Adult stem cells (ASCs) reside throughout the body and support various tissue. Owing to their self-renewal capacity and differentiation potential, ASCs have the potential to be used in regenerative medicine. Their survival, quiescence, and activation are influenced by specific signals within their microenvironment or niche. In better words, the stem cell function is significantly influenced by various extrinsic signals derived from the niche. The stem cell niche is a complex and dynamic network surrounding stem cells that plays a crucial role in maintaining stemness. Studies on stem cell niche have suggested that aged niche contributes to the decline in stem cell function. Notably, functional loss of stem cells is highly associated with aging and age-related disorders. The stem cell niche is comprised of complex interactions between multiple cell types. Over the years, essential aspects of the stem cell niche have been revealed, including cell-cell contact, extracellular matrix interaction, soluble signaling factors, and biochemical and biophysical signals. Any alteration in the stem cell niche causes cell damage and affects the regenerative properties of the stem cells. A pristine stem cell niche might be essential for the proper functioning of stem cells and the maintenance of tissue homeostasis. In this regard, niche-targeted interventions may alleviate problems associated with aging in stem cell behavior. The purpose of this perspective is to discuss recent findings in the field of stem cell aging, heterogeneity of stem cell niches, and impact of age-related changes on stem cell behavior. We further focused on how the niche affects stem cells in homeostasis, aging, and the progression of malignant diseases. Finally, we detail the therapeutic strategies for tissue repair, with a particular emphasis on aging. Adult stem cells (ASCs) are undifferentiated cells with the ability of self-renewal and differentiation into specific cell types in the adult body. Some adult tissues contain ASCs capable of producing differentiated cells that are appropriate for their locations. In other words, ACSs, as tissue stem cells, can repair and maintain tissue hemostasis through self-renewal and differentiation into distinct and specialized cell types. For instance, ASCs that reside in the central nervous system (CNS) can generate neurons, astrocytes, and oligodendrocytes. These tissue-resident stem cells play an essential role in the growth and regeneration of tissues under normal physiological conditions and following injury. ASCs are found in a variety of adult tissues and can be divided into mesenchymal stem cells (MSCs), hematopoietic stem cells (HSCs), neural stem cells (NSCs), liver stem cells (LSCs), induced pluripotent stem cells (iPSCs), pancreatic stem cells (PSCs) and the like, etc. . MSCs arin vitro expansion and subsequent employment in basic and clinical settings, providing insight into organ aging (Stem cell function is controlled by both intrinsic (cellular genetic factors) and extrinsic  factors , and satellite cells . Stem ceStem cells play an essential role in the growth and regeneration of many tissues; thereby, they are critical for maintaining normal tissue function. It is, therefore, imperative to protect stem cells from damage or loss while maintaining sufficient interaction with their environment at the same time to respond to physiological signals for cell replacement and repair. This balance between stem cell protection and interaction appears to be achieved by preserving stem cells within specialized niches . The steWithin the niche, cellular contact with surrounding cells and adjacent stem cells is responsible for structural support, adhesive interactions, and the release of soluble signals that control stem cell function . Extracein vitro  are located in a defined niche regulated by various factors to maintain the balance between the self-renewal and differentiation of GSCs. GSCs in g humans . Ishibasl niches .Drosophila revealed that GSCs maintenance is mediated by secreted factors from the testicular niche which is composed of diverse somatic cells. An imbalance between the self-renewal and differentiation of GSCs could impede reproduction, causing germ cell loss and infertility  are altered during aging. Although all cells in the brain are affected during aging, NSCs in the adult brain can generate neurons (neurogenesis) and regenerate some brain functions . The mamin vitro . CNS injOn the other hand, scar formation can inhibit the growth of injured axons. Resident NSCs give rise to new astrocytes that form glial scars at the injured site in the spinal cord. Indeed, NSC-derived astrocytes contribute to the restriction of lesion enlargement after injury.Furthermore, NSCs progeny have a neurotrophic effect that is required for the survival of neurons adjacent to the lesion. Collectively, stem cell transplantation or NSCs-derived cells lead to functional recovery of the injured spinal cord. The interplay between the NSCs and their niche has a significant impact on neurogenesis. A better understanding of niche alterations during aging may help develop novel therapeutics and interventions to improve neural repair .As outlined above, stem cell niches contain both cellular and acellular components. The stem cell niche is a dynamic microenvironment that supports stem cell functionality. Multiple mechanisms contribute to the crosstalk between stem cells and the niche, including soluble factors, adhesion molecules, and many signaling pathways such as Wnt and Notch. In addition to the cellular components within the niche, acellular components are also involved in directing stem cell fate. In the case of HSCs, quiescent HSCs reside within the niche and exit, upon activation. As an adhesion molecule, E-selectin is exclusively expressed by the BM endothelial cells in the vascular niche. E-selectin expression in the vascular niche maintains quiescent HSCs. This molecule is crucial in regulating HSC and their proliferation; hence, E-selectin is regarded as an essential component of the vascular niche . E-selecvia membrane receptors. In addition, stem cell number remain constant in many tissues; however, age-related functional decline in stem cells may lead to stem cell aging and senescence in diverse types of tissues. Prolonged activating of quiescent stem cells in tissue depletes quiescent stem cells and their regeneration ability. With this notion, stem cells are maintained within the niche by several essential factors and signals  and their environment is regulated by several signaling pathways such as Notch, Wnt/diseases .As previously discussed, NSCs reside within specific niches and differentiate into neurons, astrocytes, and oligodendrocytes. The NSC niche is a dynamic environment close to the cerebrospinal fluid (CSF) and systemic circulation. Thus, NSCs respond not only to local microenvironment factors, but also to those that exist in the systemic macroenvironment. These factors can be soluble molecules, such as cytokines and chemokines from circulation, or local factors released by microglia and astrocytes. The activity of NSCs depends on local signals, systemic factors , immune cells, and CNS resident cells such as neurons, astrocytes, and microglia. In the context of aging, systemic regulation becomes even more evident since significant changes in circulating cytokines and chemokines greatly impact the functions of NSCs .Muscle stem cells (satellite cells or MuSCs or SCs) are the long-term ASCs that are esponsible for the regeneration of skeletal muscles. Under homeostastatic condition, MuSCs are quiescent. A significant alteration occurs in niche components upon muscle injury, exposing MuSCs to signaling cues to repair damaged tissue . An age-It has been shown that exposure to circulating factors from the blood of young-aged animals caused the rejuvenation of aged MuSC with the restoration of muscle regeneration. A young host provides a favorable environment and generates a youthful phenotype from transplanted aged cells . A heterSpermatogonial stem cells (SSCs) are male GSCs that support gamete production by self-renewal and differentiation into daughter cells. The maintenance of SSC functionality unequivocally depends on the testis niche. With advancing age, dysfunction or loss of SSCs occurs. Transplantation of SSCs into aged mice showed that stem cells alone might not be able to change their functions. Instead, the niche influences the balance between self-renewal and differentiation capabilities. In this regard, SSCs transplantation of an aged mouse into a young recipient showed continual spermatogenesis over 3 years . This obDrosophila. An age-dependent decline in E-cadherin expression in the GSC niche leads to reduced GSCs in male and female Drosophila  is associated with a decreased level of stem cell factor (SCF) in aged mouse long bones. Conversely, the abundance of sinusoidal type L blood vessels remains unchanged during aging. There is a decline in type H vessel density, accompanied by a decrease in blood flow to the BM, which may elicit metabolic changes in the BM. The decline in type H vessels with age is correlated with a decrease in osteogenesis, osteoprogenitors, bone density, and endosteum niches .The aged BM endothelium also exhibits other metabolic changes, such as increased hypoxia and ROS levels. These changes were associated with decreased angiogenesis and migration capacity. Furthermore, aging reduces endothelial expression of hypoxia-inducible factor 1 (HIF-1), which is responsible for age-related changes and loss of bone density and type H endothelium. Compared to young mice, aged BM ECs express lower levels of prohematopoietic factors. Several factors contribute to HSC homeostasis including SCF, CXCL12, and Notch ligands. Additionally, type H ECs and adjacent perivascular cells exhibited higher Notch signaling activity. Indeed, there is a link between age-related decreases in endosteal vessels and impairment in endothelial Notch