Development of an oral nanovaccine for dogs against Echinococcus granulosus.

Dogs are the main source of animal and human cystic echinococcosis caused by the Cestode parasite Echinococcus granulosus. Dog vaccination seems to be a good strategy to control this parasitic disease. Here we present the development of a polymeric nanoparticle-based oral vaccine for dogs against Echinococcus granulosus delivered in enteric-coated capsules. To achieve our target, we encapsulated two recombinant antigens into biodegradable polymeric nanoparticles in the presence of Monophosphoryl lipid A as an adjuvant to ensure efficient delivery and activation of a protective mucosal immune response. The formulated delivery system showed a nanoparticle size less than 200 nm with more than 80 % antigen encapsulation efficiency and conserved integrity and immunogenicity. The nanoparticle surface was coated with chitosan to enhance adhesion to the gut mucosa and a subsequent antigen delivery. Chitosan-coated nanoparticles showed a higher cell internalization in murine macrophages and dendritic cells as well as a higher penetration into Caco-2 cells in vitro. Antigen-loaded nanoparticles were freeze-dried and enteric-coated capsules were filled with the obtained powder. The obtained results show a promising nanoparticles delivery system for oral vaccination.

Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors.

BACKGROUND: Delayed return of gastrointestinal function (DGIF) after hepatectomy can involve increased morbidity and prolonged hospital stay. Yet, data on incidence and risks factors are lacking. METHODS: All consecutive patients who underwent hepatectomy between June 2018 and December 2020 were included. All patients were included in an enhanced recovery after surgery (ERAS) program. DGIF was defined by the need for nasogastric tube (NGT) insertion after surgery. DGIF risk factors were identified. RESULTS: Overall, 206 patients underwent hepatectomy. DGIF occurred in 41 patients (19.9%) after a median time of 2 days (range, 1-14). Among them, 6 patients (14.6%) developed aspiration pneumonia, of which one required ICU for mechanical ventilation. DGIF developed along with an intraabdominal complication in 7 patients (biliary fistula, n = 5; anastomotic fistula, n = 1; adhesive small bowel obstruction, n = 1). DGIF was associated with significantly increased severe morbidity rate (p = 0.001), prolonged time to normal food intake (p < 0.001) and hospital stay (p < 0.001) and significantly decreased overall compliance rate (p = 0.001). Independent risk factors of DGIF were age (p < 0.001), vascular reconstruction (p = 0.007), anaesthetic induction using volatiles (p = 0.003) and epidural analgesia (p = 0.004). Using these 4 variables, a simple DGIF risk score has been developed allowing patient stratification in low-, intermediate- and high-risk groups. CONCLUSION: DGIF after hepatectomy was frequently observed and significantly impacted postoperative outcomes. Identifying risk factors remains critical for preventing its occurrence.

Encapsulation of Adipose-Derived Mesenchymal Stem Cells in Calcium Alginate Maintains Clonogenicity and Enhances their Secretory Profile.

Adipose-derived mesenchymal stem cells (ASCs) are well known for their secretory potential, which confers them useful properties in cell therapy. Nevertheless, this therapeutic potential is reduced after transplantation due to their short survival in the human body and their migration property. This study proposes a method to protect cells during and after injection by encapsulation in microparticles of calcium alginate. Besides, the consequences of encapsulation on ASC proliferation, pluripotential, and secretome were studied. Spherical particles with a mean diameter of 500 µm could be obtained in a reproducible manner with a viability of 70% after 16 days in vitro. Moreover, encapsulation did not alter the proliferative properties of ASCs upon return to culture nor their differentiation potential in adipocytes, chondrocytes, and osteocytes. Concerning their secretome, encapsulated ASCs consistently produced greater amounts of interleukin-6 (IL-6), interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF) compared to monolayer cultures. Encapsulation therefore appears to enrich the secretome with transforming growth factor ß1 (TGF-ß1) and macrophage inflammatory protein-1ß (MIP-1ß) not detectable in monolayer cultures. Alginate microparticles seem sufficiently porous to allow diffusion of the cytokines of interest. With all these cytokines playing an important role in wound healing, it appears relevant to investigate the impact of using encapsulated ASCs on the wound healing process.

Solid lipid nanocarriers diffuse effectively through mucus and enter intestinal cells - but where is my peptide?

