non-invasive strategy for restoring and maintaining female fertility during ageing, and for improving the success of IVF.

Objectives The influence of maternal body mass index (BMI) on pregnancy and child health outcomes is well characterised, however less is known about paternal BMI. This systematic review investigated the independent effects of increased paternal BMI on conception and pregnancy as well as neonatal and childhood outcomes. Methods Our systematic search (Sept. 2018) of PubMed, Embase, Cinahl, Web of Science, ProQuest, and OpenThesis resulted in 11,045 hits from which 17 studies met the inclusion criteria (Participants: men Exposure: BMI or waist circumferences Outcomes: associations with time to pregnancy, incidence of infertility, pregnancy loss, pregnancy complications, birthweight and length, childhood weight and height, or incidence of any childhood disease). Studies had to adjust for maternal age and BMI. Results Meta-analysis was only possible for infertility which was significantly more prevalent in obese (OR = 1.49 95%CI 1.30–1.70) and overweight (OR = 1.18 95%CI 1.11–1.26) men. Individual studies showed increased likelihoods of small for gestational age and macrosomia in fathers who had increased BMI – possibly accounting for the general finding of no effect on mean birthweight in other studies. Most studies found increased BMI in fathers correlated with altered growth curves and increased BMI in childhood, while one study found a higher likelihood of autism spectrum disorder. Conclusion Our findings support increased paternal BMI negatively affecting pregnancy and child health outcomes. Future studies must include or adjust for paternal contributions, as the longstanding assumption that only maternal factors are relevant is likely to have considerably confounded prior work.

Background Western countries are increasingly using complementary and alternative medicine (CAM) to assist with relieving ailments. Turmeric, from the ginger family Zingiberaceae, has a history of use for medicinal purposes. The polyphenols found in turmeric (curcuminoids) have demonstrated anti-inflammatory and pain relieving properties. With the use of CAMs increasing, it is important for the effectiveness of curcuminoids to be established. Objectives To identify the effectiveness of the use of curcuminoids for the amelioration of musculoskeletal pain. Inclusion criteria types of participants Persons experiencing musculoskeletal pain, including experimentally induced musculoskeletal pain. Types of intervention(s)/phenomena of interest The current review considered studies that evaluated the use of curcuminoids. Types of controls Any form including placebo, treatment as usual or before and after measurements. Types of studies Both experimental and epidemiological study designs including randomized controlled trials (RCTs), non-RCTs, quasi-experimental and before and after studies were eligible for consideration in this review. Studies published in English were considered without date restriction. Outcomes The current review considered studies that included measurement of pain. Outcome measures included visual analog scales, and/or pain questionnaires. Secondary outcome measures of functionality (activities of daily living and range of motion) were included. Any data provided on adverse events were considered. Search strategy The databases PubMed, CINAHL, Embase and ProQuest were searched in March 2015 (and updated in April 2016) using the Joanna Briggs Institute (JBI) three-step search strategy. The reference lists of identified articles were reviewed for additional studies. Methodological quality Papers selected were assessed by two independent reviewers using standardized instruments from the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data extraction Data were extracted using the data extraction tool from JBI-MAStARI. Data extracted included details about the populations, interventions, study methods and outcomes. Data synthesis Narrative and tabular synthesis was conducted. Meta-analysis was precluded due to methodological and clinical heterogeneity across all included studies. Results Thirteen studies with a combined total of 1101 participants were included. Three studies of limited sample size examined the effects of curcuminoids compared with the use of placebo on musculoskeletal pain, with one study showing a statistically significant effect. Four studies examined the effects of curcuminoids compared with non-selective non-steroidal anti-inflammatory drugs on musculoskeletal pain. Two of these four studies were non-inferiority studies showed that the use of both curcuminoids and ibuprofen were associated with a similar significant reduction in pain over the study durations of four and six weeks, respectively, with curcuminoid use non-inferior to the use of ibuprofen over the study durations. Six studies investigated presentations of curcuminoid-containing herbomineral mixtures versus placebo or active controls. Conclusion There is insufficient evidence to recommend that curcuminoids be considered for relieving pain and improving function in musculoskeletal pain conditions. This finding needs to be considered in the context of limitations imposed by the variability in the quality of studies, small sample sizes, short duration of interventions, a gender-bias toward females, absence of long-term data extraction and small number of relevant studies.