activity, together with a decline in type H vessels. In line with this, activation of the endothelial Notch signaling pathway enhances bone blood flow and the abundance of HSCs. In addition to functional and metabolic alterations, the aged endothelium also exhibits remarkable morphological changes, such as vascular leakage, vasodilation, and impaired vessel integrity. During aging, perivascular cells also undergo functional changes, and with age, the abundance of pericytes decreases, leading to a reduction in quiescence factors, such as SCF, Bmp4 and Bmp6. These events contribute to the loss of quiescence of HSCs and cancer cells .in vivo infusion of aged ECs following myelosuppression inhibits repopulation capacity and is linked to myeloid lineage bias in the hematopoietic system. Infusion of young ECs significantly enhances repopulation potential and partially restores HSC function, indicating a bidirectional interplay between HSC aging and alterations of the vascular niche. Hematopoietic aging decreases immune system functionality. A compromised immune system increases the likelihood of infection, autoimmune diseases, and hematological malignancies, which further alters the vascular niche and interferes with HSC homeostasis  is necessary for autologous and allogeneic HSCs transplantation, a niche-targeted strategy can be used for this purpose. Indeed, radiation and chemotherapeutics have been replaced by niche-targeted therapy to clear the HSC niche. The ideal condition is the presence of a target molecule on HSPC, not outside the hematopoietic system, such as CD117 (c-Kit) . C-Kit aex vivo expansion of stem cells. Clinical transplantation of HSCs is limited and is influenced by several factors, such as the low number of isolated HSCs in patients. Allogeneic transplantation of HSCs has been applied clinically with a suitable donor; however, for patients without a matched donor, autologous HSCs have been used with a low risk of graft-versus-host (GVH). The limited number of HSCs that can be obtained from patients is a major challenge for clinical applications. As a result, there is an unmet medical need for HSCs expansion for applications in regenerative medicine and other therapeutic purposes. Niche signals play an essential role in regulating the self-renewal and differentiation of HSCs. Niche cells secrete various growth factors and cytokines to regulate the self-renewal and differentiation of HSCs , SCF, interleukin 6 (IL-6), TPO, and FMS-like tyrosine kinase 3 (Flt-3) ligand  ligand .+ MSCs and stimulate osteolineage differentiation  can mediate the proliferation of nestinntiation . Esmaeilood-HSCs . PTH treood-HSCs . PTH alsood-HSCs . Given tood-HSCs .ex vivo expansion leads to a loss of regenerative potential. The MuSC function depends on the regulation of protein synthesis mediated by eIF2α phosphorylation. Therefore, preventing the dephosphorylation of eIF2α could promote ex vivo expansion of MuSCs concomitant with restoring regenerative capacity after engraftment into an animal model of muscular dystrophy  signaling pathways in cancer stem cells (CSCs), with major alterations in their receptors and downstream elements. The BMP pathway plays a vital role in the control of stem cells and their niches. BMP signaling regulates the proliferation and fate of normal HSCs and their interactions with their niches. Growing evidence has revealed that BMPs can promote cancer progression by orchestrating the interaction between cancer cells and their niche. These interactions direct the functions of tumor and stromal cells in the niche to promote the initiation of tumor growth, angiogenesis, local invasion, and metastasis. This leads to the establishment of cancer cells in the tumor niche . Extracesurvival .Hedgehog signaling plays a critical role in the normal development and maintenance of homeostasis in adult tissues. In addition, this pathway modulates the microenvironment to provide a suitable niche for tumor cells by inducing angiogenesis, escaping from the immune system, and creating a niche for invasion and metastasis. Conversely, hedgehog downregulation is associated with age-related diseases . There iRecent studies have shown the significance of a CSC-like niche in promoting the production and maintenance of CSCs. Thus, the CSC niche plays a key role in maintaining the stem cell pool. CSCs are associated with tumor survival. These cells have high metastatic potential and give rise to solid tumor heterogeneity and complex architecture. CSCs express tumorigenic characteristics in response to signaling by their niches. Therapeutic approaches targeting pathways common in cancer stem cells and their niche may control tumor progression .A growing body of evidence indicates that aging is associated with cancer-initiating potential. DNA damage, telomere shortening, and metabolic reprogramming have been observed upon aging. Aged stem cells display telomere shortening, epigenetic remodeling, and replication stress, all of which are involved in the development of CSC-linked features. Notably, aging can enhance the CSC niche by altering the microenvironment to create an aged niche in the young niche .During the aging process, inflammatory responses are associated with the tumor microenvironment. Senescent microenvironments can induce alterations in cells with genomic instability to turn premalignant cells into cancer stem-like cells . FurtherThe success of metastasis depends on the genetic and epigenetic deregulation of cancer cells and their interplay with the stromal microenvironment. The interaction between CSCs and their niche is bidirectional, in which cancer cells modify their niche; conversely, the niche acts as a “fertile soil” to produce all carcinoma cells of the tumor mass .in vitro in response to CXCL12. These molecular axes are associated with leukemic cells that communicate with the BM stromal niche. Targeting aberrant niches or their deregulated components may be beneficial for reversing the disease course  is an age-associated condition resulting from the acquisition of somatic mutations. CHIP is a premalignant disorder that can be used as a predictor of hematological and cardiovascular diseases. However, during chronological aging, HSCs lose their ability to self-renew and exhibit skewed differentiation, which can increase the risk of anemia and impair adaptive and innate immunity. Most of these alterations are triggered by cell-intrinsic events such as genetic and epigenetic modifications, which determine the stages of clonal selection .Although previous studies in mice have suggested that HSC aging is largely a result of intrinsic molecular changes within cells, the significance of microenvironment-related factors may be undervalued in short-lived models with limited exposure to environmental stressors.In humans, the BM niche plays a prominent role in hematopoiesis. Several lines of evidence indicate that external pressure  can influence normal hematopoiesis. Despite an understanding of the genetic mechanisms of clonal hematopoiesis in malignant states, the clinical importance of clonality in healthy aging remains unclear. As part of this review, we briefly discuss the cell-intrinsic molecular mechanisms involved in the aging of HSCs and describe the clonal drivers associated with aging hematopoiesis. In this section, we discuss various cell-extrinsic factors that potentially influence CHIP development within the BM niche.The transplantation of aged HSCs into young mice retains the aging phenotype, suggesting that intrinsic changes are the primary cause of HSC aging. Several cell-intrinsic mechanisms implicated in the aging of HSCs, which may be related to clonal selection during aging, are described below .in vitro. Furthermore, somatic mutations in cancer-associated genes may facilitate clonal expansion through selective growth. It is important to note that these paths to clonal hematopoiesis are not equally exclusive and each is influenced by external factors. However, these pathways also have different clinical implications (It has been proposed that accumulation of DNA damage is an irreversible cause of HSC aging. Mutations in genes encoding DNA damage response (DDR) proteins may trigger senescence of HSCs, leading to depletion of the functional pool. This theory is supported by increased levels of histone 2A family member X (γ-H2AX) and foci formation in aged HSCs. γ-H2AX is a sensitive indicator for DNA double-strand breaks (DSB). HSC reserves are preserved with age in mice lacking DNA repair genes; however, HSCs exhibit severe functional limitations. Similarly, HSCs in mice lacking the BRCA1 gene showed expansion in the BM, but exhibited less hematopoietic colony formation ications .Aging of HSCs is associated with telomere erosion, a specific form of DNA damage. A sequence of repetitive DNA located at the ends of chromosomes prevents DDR activation. Each cell division results in shorter telomeres, which ultimately cause unprotected chromosome ends, eliciting senescence or apoptosis. By breeding telomerase mRNA-deficient mice, telomeres are eventually critically shortened, resulting in impaired long-term viability of cells and compromised renewal of HSCs. Stochastic loss of HSCs occurs through telomere attrition and expansion of clones with superior growth characteristics. According to two studies of germline sequence variants in the TERT locus, telomerase activity may play a substantial role in the development of clonal hematopoiesis. TERT and TERC are components of the telomere complex that are altered in telomeropathies such as dyskeratosis congenita. There is a high probability that short telomere syndromes cause early BM failure in children, and a higher propensity for MDS or acute myeloid leukemia (AML) in adults. Accelerated telomere erosion resulting from underlying genetic mutations, in combination with cytokine overproduction, may promote depletion of the HSC pool and premalignant clonal expansion .Clonal mutations associated with aging