Peptides are therapeutic molecules with high potential to treat a wide variety of diseases. They are large hydrophilic compounds for which absorption is limited by the intestinal epithelial border covered by mucus. This study aimed to evaluate the potential of Hydrophobic Ion Pairing combined with Solid Lipid Nanoparticles (SLN) and Nanostructured Lipid Carriers (NLC) to improve peptide transport across the intestinal border using Caco-2 cell monolayers (enterocyte-like model) and Caco-2/HT29-MTX co-cultured monolayers (mucin-secreting model). A Hydrophobic Ion Pair (HIP) was formed between Leuprolide (LEU), a model peptide, and sodium docusate. The marked increase in peptide lipophilicity enabled high encapsulation efficiencies in both NLC (84%) and SLN (85%). After co-incubation with the nanoparticles, confocal microscopy images of the cell monolayers demonstrated particles internalization and ability to cross mucus. Flow cytometry measurements confirmed that 82% of incubated SLN and 99% of NLC were internalized by Caco-2 cells. However, LEU transport across cell monolayers was not improved by the nanocarriers. Indeed, combination of particles platelet-shape and HIP low stability in the transport medium led to LEU burst release in this environment. Improvement of peptide lipidization should maintain encapsulation and enable benefit from nanocarriers enhanced intestinal transport.

Development of enteric polymer-based microspheres by spray-drying for colonic delivery of Lactobacillus rhamnosus GG.

Antibiotics are well-known disruptive elements of the intestinal microbiota and antibiotic-associated diarrhea appeared as the most common complication related with post-antibiotic dysbiosis. Lactobacillus rhamnosus GG (LGG) strain is very effective in preventing antibiotic-associated diarrhea in children and adults. However, as any probiotics, it is concerned by the loss of viability during storage and gastrointestinal transit. The aim of this study was to develop an encapsulation system suitable for the specific colonic delivery of LGG strain after oral administration. For this purpose, spray-dried Eudragit® S100 microparticles encapsulating LGG bacteria were developed by using an aqueous based spray-drying approach, avoiding the use of organic solvents. Carbohydrates were added to the formulation since they are widely used as protective agents of bacteria against the harmful effect of dehydration stress. Here, both Surface Enhanced Raman Scattering (SERS) and conventional plate count methods showed that carbohydrates increased the survival ratio of bacteria after spray-drying from 3 to more than 50%. Moreover, these protective agents ensured low residual moisture content thus providing great stability of the cells in the spray-dried powder during storage. Significant improvement of the cell viability in simulated gastro intestinal fluid (SGIF) was observed for encapsulated cells as compared with free LGG bacteria for which no viable cell was detectable after 1 h incubation in gastric fluid only. As a consequence, 4.5 × 107 CFU/g of encapsulated LGG were found viable after incubation of microparticles 1 h in Simulated Gastric Fluid followed by 6 h in Simulated Intestinal Fluid, corresponding to less than 3 log reduction of viable cells during the 7 h incubation in Simulated Gastro Intestinal Fluid. These results attested that the developed encapsulation system is suitable for its use as a bacteria carrier for specific colonic delivery.

Development of uncoated near-spherical gold nanoparticles for the label-free quantification of Lactobacillus rhamnosus GG by surface-enhanced Raman spectroscopy.

The Surface-enhanced Raman spectroscopy (SERS) method based on gold nanoparticles as SERS substrate was investigated for the label-free detection and quantification of probiotic bacteria that are widely used in various pharmaceutical formulations. Indeed, the development of a simple and fast SERS method dedicated to the quantification of bacteria should be very useful for the characterization of such formulations in a more convenient way than the usually performed tedious and time-consuming conventional counting method. For this purpose, uncoated near-spherical gold nanoparticles were developed at room temperature by acidic treatment of star-like gold nanoparticle precursors. In this study, we first investigated the influence of acidic treatment conditions on both the nanoparticle physicochemical properties and SERS efficiency using Rhodamine 6G (R6G) as "model" analyte. Results highlighted that an effective R6G Raman signal enhancement was obtained by promoting chemical effect through R6G-anion interactions and by obtaining a suitable aggregation state of the nanoparticles. Depending on the nanoparticle synthesis conditions, R6G SERS signals were up to 102-103-fold greater than those obtained with star-like gold nanoparticles. The synthesized spherical gold nanoparticles were then successfully applied for the detection and quantification of Lactobacillus rhamnosus GG (LGG). In that case, the signal enhancement was especially due to the combination of anion-induced chemical enhancement and nanoparticle aggregation on LGG cell wall consecutive to non-specific interactions. Both the simplicity and speed of the procedure, achieved under 30 min, including nanoparticle synthesis, sample preparation, and acquisition of SERS spectra, appeared as very relevant for the characterization of pharmaceutical formulations incorporating probiotics. Graphical abstract.