primarily involve DNA methyltransferase 3A (DNMT3A) and Tet Methylcytosine Dioxygenase 2 (TET2), two genes responsible for the DNA methylation/demethylation status. Therefore, the maintenance of epigenetic regulation is crucial for proper regulation of HSCs. The methylation profiles of young and old human HSCs showed hypomethylation of genes that were ordinarily hypomethylated and activated during the differentiation of myeloid cells. Such alterations in the epigenomic profile during HSC aging may explain the lower differentiation potential of older HSCs. The higher replicative history associated with aging appears to be partially responsible for the decreased self-renewal capacity of the HSCs. Inaccuracy in transmitting epigenetic marks to daughter cells can gradually and randomly cause erosion of epigenetic elements during HSC division with age. Aged HSCs may exhibit aberrant epigenetic status due to the loss of transcriptional fidelity. The inability of daughter cells to maintain the HSC pool may pave the way for further clonal selection. This process can be accelerated by the presence of somatically mutated epigenetic regulators .Is clonal hematopoiesis a normal result of aging?In the presence of mutations in genes associated with myeloid malignancy, it is important to determine whether CHIP is specifically indicative of preleukemic conditions.Several seminal studies have shown that CHIP is associated with an increased risk of hematologic malignancies, similar to monoclonal gammopathies and B cell lymphocytosis. Based on two population-based studies, it appears that individuals without antecedent candidate gene mutations have a negligible risk of developing hematological malignancies. Approximately 0.5% of the 12,000 participants evaluated in both studies developed hematological malignancies, and only one-third had candidate driver mutations. There was an association between clonal abundance and cancer risk, suggesting that clone size was a more relevant factor than mere presence. With error-corrected sequencing, researchers can detect somatic variants at a level two orders of magnitude lower than that of standard next-generation sequencing (NGS). Using this ultrasensitive technique, Young et al. studied the prevalence of clonal hematopoiesis in healthy middle-aged women .Clonal hematopoiesis was observed in 95% of the studied individuals, often with mutations in DNMT3A and TET2. Using a whole-genome approach, Zink et al. discovered that elderly individuals exhibit macroscopic clonal hematopoiesis.A previous study found that only 5% of middle-aged individuals had clonal hematopoiesis; therefore, clonal hematopoiesis is not necessarily pathogenic but rather a nearly universal feature of aging. In advanced age, when most of HSC proliferative capacity have diminished, clonal expansion may be a compensatory mechanism to maintain normal hematopoiesis. Experiments in murine models have demonstrated that the two most prevalent mutations associated with clonal hematopoiesis, DNMT3A and TET2, promote the self-renewal of HSCs. However, mouse models do not necessarily reflect CHIP in humans. The phenotypic profile of TET2-deficient mice is similar to that of chronic myelomonocytic leukemia in humans. As an example of how mutations can bestow HSCs with adequate self-renewal potential, an 115-year-old woman with a single clone harboring 450 somatic mutations maintained normal blood production during her prolonged life. She died from metastatic gastric cancer rather than any malignant hematopoietic disorder . AlthougOver the past years, the advances of stem cell research has revealed many aspects of stem cell niches, including stem cell interactions and other niche cells as well as the ECM, signaling pathways , various soluble factors, biochemical and biophysical components of stem cell niche. Although stem cells hold tremendous promise in regenerative medicine, they do not play a role in tissue hemostasis and regeneration. The interaction of stem cells with adjacent stem cells and the surrounding ECM microenvironment can determine the migration, proliferation, differentiation and regenerative capacity of stem cells. Since stem cells are extremely responsive to extrinsic signals, they must interact closely with their environment to receive niche signals, which drive their function.There is now an increased interest in investigating the BM niche owing to its therapeutic and translational potential. Various approaches, including humanized niche, model single-cell profiling, and spatial transcriptomics data, will contribute to consolidating and deepening our understanding of how the BM niche can support HSC function over time. It is generally accepted that the intrinsic elements driving HSC aging are mostly fixed within the cells, and microenvironment or systemic rejuvenation interventions have little effect on this condition (166). It is interesting to note that rejuvenating aged HSCs is beneficial to different tissues and may also impact the BM niche. Currently, we are only beginning to explore the boundaries between the intrinsic and extrinsic aging of HSCs and how they are interconnected. Considering the current perspective, interventions affecting both features might profoundly affect hematopoiesis. Ideally, this combined strategy targeting HSC intrinsic and extrinsic aging could be applied to other somatic stem cells and tissues to eventually extend the lifespan and slow the aging process in the entire body.In this regard, a better understanding of stem cells, the surrounding microenvironment, and molecular signals may help develop niche-targeted interventions to promote tissue regeneration and reverse or ameliorate age-related complications. Accordingly, by targeting deregulated molecular pathways or dysfunctional components within the niches, novel strategies can be developed to combat stem cell loss, such as that caused by aging or degenerative diseases. In addition to aging, targeting aberrant niches or their deregulated component may be beneficial in preventing or reversing the malignant transformation in cancers).


Efficient resource allocation can contribute to an organism’s fitness and can improve evolutionary success. Resource Balance Analysis (RBA) is a computational framework that models an organism’s growth-optimal proteome configurations in various environments. RBA software enables the construction of RBA models on genome scale and the calculation of medium-specific, growth-optimal cell states including metabolic fluxes and the abundance of macromolecular machines. However, existing software lacks a simple programming interface for non-expert users, easy to use and interoperable with other software.The python package RBAtools provides convenient access to RBA models. As a flexible programming interface, it enables the implementation of custom workflows and the modification of existing genome-scale RBA models. Its high-level functions comprise simulation, model fitting, parameter screens, sensitivity analysis, variability analysis and the construction of Pareto fronts. Models and data are represented as structured tables and can be exported to common data formats for fluxomics and proteomics visualization.https://sysbioinra.github.io/rbatools/. General information about RBA and related software can be found at rba.inrae.fr.RBAtools documentation, installation instructions and tutorials are available at  How can we understand and anticipate the impact of genomic modifications and environmental perturbations on microbial cells? A guiding idea is that organisms efficiently allocate their resources to succeed within their ecological niche  predictiThe basic structure of RBA models is shown in The existing software RBApy  can be predicted. It is possible to compute Monod curves and the associated medium exchange rates  and to iTo study the effects of parameter variation and uncertainty, RBAtools provides different types of sensitivity analyses. (i) In a global variability analysis, the effects of variable or uncertain enzyme efficiencies on fluxes or other state variables can be assessed by random sampling . (ii) ByBioengineering has to deal with trade-offs between compound production and a cell’s own objectives such as cell growth or the capacity to respond to stress. Compound production redirects resources such as energy, precursors or available cell space towards non-native processes, which puts a burden on cells and slows down cell growth. In engineered microbes, slower growth can lead to the emergence of non-producing, fast-growing mutants. To anticipate and avoid this, we may simulate trade-offs between growth and objectives such as protein or ATP production. In RBA, growth-optimal states usually do not leave any space for variations, so there is no extra capacity for other processes. At sub-maximal growth rates, cells can deviate from the growth-optimal phenotype, and since this tolerance tends to increase with decreasing cell growth, there can be a trade-off between growth and other objectives. RBAtools provides methods to study such trade-offs.Resource Variability Analysis (RVA) resembles Flux Variability Analysis , but is Plotting the compromise between growth and an extra metabolic capacity  as a Pareto front resembles phenotypic phase-plane analysis in FBA , but theRBAtools is a convenient programming interface for RBA models, enabling a deep exploration of cell behaviour on genome scale. It is more flexible and user-friendly than existing RBA tools, leveraging the idea of cellular resource allocation to model cell physiology by combining biochemical facts, optimality considerations and organism-specific empirical knowledge. While RBApy remains the main tool for building RBA models, RBAtools with its simpler interface and broader functionality makes it easy to simulate the impact of genomic or environmental perturbations on cell phenotypes. Thereby, it supports a wide range of applications in synthetic biology, metabolic engineering or white biotechnology.


What are the barriers to and enablers of implementing patient-reported outcome measures (PROMs) in gender-affirming care?In this systematic review of 286 studies, the main barriers to implementing PROMs in gender-affirming care were issues with evidence strength and quality of the PROM, engaging participants, and complexity of the PROM.This study’s findings may help to guide PROM implementation initiatives for gender-affirming care with potential generalizability to other clinical areas. This systematic review identifies patient-reported outcome measures for gender-affirming care and the barriers to and enablers of implementation. Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs. To develop an implementation plan for PROMs in gender-affirming care, barriers and enablers to implementation must be understood, and an evidence-based PROM implementation plan is needed.15One area that may benefit from widespread and organized PROM implementation is gender-affirming care. Gender-affirming care comprises a range of psychosocial, hormonal, and surgical care offered to transgender and nonbinary individuals to help with a person’s gender transition. However, not all gender identity service delivery is gender affirming due to pathologization, discrimination, and cisnormativity existing in some gender identity centers.16 Normalization process theory is particularly applicable for PROM implementation and describes how innovations become routinized.17 The Knowledge to Action model applies to PROM implementation through describing steps to translate research into practice.18 The Consolidated Framework for Implementation Research (CFIR) can be used to systematically categorize barriers to and enablers of implementation and is known as a meta-framework that incorporates key concepts from implementation science into 1 framework.19 The CFIR also allows for systematic linking of identified barriers to implementation strategies and has been applied successfully in PROM implementation.19 The aims of this systematic review are to (1) identify PROMs previously implemented for use in gender-affirming care and identify constructs measured; (2) identify how patients complete PROMs and how results are reported and used; and (3) identify barriers to and enablers of PROM implementation for use in gender-affirming care, categorizing results using the CFIR. We use the results of this systematic review to create a framework that can be used to develop PROM implementation initiatives for gender-affirming care.Implementation science offers approaches to identify implementation barriers and enablers, develop an implementation strategy, and evaluate implementation effectiveness.20 and was registered with the International Prospective Register of Systematic Reviews (CRD42021233080). This study was reviewed by the Clinical Trials and Research Governance Body at the University of Oxford, who determined that this study did not require ethics approval, as this review did not collect human participant data.This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelineSix patient and public partners were involved in designing and conducting this review, including confirming the relevance of the research question, aiding with search strategy development (identifying key terms and gray literature sources), and confirming applicability of findings. Patient and public partners represented individuals from the transgender and nonbinary community recruited through representatives from national transgender charity organizations and community support groups.We included original articles evaluating a formally developed PROM  or ad hoc instrument . The PROM had to be administered to patients accessing gender-affirming care  or where subgrouped data were available for patients accessing gender-affirming care.Six databases, including PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science, were searched from inception to October 25, 2021. The search was updated on December 15, 2022. There were no restrictions on language, country of origin, or publication date. Gray literature was searched through gray literature databases , customized searching via online search engine, and targeted searching of relevant websites , with conflicts resolved by a third reviewer. Two reviewers  extracted data from the included articles independently, with conflicts resolved by a third reviewer. Non-English articles were screened and extracted by a reviewer  fluent in the article’s original language and a second reviewer (R.K.) using artificial intelligence–powered translation software .Extracted data included study information , PROM characteristics , and barriers to and enablers of PROM implementation categorized according to CFIR constructs. Data items were chosen based on key concepts in PROM implementation and CFIR.21 was used by 2 independent reviewers  to evaluate the quality of included studies, with conflicts resolved by a third reviewer. The CFIR guidance was followed to categorize barriers to and enablers of PROM implementation by 2 independent reviewers .19 Patient and public partners reviewed CFIR-based frameworks generated from this study to confirm their relevance and applicability.The Critical Appraisal Skills Programme tool22 was followed for data synthesis reporting.Descriptive statistics were used to report demographic characteristics and study information. Agreement for CFIR categorization was calculated through identifying the percentage of overlap between reviewers. Discrepancies with CFIR categorization were resolved through discussion between reviewers . Analyses were performed using Microsoft Excel, version 2019 (Microsoft Corporation) software. Guidance from Synthesis Without Meta-Analysis308 included in the review  measured outcomes with only an ad hoc instrument. Of the remaining 205 studies, 34 (17%) used a combination of ad hoc instruments and PROMs, or PROMs only . Studies administered between 1 and 11 PROMs  .In total, 205 different PROMs were administered for gender-affirming care, varying between 1 and 250 items each . The total items administered per study ranged from 1 to 284 . The PROMs covered a range of constructs, and most commonly measured psychological functioning, quality of life, and appearance . Few PROA total of 24 studies (8%) focused on pediatric populations, and 262 (92%) focused on adult populations. Patient burden was higher in pediatric gender-affirming care, with a mean of 116 items  administered to pediatric patients vs a mean of 57 items  for adult gender-affirming care.Most studies did not report staff training on PROM administration . Most participants completed PROMs in the clinic  .Reasons for implementing PROMs varied. Most studies implemented PROMs for research use  . Cost coPatient-reported outcome measures were administered between 1 and 9 times  . Of the The mode of administering PROMs varied . Most weScores from PROMs were most often reported as a table of means and SDs   were consistent between the 2 reviewers . There were disagreements for 17 codes (6%), which were resolved through discussion.The top 3 reported barriers to PROM implementation from the organizational perspective included issues with PROM evidence strength and quality, engaging participants, and PROM complexity. Regarding the construct of evidence strength and quality (86 codes), high variability of available PROMs used in gender-affirming care, lack of PROMs validated for gender-affirming care, and administration of PROMs for too short a follow-up time were barriers to implementation. These barriers limited the ability to incorporate results into clinical decision-making.It was frequently mentioned in 81 codes that implementation of PROMs did not serve particular populations well; for example, patients from ethnic minority groups and those with lower socioeconomic status, lower education, and residence in rural areas were not engaged to complete PROMs. Difficulties engaging with participants after their transition were also reported due to some participants changing contact information and moving. Complexity of the PROM, specifically logistics of how to administer and score PROMs in the clinic, and online survey software failing to send out links to complete PROMs were additional key barriers mentioned in 22 codes.The top reported barriers to PROM implementation from the patient perspective included issues with patient engagement for PROM completion and PROM complexity. Specifically, PROM length limited implementation due to higher patient burden. Furthermore, PROMs viewing gender as binary was a key barrier to implementation from the patient perspective. The top enablers of PROM implementation from the organizational perspective included evidence strength and quality, adaptability, complexity, organization needs, organization climate, and engaging key stakeholders and participants . Clinics found it easier to implement a PROM that demonstrated strong psychometric properties and content validity (11 codes). Using a PROM validated for gender-affirming care increased clinic staff motivation to use the PROM (8 codes). Being able to adapt PROM administration (options for pen and paper or online) and using shorter and easy-to-score instruments enabled implementation (12 codes).Implementation success increased when PROMs were integrated into existing quality improvement initiatives and when organizations viewed PROMs as a key component of clinic appointments (8 codes). An organizational climate of wanting to improve patient monitoring and experiences and comparing outcomes between treatments enabled PROM implementation.Also enabling PROM implementation was clinics working in partnership with key stakeholders, such as local transgender and nonbinary organizations and community members, on developing a plan for PROM administration (3 codes). Some clinics worked in partnership with local transgender and nonbinary community members who formed a stakeholder advisory group and were involved in creating a strategy for PROM implementation, which enabled PROM engagement (2 codes).From the patient perspective, implementation was enabled with clear communication on how PROM data would be handled (8 codes), including anonymity of responses when used in research or confidentiality when used in clinical practice. Critical Appraisal Skills