In-vitro evaluation of solid lipid nanoparticles: Ability to encapsulate, release and ensure effective protection of peptides in the gastrointestinal tract.

Peptides are rarely orally administrated due to rapid degradation in the gastrointestinal tract and low absorption at the epithelial border. The objective of this study was to encapsulate a model water-soluble peptide in biodegradable and biocompatible solid lipid-based nanoparticles, i.e. Solid Lipid Nanoparticles (SLN) and Nanostructured Lipid Carriers (NLC) in order to protect it from metabolic degradation. Leuprolide (LEU) and a LEU-docusate Hydrophobic Ion Pair (HIP) were encapsulated in SLN and NLC by High Pressure Homogenization. The particles were characterized regarding their Encapsulation Efficiency (EE), size, morphology, peptide release in FaSSIF-V2, and protective effect towards proteases. Nanoparticles of 120 nm with platelet structures were obtained. Formation of HIP led to a significant increase in LEU EE. Particle size was moderately affected by the presence of simulated fluids. Nonetheless, an important burst release was observed upon dispersion in FaSSIF-V2. NLC were able to improve LEU-HIP resistance to enzymatic degradation induced by trypsin but presented no advantages in presence of α-chymotrypsin. SLN provided no protection regarding both proteases. Despite an increased amount of encapsulated peptide in solid lipid-based nanoparticles following HIP formation, the important specific surface area linked to their platelet structures resulted in an important peptide release upon dispersion in FaSSIF-V2 and limited protection towards enzymatic degradation.

Behaviour of Tetrabenazine in Acid Medium: Reassessment and Impact on Formulation.

Thorough studies of previous analytical stress data of tetrabenazine, a dopamine depleting agent, showed a potential susceptibility to acidic conditions. Hence, the behavior of tetrabenazine acidic solutions was studied by LC-MS and NMR spectroscopy. Reverse-phase LC-MS analysis of tetrabenazine acidic aqueous solutions consistently showed a main lipophilic impurity in a proportion of 15 to 20%. NMR spectroscopy studies did not allow to completely ascertain its structure. However, we hypothesize an interconversion of trans-tetrabenazine with its unstable cis isomer via an open isoquinolinium intermediate. Evaluation of tetrabenazine integrity in orodispersible films was reassessed in light of these observations after formulation and during stability study. Even if interconversion of trans-tetrabenazine with its cis isomer was observed in orodispersible films containing tetrabenazine, this phenomenon seems not to have any consequences for the overall tetrabenazine bioavailability.

Lipid-based nanosuspensions for oral delivery of peptides, a critical review.

Peptides are therapeutic molecules that can treat selectively and efficiently a wide range of pathologies. However, their intrinsic properties cause their rapid degradation in the human gastrointestinal (GI) tract resulting in poor bioavailability after oral administration. Yet, their encapsulation in nanocarriers offers them protection from this harsh environment and increases their permeability across the epithelium border. In particular, Solid Lipid Nanoparticles (SLN) and Nanostructured Lipid Carriers (NLC) have proven to improve peptide oral bioavailability. This article details different techniques used to produce SLN and NLC with potential or effective peptide encapsulation. Basic principles of covalent and non-covalent lipidization are described and discussed as a prerequisite to improve hydrophilic peptide encapsulation in lipid-based nanosuspensions. The last part of this review provides the key evaluation techniques to assay SLN and NLC for peptide oral bioavailability enhancement. Methods to assess the protective effects of the carriers are described as well as the techniques to evaluate peptide release upon lipid digestion by lipases. Furthermore, this review suggests different techniques to measure permeability improvements and describes the main in vitro cell models associated.

Ophthalmic Drug Delivery Systems for Antibiotherapy-A Review.