Programme checklists were used to assess quality of studies. In general, most studies  demonstrated acceptable recruitment. However, most studies  did not identify or include all confounding factors in their analyses. Most studies also had limited follow-up  (eTable 7 in This systematic review identifies key areas of focus relevant to PROM implementation for gender-affirming care. The CFIR-based frameworks generated from this study can be used for future PROM implementation initiatives for gender-affirming care, with potential generalizability to other clinical areas interested in implementing PROMs. The frameworks generated from our study are also living models upon which subsequent studies can build.Overall, PROM implementation in gender-affirming care was inconsistent and did not follow evidence-based approaches in implementation science. There was a lack of patient input in creating implementation strategies for PROMs, suggesting a need for patient-centered approaches to PROM implementation in gender-affirming care. Most of the PROMs were also implemented for research purposes, which may explain why most were administered only once (eTable 5 in 9 patient and public partners emphasized confidentiality as key for PROM sections that evaluate satisfaction with health care professionals so that their care is not negatively impacted. Furthermore, applying techniques in computerized adaptive testing, a form of artificial intelligence that can reduce PROM length, may reduce patient burden of completing lengthy PROMs, resulting in higher engagement.309 Patient and public partners from this study also emphasized the importance of implementing a PROM in gender-affirming care that does not view gender as binary.Key barriers to PROM implementation in gender-affirming care from the patient perspective include patient engagement to complete PROMs and PROM length and complexity. Practical considerations for overcoming these barriers include communication between clinicians and patients on how PROM results will be used for research and care purposes and providing patients information on how their data will be handled securely. Due to discrimination experienced by patients in some specialist centers delivering gender-affirming care,23 the Trans Woman Voice Questionnaire,310 or the iTransQoL.311 Such consideration would ensure that the PROM has relevance for transgender and nonbinary patients and higher-quality measurement. Automating administration and scoring of PROMs may enable implementation through reducing complexity. Clinics aiming to develop PROM implementation initiatives may find increased patient engagement when working with members of the transgender community to develop an implementation plan. Aligning PROMs as an important and accepted part of clinic culture may also enable implementation success.Key barriers to PROM implementation for gender-affirming care from the organizational perspective include complexity of administering and scoring PROMs and using PROMs not validated for gender-affirming care. Practical considerations for overcoming these barriers include selecting a PROM that has been validated for gender-affirming care, such as the Gender Congruence and Life Satisfaction Scale,High variation in PROMs used and constructs measured and lack of reporting on data security for PROMs were identified. There is also a need to improve standardization of concepts measured in gender-affirming care, including consensus on the most important concepts to measure. Patient and public partners from our study emphasized the importance of data security as a key concept relevant to implementation. Information on how PROM data are stored, who can access data, and whether there is a risk that PROM data could adversely impact access or quality of care were their key concerns. Past literature is limited in reporting information on data security, representing an important future area of research for PROM implementation.313 This review is the first to focus on implementation using the CFIR. It is necessary to identify and categorize barriers and enablers to PROM implementation prior to developing PROM implementation plans, as PROM implementation strategies that are not evidence based may result in poor PROM adoption, lack of realization of PROM benefits, and research waste.314Past systematic reviews on PROMs for gender-affirming care focused on measurement properties of PROMs.Strengths of this study include a comprehensive review of available evidence for PROM implementation in gender-affirming care and using established approaches in implementation science for data analysis. In addition, our research was conducted with patient and public partners, an essential component of PROM implementation research. Our patient and public partners confirmed face validity of the CFIR-based frameworks generated from this study.This study has several limitations. First, there is a risk of publication bias, as this review is of published studies. Second, despite the comprehensive literature search, some articles might have been missed. Third, barriers to and enablers of PROM implementation reported in the literature focused primarily on the organizational and clinician perspectives, lacking patient perspectives. Fourth, there may have been PROM implementation attempts in gender-affirming care that were not studied or published and, thus, not covered in this review. Fifth, reasons for limited engagement among patients from ethnic minority groups and those with lower socioeconomic status, lower education, and residence in rural areas were not explored in the literature.To overcome these limitations, our team is currently conducting a qualitative study on barriers to and enablers of PROM implementation in gender-affirming care to generate research from the patient perspective. Results from focus groups will build on the CFIR-based frameworks generated from this study, which can be used to guide PROM implementation initiatives in gender-affirming care.In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, we described key concepts relevant for evidence-based PROM implementation in gender-affirming care. These findings can be used to help to guide PROM implementation initiatives in gender-affirming care.


Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation. Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is an infrequent disorder often associated with end-stage kidney disease (ESKD). It clinically presents as skin ischemia and necrosis . The morA 48-year-old male with essential hypertension, end-stage kidney disease on hemodialysis (HD) for nine months secondary to type 2 diabetes mellitus (DM), ESKD complicated with secondary hyperparathyroidism, penile calciphylaxis requiring partial penile amputation, diverting colostomy for sacral decubitus ulcer, and poor treatment adherence presented with worsening sacral ulcer and colostomy lip leak. He was hemodynamically stable on presentation. A thorough examination revealed a pale colostomy with stool leak around the colostomy bag, abdominal tenderness with induration around the colostomy without erythema or fluctuance, and a foul-smelling sacral ulcer that was deep, especially in the left lateral hip Figure . Black dX-ray of the bilateral foot revealed significant arterial calcification. Computed tomography (CT) of the abdomen and pelvis was remarkable for gas collection within soft tissue around the left side of the colostomy concerning for peristomal abscess and extensive calcification of abdominal blood vessels Figure . ArteriaThe patient underwent exploratory laparotomy with partial colectomy of the descending and sigmoid colon due to intramural ischemia. Histopathology revealed architectural simplification and necrosis of the colonic mucosa and extensive calcification of the arterioles and pericolonic tissues without any signs of active inflammation consistent with calciphylaxis Figure . The posThe incidence of calciphylaxis per a study done in 2016 was estimated to be 3.5 new cases per 1,000 patient-years among chronic hemodialysis patients . The mosAlthough no specific laboratory findings are diagnostic, increased parathyroid hormone (PTH), calcium, and phosphorus may be seen. The gold standard of diagnosis is usually by skin biopsy revealing calcification of the medial layer of arteries and arterioles . HoweverOur patient had a confirmed diagnosis of systemic calciphylaxis complicated by penile amputation and was being treated with sodium thiosulphate. His physical examination was classic for uncontrolled calciphylaxis, and abdominal CT revealed extensive calcification of the intra-abdominal arteries, the degree of ischemia involving the sigmoid up to the mid-descending colon. Histopathology of the resected colon also showed signs of calcification without any signs of inflammatory infiltrates, ruling out vasculitis. Thus, we highly suggest calcific uremic arteriopathy as a cause of colon ischemia and necrosis resulting in perforation and abdominal infection.There are no definitive treatment guidelines for CUA given the low prevalence and high mortality, making it difficult to perform large clinical trials. The treatment is the same for all manifestations of calciphylaxis, irrespective of the site involved. It is usually multidisciplinary, involving nephrology, surgery, infectious disease, wound care, and finally pain and palliative care specialists . The maiA systematic search of the literature for available case reports related to gastrointestinal manifestations yielded nine case reports, the summary of which is listed in Table Although the prognosis is poor, our patient responded well to resection and debridement for osteomyelitis of the coccyx. Plastic surgery evaluation was also considered, but given the patient’s decision, he was discharged under hospice care.Calciphylaxis is a lethal disease despite treatment. Visceral, penile, and proximal extremity involvement has been associated with more significant morbidity and mortality. Although gastrointestinal calciphylaxis is favored in patients with ischemic colitis or GI hemorrhage in the background of calciphylaxis and histopathology finding of extensive arterial calcification, differential diagnosis including atherosclerosis, warfarin-induced necrosis, vasculitis, and cholesterol embolization should be considered.


Judgement is a higher-order brain function utilized in the evaluation process of problem solving. However, heterogeneity in the task methodology based on the many definitions of judgement and its expansive and nuanced applications have prevented the identification of a unified cortical model at a level of granularity necessary for clinical translation. Forty-six task-based fMRI studies were used to generate activation-likelihood estimations (ALE) across moral, social, risky, and interpersonal judgement paradigms. Cortical parcellations overlapping these ALEs were used to delineate patterns in neurocognitive network engagement for the four judgement tasks. Moral judgement involved the bilateral superior frontal gyri, right temporal gyri, and left parietal lobe. Social judgement demonstrated a left-dominant frontoparietal network with engagement of right-sided temporal limbic regions. Moral and social judgement tasks evoked mutual engagement of the bilateral DMN. Both interpersonal and risk judgement were shown to involve a right-sided frontoparietal network with accompanying engagement of the left insular cortex, converging at the right-sided CEN. Cortical activation in normophysiological judgement function followed two separable patterns involving the large-scale neurocognitive networks. Specifically, the DMN was found to subserve judgement centered around social inferences and moral cognition, while the CEN subserved tasks involving probabilistic reasoning, risk estimation, and strategic contemplation. Judgement is a complicated aspect of higher cognition that relates to the capacity to make decisions and form reasonable opinions . DespiteTerms including judgement, decision making, problem solving, and reasoning are often used interchangeably throughout the neuropsychiatric literature ,3. JudgeIncreasing evidence from the field of “connectomics” has more accurately suggested that the brain involves dynamically interacting brain networks that are efficiently organized to subserve complex human thinking and behavior . Of partThe present study aims to develop a clearer picture of exactly where in the brain the faculty of judgement is localized, particularly in the areas of moral judgement, self/other-referential judgement, and judgement in conditions of variable certainty. To address this, we conducted an activation-likelihood estimation (ALE) coordinated-based meta-analysis (CBMA), using data from task-based functional magnetic resonance imaging (fMRI) studies of healthy participants. Our study integrated data from a range of experimental paradigms, grossly divided into four subgroups on the basis of the task modality used within each. In this way, we aimed to reduce the manifold expressions of judgement into a unified pattern of network engagement and, furthermore, to differentiate between brain areas that serve computational roles essential for all judgement and accessory regions preferentially engaged for certain applications. Furthermore, our results are reported in an anatomically specific parcellation nomenclature, which may allow our preliminary model to be utilized as a basis for future study.A literature search was conducted across two databases (Pubmed and Embase) using the search queries “Judgement & fMRI” on Pubmed and “(Judgement OR decision-making) AND ” on Embase. The literature was screened in accordance with PRISMA guidelines ,10 and cp value < 0.001 or a corrected cluster probability of p value < 0.05. Studies were required to have task-based fRMI with an active judgement task of either making a decision or an evaluation. A matched or baseline control task was also required to be performed. Studies were required to have eight or more study participants. All studies met current best practice guidelines for CBMA, except for one study that had a total of eight study participants.The primary selection of articles was directed by the main screening criteria outlined in https://bioimagesuiteweb.github.io/webapp/mni2tal.html (accessed on 1 October 2021). The BrainMap GingerALE 3.0.2 was then used to generate an ALE for each sub-analysis at a cluster level threshold of 0.05, threshold permutation of 1000, and uncorrected p value less than 0.001 [All Talairach coordinates were converted to the MNI stereotaxic space using an online conversion tool available at an 0.001 ,13.ric.uthscsa.edu/mango, 10 December 2021).The activation likelihood estimation treated each  coordinate as a spatial uncertainty distribution modelled by a three-dimensional gaussian kernel, the center of which was equivalent to the location of the peak cortical activation encoded in the BOLD-contrast . The radALE clusters were then matched for volumetric overlap with the cortical parcellations described under the human connectome projects (HCP) multimodal parcellation scheme. A complete table of correspondences describing the MNI locus of each ALE cluster, intersected HCP parcellations and the percentage overlap between them is recorded in We then matched all identified parcellations to their belonging as a component of one of the core brain networks as described under Yeo’s 7 network model . These iALE contrast analysis was conducted to identify potential core and accessory brain regions involved in judgement. A core region is defined as a brain area that is found to be activated across multiple ALEs, whereas an accessory region is found to be uniquely associated with a given modality or paradigm subtype. Patterns of large-scale network engagement were uncovered by relating these brain regions to the broader networks they formed a component of.https://www.brainmap.org/, accessed on 1 January 2022) to find the top most similar behavioral experiments (based on task-related activations) in the BrainMap database to each judgement paradigm. The data from the top 10 experiments from each judgement paradigm were retrieved .To examine how our ALE coordinate data for each judgement paradigm were related to behavioral experiments in the literature, a behavioral analysis across moral, social, risky, and interpersonal judgement paradigms was completed. The ALE coordinate data were analyzed using the activation coordinate experiment-wise search (ACES) on BrainMap , which involves making a judgement of another person based on incomplete information; moral judgement (MJ), which involves making a judgement between two opposing scenarios or moral principles; risk judgement (RJ), which involves those tasks where decision outcomes can cause potential financial or physical harm to exclusively the decision maker themselves; and interpersonal judgement (IJ), which includes paradigms where choice outcome is influenced by the choice of another person. Unfortunately, 10 studies that met our inclusion/exclusion criteria were excluded because they could not be delegated to an analysis without compromising the homogeneity of the dataset. A complete description of the included studies is listed in Demonstrated in A behavioral analysis across moral, social, risky, and interpersonal judgement paradigms was also completed. ALE coordinate data, consisting of anatomical coordinates most representative of each judgement paradigm, were analyzed using the activation coordinate experiment-wise search (ACES) on BrainMap to find the top most similar behavioral experiments (based on task-related activations) to each of these judgement paradigm coordinates in the BrainMap database. These data are presented in Broadly, each paradigm was related to experiments with activations including similar aspects of judgement. Notably, experiments were most similar between moral and social judgements, while risk and interpersonal judgements were more similar. Risk and interpersonal judgement paradigms demonstrated similar activations in studies that examined stimuli in the environment and between others generally for the purpose of a reward or calculated decision making. Risk judgement had activation coordinate similarities to studies that examined adverse stimuli  and performance feedback. Interpersonal judgement had coordinate similarities shared across studies more related to interactions between oneself and other subjects or objects in the environment, such as transitive inference (inferring relations between objects), pattern matching, decisions according to reward probability, and provocation in a situation. When examining moral judgement, coordinate similarities from our moral activation map included a number of studies examining opposing scenarios, such as meaningful versus non-meaningful stimuli, two different body movements, and rest versus action. Social judgement had coordinate similarities to the social activation map across studies that examined a variety of emotional stimuli, such as emotional pictures, depression, and also responses to painful stimuli or scenarios.Our study found that cortical activation in normophysiological judgement function follows two general and separable patterns involving the large-scale neurocognitive networks. Specifically, the DMN was found to subserve judgement centered around social inferences and moral cognition, while the central executive network (CEN) subserved tasks involving probabilistic reasoning, risk estimation, and strategic contemplation. Consequently, we conjecture that the average age of competency observed across different decision-making modalities  is actuaThe functional reliance of judgement on the DMN, SN, and CEN aligns with recent work that has attempted to systematically resolve the diverse phenotypic expression of psychopathology to the aberrant connectivity and organization of these same neurocognitive networks . ReferreNeurocognitive network engagement for judgement was found to robustly separate into two systems: a DMN system implicated for moral and social tasks and a salience/CEN system implicated for risky and interpersonal tasks. Furthermore, the DMN system was found to be left dominant, while the salience/CEN system was strongly right dominant.Despite an absence of parcellation co-activity between moral and social judgement, there was strong shared activation of the DMN between these sub-analyses. Conceptually, the MJ and SJ active tasks were unified in their dependence on inferring the “goodness” of a target stimulus and integrating this into a behavioral decision. While the DMN was first discovered as a resting-state ICN , our worJudgement under conditions of risk and interpersonal judgement evoked strong co-activation of the right-sided CEN and bilateral SN. Conceptually, the experimental tasks included within these two sub-analyses were similar in that they involved the pursuit of reward maximization, outcome anticipation, and strategizing. While the role of the CEN in goal-directed judgement  and the By age two, the cerebral network topology has matured such that the salience, default mode, and central executive networks are recognizable . From thWe have also shown that judgement involving strategic thinking, planning, and risk estimation is largely subserved