The last fifty years, ophthalmic drug delivery research has made much progress, challenging scientists about the advantages and limitations of this drug delivery approach. Topical eye drops are the most commonly used formulation in ocular drug delivery. Despite the good tolerance for patients, this topical administration is only focus on the anterior ocular diseases and had a high precorneal loss of drugs due to the tears production and ocular barriers. Antibiotics are popularly used in solution or in ointment for the ophthalmic route. However, their local bioavailability needs to be improved in order to decrease the frequency of administrations and the side effects and to increase their therapeutic efficiency. For this purpose, sustained release forms for ophthalmic delivery of antibiotics were developed. This review briefly describes the ocular administration with the ocular barriers and the currently topical forms. It focuses on experimental results to bypass the limitations of ocular antibiotic delivery with new ocular technology as colloidal and in situ gelling systems or with the improvement of existing forms as implants and contact lenses. Nanotechnology is presently a promising drug delivery way to provide protection of antibiotics and improve pathway through ocular barriers and deliver drugs to specific target sites.

Orodispersible films based on amorphous solid dispersions of tetrabenazine.

In this work, the formation and stability of amorphous solid dispersions (SDs) as orodispersible films (ODF) were investigated using tetrabenazine (TBZ) as a poorly water soluble drug. The influence of polymer nature and pH-modifier incorporation to form and maintain SDs was investigated. TBZ-loaded ODF were formulated using 4 different polymers (HPMC, PVP, Pullulan, and HEC). Binary systems (BS) were obtained mixing the drug with different polymers, while ternary (TS) systems were also obtained by adding citric acid to solubilize TBZ in the mixture. Drug dissolution studies, thermal analysis and X-ray diffraction were carried out to characterize the physical state of API in ODF. ODF made of TS allowed a major improvement of TBZ dissolution profile in buccal conditions compared to a pure drug or BS. DSC and X-ray diffraction revealed that API was in amorphous state in TS while remained crystalline in BS. Following 6 months of storage, TBZ recrystallization occurred for PVP-TS and HEC-TS which induced a decrease of drug release in saliva conditions. HPMC and PUL-TS maintained API in amorphous state during 6 months. Briefly, amorphous SDs were obtained by the pre-dissolution of the drug in acidified water and incorporation in polymeric films. The miscibility and potential interaction between TBZ and polymers have been identified as important factor to explain stability differences.

Formulation of orodispersible films for paediatric therapy: investigation of feasibility and stability for tetrabenazine as drug model.

OBJECTIVES: Orodispersible films (ODF) were formulated to facilitate tetrabenazine (TBZ) administration to paediatric population for the treatment of hyperkinetic movement disorders. METHODS: ODF were obtained by solvent casting/evaporation method using four different polymers (HPMC, PVP, pullulan and HEC). Physicochemical, mechanical and biopharmaceutical characterizations as well as API state in ODF by thermal analysis were investigated to define and compare formulations. ODF stability was also monitored during 6 months to follow evolution of properties. KEY FINDINGS: Analyses at T0 showed few differences between formulations: results of physicochemical and mechanical characterizations were almost similar for each formulation and TBZ appeared at the amorphous state in all cases. ODF delivery system allowed a major improvement of TBZ dissolution profile in buccal conditions compared with pure drug. However, after 3 and 6 months of stability, a TBZ recrystallization occurred for formulations based on PVP and HEC associated with a decrease of drug release in saliva conditions. CONCLUSIONS: HPMC-ODF (F1) appeared as the best formulation. Indeed, physicochemical, mechanical and biopharmaceutical characteristic remained intact. In addition, TBZ remained in amorphous state during stability study.

Problems associated with the microbiological control of the breast milk from hospital milk bank units.

The microbiological tests on breast milk performed when samples of pasteurized breast milk are added to hospital milk banks are covered by French regulations dating from December 3rd 2007. They involve counts of the aerobic total flora and of Staphylococcus aureus in a sample of milk before pasteurization, and culture after pasteurization to check that the treated milk is sterile. The regulations specify the nature of the agar plates to be used, together with the conditions for plating and incubation, but they lack detail in other areas. We developed a quality assurance system, modified our process to meet the statutory requirements, prepared for COFRAC certification of the laboratory for this parameter, and proposed solutions to overcome the inadequacies of the regulations. The modifications of the process associated with the quality approach led to a successful initial certification visit. However, the preparation for this certification highlighted other inadequacies of the regulations that might affect the final results obtained for total flora and S. aureus counts. We think that the text should be modified to overcome these problems and to ensure high-quality counting such that those running hospital milk banks can have confidence in the laboratory results they receive.