by the CEN. Central to CEN functionality is its dynamic relationship with the SN, largely mediated by connections through the AI . Lebel aOne of the core exercises of neurosurgery is the optimization of onco-functional balance, that is, to maximize the extent of tumor resection while minimizing the induction of new neurological deficits ,51. HistDespite these limitations, some neurosurgeons have begun utilizing graph theory metrics as a non-specific method for conserving higher cognition by optimizing the brains post-operative capacity for informational integration . One sucRepetitive transcranial magnetic stimulation (rTMS) involves the application of extracranial magnetic fluctuations to induce electrical currents within the cortex . This noAll ALE meta-analyses are inherently limited by the large number of studies required for inclusion to detect smaller effects and to negate the over-representation of any one dataset . Of the There is also a potential for selection bias to skew our results. One source of this is the lack of deliberate balancing of paradigm subtypes within individual ALEs. As a result, the ALE products may over-represent some paradigm-specific evocations for task types that dominate the dataset. An additional confounder of selection bias is the potential for our results to overly represent a certain patient demographic. Task-based fMRI activations have been shown to often follow patterned deviations depending on the characteristics of the participant demographic, including the level of education , gender To eliminate spurious cognitive processing that is functionally associated yet non-essential to judgement, we selected a majority of studies that used a matched control task to produce their BOLD signal contrast. These matched tasks worked to eliminate accessory cortical activation inspired by visual, motor, and semantic cues featured in the active task . DespiteFinally, an unavoidable source of bias in this study is the subjective categorization of the ALE sub-analysis groups. These categories form the interpretative framework for this study, and so alternative categorizations could potentially show a different pattern of network engagement. While we sampled and examined four large components of judgement, the sum of these groups does not represent the function in its entirety. Consequently, there remain other task modalities that are often used to study judgement not included in our final analysis. Thus, whether these other domains of judgement organize under the two-system framework described above remains an area for future research.Judgement is a complicated aspect of higher cognition that has been studied in a multitude of ways. Despite an abundance of research, inconsistency in the way judgement is defined and in the parcellation and network atlases used to guide the interpretation of these studies has limited the clinical actionability of past findings. Here, we have used ALE CBMA to demonstrate that judgement function broadly involves the separable engagement of the DMN and CEN. Dividing judgement paradigms into moral, social, interpersonal, and risk, we found that the bilateral superior frontal gyri, right temporal gyri, and left parietal lobe were implicated in moral judgement. The left-dominant frontoparietal network and right-sided temporal limbic regions were implicated in social judgement. Both interpersonal and risk judgement involved the right-sided frontoparietal network and left insular cortex. Although these findings are consistent with the functional imaging literature, some ALEs were under-powered, and so this preliminary model requires further validation. Nevertheless, we suspect that improved anatomical models of judgement such as described here will contribute to the improved preservation and restoration of judgement-related cognition in clinical practice in the future.


There is a limited understanding of health care provider behavior change approaches and how they're being measured. This rapid review identifies methods and measures to understand opportunities and gaps in assessing and improving health care provider performance. This rapid review identified opportunities and gaps in measurement of health care provider behavior by focusing on domains that correspond to factors that influence provider behavior and service provision and incorporate elements beyond provider competency and skills.Of the studies included in this review, 65% focused on providers' ability ; 70% focused on predisposing factors ; 57% focused on enabling factors ; and 36% focused on reinforcing factors .Most studies did not test associations between behavioral determinants and provider behaviors.Program implementers, donors, and researchers should support the evaluation of provider behavior change programs to shift the evidence base from one that is focused on describing behaviors to one that uses theory-driven approaches to understand behavioral antecedents and impacts of behavior change interventions on provider behaviors and their drivers.Evaluators should develop and apply validated measures of provider behavior to enable comparable learning and support policymakers to target quality improvement and invest in evidence-based behavior change programs. Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010–2021). Information on study identifiers , select domains from Green and Kreuter's PRECEDE-PROCEED framework , study characteristics , and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes. Addressing these challenges requires a process where the problem and its determinants are clearly defined in measurable terms. The Breakthrough RESEARCH project—funded by the U.S. Agency for International Development—and the SBC for Service Delivery Working Group, a community of professionals committed to improving the practice of integrating SBC across the service continuum,Supplement 1. We excluded reviews, commentaries/editorials, and news articles.In line with Cochrane guidance, we conducted a rapid review of the peer-reviewed literature from January 2000 through May 2021 by searching the PubMed database.We imported citations into Zotero software and removed duplicates. The initial screen was done in collaboration with a second team engaged with the SBC for Service Delivery Working Group . Reviewers screened titles of the articles retrieved  to exclude articles that did not take place in low- and middle-income countries, did not focus on RMNCH, or did not interview or observe providers . FollowiDuring the abstract screening, a single reviewer assessed articles to determine if (1) client-provider interactions were measured/observed, (2) provider behavior was explained or explored from the provider perspective, or (3) provider norms, attitudes, or biases were measured. A sample of 10% of articles was double screened by 2 study team members to ensure agreement with the inclusion criteria. Any decisions that did not meet consensus were discussed and resolved. The study team then completed full-text extraction of the 105 abstracts that met the inclusion criteria, during which 16 articles were further excluded for failing to meet the inclusion criteria, resulting in 89 articles for full review and data extraction.Supplement 2). We also categorized whether the articles measured provider ability and select domains using a well-established behavior change model, PRECEDE-PROCEED, as an organizing framework for the analysis.We designed and piloted a data extraction table using Google Sheets to record study identification , health area, geographic information , type of health worker, what types of provider behavior/client-provider interactions were measured, and whether the behavior was self-reported or observed  predisposing factors ; (2) reinforcing factors ; and (3) enabling factors, which are the resources and skills required to make desired behavioral and environmental changes .We conducted descriptive analyses of closed-ended questions in the extraction sheet using Stata 16. Open-ended responses in the extraction table were grouped and synthesized by measurement domains.–––,,,,,,–,–Across all domains, the majority of studies used multiple-item closed-ended questions or qualitative measures . Few art,,–,–,,,Among the 89 studies reviewed, 76% assessed client-provider interactions. Client-provider interaction was measured primarily through multiple-item closed-ended questions (38%) or qualitative methods (28%), and a small number of studies used a single-item question (8%) or applied a composite measure, such as an index or scale (2%). Several studies focused on the quality of client-provider interactions, including assessments of respect toward clients and their perspectives/opinions/concerns, verbal and physical abuse of clients, emotional support and empathy toward clients, confidentiality and privacy during interactions, locus of decision-making and consent for care, and communication style with clients. Commonly measured themes included documentation of clinical care practices during client visits and counseling about a particular service or product. Among articles focused on FP, nearly half measured provider behaviors related to contraception counseling and provision of contraceptives,,,,,–,,,,,,,Approximately two-thirds of the studies (n=58) assessed provider ability, primarily measured through multiple-item closed measures (35%) and qualitative measures (19%), while only approximately 6% of studies used single-item closed measures or scores/scales . StudiesApproximately two-thirds of the studies assessed provider ability, primarily measured through multiple-item closed measures and qualitative measures.,–,,,,,,,,,,,,Of the 89 articles reviewed, 70% (n=62) measured predisposing factors. These measures were primarily captured through self-report, although 25 studies also or exclusively assessed or inferred attitudes and perceptions through observation, including by mystery clients. As shown in ,,,,,,,,About one-third of the articles (n=32) measured the reinforcing domain, of which half (n=16) used qualitative measures. Only 1 study examined reinforcing factors using a structured index (provider support environment index and management index).,,,,A little more than half (57%) of the articles reviewed measured enabling factors. Half of these studies used qualitative (30%) or multiple-item closed-ended (20%) measures to assess enabling factors . Fewer t,,,,–,,The use of the PRECEDE-PROCEED model as an organizing framework provided an opportunity to highlight instances where studies addressed multiple domains influencing provider behavior. In total, 9 studies incorporated all PRECEDE-PROCEED domains and measured provider behavior and ability.Less than 10% (n=8) of articles were guided by a conceptual framework or were theory driven. Given that assessment of provider behavior has traditionally been viewed through the lens of health systems strengthening and quality-of-care frameworks, we did identify a couple of articles that acknowledged WHO's guidelines