Pectin gelation with chlorhexidine: Physico-chemical studies in dilute solutions.

Low methoxyl pectin is known to gel with divalent cations (e.g. Ca(2+), Zn(2+)). In this study, a new way of pectin gelation in the presence of an active pharmaceutical ingredient, chlorhexidine (CX), was highlighted. Thus chlorhexidine interactions with pectin were investigated and compared with the well-known pectin/Ca(2+) binding model. Gelation mechanisms were studied by several physico-chemical methods such as zeta potential, viscosity, size measurements and binding isotherm was determined by Proton Nuclear Magnetic Resonance Spectroscopy ((1)H NMR). The binding process exhibited similar first two steps for both divalent ions: a stoichiometric monocomplexation of the polymer followed by a dimerization step. However, stronger interactions were observed between pectin and chlorhexidine. Moreover, the dimerization step occurred under stoichiometric conditions with chlorhexidine whereas non-stoichiometric conditions were involved with calcium ions. In the case of chlorhexidine, an additional intermolecular binding occurred in a third step.

Microencapsulation of rifampicin for the prevention of endophthalmitis: In vitro release studies and antibacterial assessment.

Rifampicin encapsulated microparticles were designed for intraocular injection after cataract surgery to prevent postoperative endophthalmitis. Microparticles were formulated by emulsification diffusion method using poly(lactic acid-co-glycolic acid) (PLGA) as polymer in order to propose a new form of rifampicin that overcome its limitations in intraocular delivery. Depending on processing formulation, different types of microparticles were prepared, characterized and evaluated by in vitro release studies. Two types of microparticles were selected to get a burst release of rifampicin, to reach minimal inhibitory concentrations to inhibit 90% of Staphylococcus epidermidis mainly involved in postoperative endophthalmitis, combined with a sustained release to maintain rifampicin concentration over 24h. The antibacterial activity and antiadhesive property on intraocular lenses were evaluated on S. epidermidis. Microparticles, with a rapid rifampicin release profile, showed an effect towards bacteria development similar to free rifampicin over 48h. However, slow-release profile microparticles exhibited a similar antibacterial effect during the first 24h, and were able to destroy all the S epidermidis in the medium after 30h. The association of the two formulations allowed obtaining interesting antibacterial profile. Moreover, rifampicin-loaded microparticles have shown a very efficient anti-adherent effect of S. epidermidis on intraocular lenses at 24h. These results propose rifampicin microparticles as suitable for antibioprophylaxis of the postoperative endophthalmitis.

[Accreditation of a hygiene hospital laboratory for sampling and analysis activities for the detection and counting of Legionella in water]. / Accréditation d'un laboratoire d'hygiène hospitalière pour le prélèvement et l'analyse de recherche et dénombrement des légionelles dans l'eau.

Since January 1(st) 2012, detection and counting of Legionella bacteria have been obligatory in France and must be carried out by COFRAC-accredited laboratories. In our establishment, sampling and analysis were outsourced and our hospital was scheduled to move to a new site. We aimed to develop both these activities in-house and to obtain COFRAC accreditation, whilst organizing the move to the new site. We set up a quality assurance system bringing together staff from the hygiene laboratory and institutional resource managers. We set up sampling and analysis activities in-house 13 months before requesting accreditation. The initial evaluation took place before we moved and identified 17 areas of deficiency, six of which were considered critical. After we had moved, a subsequent evaluation considered 14 of these deficiencies to have been corrected, included the six initially identified as critical. We were therefore awarded accreditation. The quality assurance system established during the year before our request was submitted led to accreditation two and a half years after the transfer in-house of sampling and analysis activities, despite our hospital moving during this period.

The development, physicochemical characterisation and in vitro drug release studies of pectinate gel beads containing Thai mango seed kernel extract.

Pectinate gel beads containing Thai mango seed kernel extract (MSKE, cultivar 'Fahlun') were developed and characterised for the purpose of colon-targeted delivery. The MSKE-loaded pectinate beads were prepared using ionotropic gelation with varying pectin-to-MSKE ratios, MSKE concentrations, and concentrations of two cross-linkers (calcium chloride and zinc acetate). The formulated beads were spherical in shape and ranged in size between 1.13 mm and 1.88 mm. Zinc-pectinate (ZPG) beads containing high amounts of MSKE showed complete entrapment efficiency (EE) of MSKE (100%), while calcium-pectinate (CPG) beads demonstrated 70% EE. The in vitro release tests indicated that MSKE-loaded CPG beads were unstable in both simulated gastric medium (SGM) and simulated intestinal medium (SIM), while MSKE-loaded ZPG beads were stable in SIM but unable to prevent the release of MSKE in SGM. The protection of ZPG beads with gastro-resistant capsules (Eudragit® L 100-55) resulted in stability in both SGM and SIM; they disintegrated immediately in simulated colonic medium containing pectinolytic enzymes. MSKE-loaded ZPG beads were stable at 4, 25 and 45 °C during the study period of four months. The present study revealed that ZPG beads in enteric-coated capsules might be a promising carrier for delivering MSKE to the colon.

A safe and practical method for the preparation of 7α-thioether and thioester derivatives of spironolactone.

Spironolactone is a renal competitive aldosterone antagonist. One of its most important metabolite is the 7α-methylthio spironolactone: thus it is very important to have an efficient and safe access to this compound, for pharmacokinetic studies. In this context, we synthesized this metabolite by thioalkylation of 7α-thio spironolactone using Hünig's base with a very good yield. We also used our procedure to prepare, with an easy work-up and high yields, 7α-thioether and thioester derivatives of spironolactone, that could be useful for further Structure-Activity Relationships studies.

Nano-encapsulation of vitamin D3 active metabolites for application in chemotherapy: formulation study and in vitro evaluation.

PURPOSE: Calcitriol (1,25-dihydroxyvitamin D3), the active metabolite of vitamin D3, is a potential anticancer agent but with high risk of hypercalcemia which limits the achievement of effective serum concentrations. Thus, calcitriol targeting delivery by nanoparticles may present a good solution. METHODS: Vitamin D3 active metabolites were encapsulated into polymeric nanoparticles and different formulation parameters were tested. The growth inhibitory efficiency of these nanoparticles was carried out in vitro on human breast adenocarinoma cells (MCF-7). RESULTS: Using cholecalciferol (the inactive metabolite), different polymer and oil ratios were compared to select nanoparticles presenting high encapsulation efficiency and sustained release profile. Calcidiol/calcitriol loaded nanoparticles had good encapsulation efficiencies (around 90%) associated with sustained releases over 7 days and enhanced stability. Moreover, loaded nanoparticles showed similar growth inhibition to non-encapsulated metabolites of vitamin D3 on day 4 and higher activities on days 7 and 10 after treatment initiation. CONCLUSION: The nano-encapsulation of vitamin D3 active metabolites may offer a new and potentially effective strategy for vitamin D3-based chemotherapy overcoming its actual limitations. The targeting delivery of vitamin D3 metabolites should be encouraged.

Development of a nanoparticle-based system for the delivery of retinoic acid into macrophages.

The aim of the present work is to prepare nanoparticulate systems that can target and modulate the functions of mononuclear phagocytes by local administration. All-trans retinoic acid (RA) was chosen as an immunomodulator to be encapsulated in biodegradable nanoparticles (NP). Different formulations were prepared by the nanoprecipitation method and poly(d,l)lactic acid based nanocapsules (NC) were selected to continue the study. RA-NC demonstrated a sustained release profile and an enhanced stability for 7 days. The uptake of fluorescent (NileRed) labeled NP was conducted on bone marrow derived macrophages (BMM) in vitro and xenograft glioma nude mice in vivo. Fluorescent microscopy observations and flow cytometry analysis demonstrated that NR-NC were engulfed by BMM in vitro and lasted inside over 7 days. The intratumoral injection of NR-NC confirmed that NC were efficiently uptaken by infiltrated macrophages. The effects of RA loaded NC on BMM were also evaluated by RT(2)-PCR array. Our results suggest that polymeric nanoparticles are suitable carriers to deliver RA into macrophages and can offer a new strategy in tumor macrophage-based treatment.