for essential elements of clinical care and Rowe's framework for explaining health worker practices,,,,–,,,,,,,,–,,,,,Approximately half (56%) of the studies reviewed assessed client-provider interaction using quantitative methods. We assessed whether these studies measured associations between behavioral determinants and provider behavior. Overall, most studies were cross-sectional and descriptive and did not test associations between behavioral determinants and provider behaviors.,,,,–,,This rapid review establishes a foundation of evidence on measures related to provider behavior for RMNCH services and identifies opportunities and gaps in measurement that can inform future PBC strategies. The review identifies several promising studies that have aimed to understand the complex environment where providers operate by capturing information across multiple domains. These studies have endeavored to measure the predisposing, reinforcing, and enabling domains, as well as providers' ability and behavior.The review identifies several promising studies that have aimed to understand the complex environment where providers operate by capturing information across multiple domains.,Overall, most studies were descriptive or formative in nature and were largely composed of qualitative and cross-sectional studies. While these studies provide valuable information to support programs by describing relevant features of the clinical context, including current care practices and provider attitudes, they are limited in their ability to assess change over time and cohorts of providers. The limited methodological approaches may reflect challenges in establishing a facility sampling strategy, linking client-provider observations to facility-level determinants, as well as recognizing the need to capture the domains through different methodologies such as observations, client-exit interviews, facility assessments, and provider interviews, which are not always feasible given some facilities have low client volume or providers are busy and unavailable to participate in interviews.–There were few standardized measures that emerged during the review that could be applied for learning across settings. Despite the fact that attitudes are multidimensional and should be grounded in qualitative formative research and considered across multiple domains, the majority of studies assessed provider behavioral determinants through multiple-item closed-ended questions, and only a few based these questions on literature, qualitative formative research, or empirically grounded scales. Validated scales were rarely used to measure latent constructs critical to informing PBC interventions, such as provider bias.Finally, while many studies incorporated multiple domains and constructs related to provider performance, the majority did not refer to an explicit theoretical foundation and, in particular, behavioral theory. Some of the articles that assessed provider performance were grounded in Donabedian's quality-of-care frameworkWithout an explicit theoretical foundation, research with and measurement of providers is more likely to miss the empirically grounded determinants of provider behavior and comprehensively assess these determinants.There are several limitations that should be considered in the context of this rapid review, which uses a less comprehensive approach than a systematic review. We did not include studies from the gray literature or from high-income countries. The review also did not identify many studies on provider behavior related to child health, which may be a function of the search terms. Given the limited time for the review, the review team did not review references in articles that met the inclusion criteria. As a result, salient findings outside our search criteria are not reflected in these findings. Because the objective was to understand the breadth of methods and measures applied and given the diversity of articles captured during this review, we did not assess or weight the quality of methods and measures applied nor the associations between determinants and behaviors and are also unable to draw conclusions on ideal measures for assessing PBC interventions. Further, we were also not seeking to categorize the specific underlying factors critical to a particular provider behavior. Rather, we focused on how those factors and corresponding outcomes were measured, if at all. Subsequent research may need to focus specifically on developing validated, reliable measures for evaluating PBC interventions across health areas. Finally, in this review, we focused solely on research done with providers; future reviews should focus on the client perspectives, as well as how larger community norms affect client-provider interactions, including fear of retribution and social sanctions, to have a better understanding of research on provider behaviors.This review supports a call to action for programmers and researchers to advance evidence generation through theory-driven, systematic measurement of PBC programs. The design of interventions and research should incorporate a behavioral theory approach that recognizes and addresses the importance of internal and structural factors related to a provider's behavior and identifies empirically measurable outcomes that are comparable across programs and contexts. Measurements of core concepts of provider behavior are necessary to concretely assess and address provider performance.


Extinct megafaunal mammals in the Americas are often linked to seed-dispersal mutualisms with large-fruiting tree species, but large-fruiting species in Europe and Asia have received far less attention. Several species of arboreal Maloideae (apples and pears) and Prunoideae (plums and peaches) evolved large fruits starting around nine million years ago, primarily in Eurasia. As evolutionary adaptations for seed dispersal by animals, the size, high sugar content, and bright colorful visual displays of ripeness suggest that mutualism with megafaunal mammals facilitated the evolutionary change. There has been little discussion as to which animals were likely candidate(s) on the late Miocene landscape of Eurasia. We argue that several possible dispersers could have consumed the large fruits, with endozoochoric dispersal usually relying on guilds of species. During the Pleistocene and Holocene, the dispersal guild likely included ursids, equids, and elephantids. During the late Miocene, large primates were likely also among the members of this guild, and the potential of a long-held mutualism between the ape and apple clades merits further discussion. If primates were a driving factor in the evolution of this large-fruit seed-dispersal system, it would represent an example of seed-dispersal-based mutualism with hominids millions of years prior to crop domestication or the development of cultural practices, such as farming. Malus pumila (formerly M. domestica)) is closely intertwined with humans. There are 3,000 species in the Rosaceae family, many of which are economically important, such as apples, peaches (Prunus persica), plums (Prunus spp.), and pears (Pyrus spp.). Malus encompasses 55 species   were recovered from the Epipaleolithic cave site of Öküzini in Anatolia, along with other wild arboreal fruit seeds  evolved in parallel at least twice  across the Rosaceae clade in Eurasia starting in the late Miocene  may have had much wider ranges across refugial pockets during the Pleistocene; and (3) humans were likely utilizing these resources. In this article, we take this evidence for hominin–Malus spp. interactions a stage further to argue that the evolution of large fruits in the Rosaceae lineage may have been linked to seed-dispersal-based mutualism prior to the Pleistocene. We base our hypothesis on: (1) the fossil and genetic record for Malus spp.; (2) morphological traits of fruits in the clade; (3) the dominance of frugivorous or folivorous primates on the landscape during the development of fleshy fruits in the Miocene; (4) the fossil and extant record for large primate frugivory; and (5) the prominence of seed dispersal in other primate clades.These publications suggest: (1) wild fruit forests were common in pre-Holocene Eurasia; (2) many of the megafruits with restricted ranges during the mid-Holocene  driving evolution of large fruits. Velasco et al. , and has an anteroposteriorly elongated temporomandibular joint, both of which have been associated with an enlarging jaw gape—a possible adaptation for processing large food items with the anterior dentition  may have caused large-scale species extinction, and both floral and faunal communities were dramatically changed .Modern ecological studies show how effective primates are at dispersing seeds, an observation that can be extrapolated back to their frugivorous ancestors. Extensive studies across the tropics and beyond have illustrated the prevalence of seed dispersal by primates , chimpanzees , and gorillas (Gorilla gorilla). The seeds dispersed by chimpanzees and gorillas ranged in size from 0.1 to 2.7 cm, and seeds larger than 2.0 cm were readily dispersed over great distances  may serve as a rough case study for at least some of the ecologies that European apes lived in, given their existence in deciduous forests that are snow-covered for a portion of the year. This level of seasonality is probably more extreme than what most European late Miocene apes dealt with; nonetheless, seasonal fruit availability would have been key to their survival. Extensive observational studies of semi-captive (in confined preserves) macaques illustrate the seasonal importance of fruits in their diet and the year-round importance of plants  of the Danum Valley, Sabah, Malaysia, show that they will intensively consume fruits of Dipterocarpus during masting periods and regularly consume moderate amounts of continually fruiting Ficus and Spatholobus during periods between , Rhinopithecus, Pygathrix, Trachypithecus, Nomascus, and Pongo , boar (Sus spp.), and bears —collectively suggesting that forests were rich in fruiting trees.Beyond a review of the hominids of Miocene Europe, another way to probe the likelihood that Miocene apes were major fruit seed dispersers is to explore what happened to fruit distributions in other cases where megafaunal primates went extinct. As an example, in South and Southeast Asia, large-bodied primates may have been a disperser of large fruits in the Megaladapis edwardsi). Paleoprimatologists estimate that as many as ten species of lemur went extinct as recently as two millennia ago; this recent extinction allows scholars to study the effects of the loss of seed-dispersal services , the only New World primates (platyrrhines) with color vision, have reduced olfactory perception as well  and quince (Cydonia). These mega-fruits evolved to attract a seed disperser much larger than a bird; therefore, we can think of an apple tree as a mega-floral rose bush. Looking at the temperate forests of Eurasia, there are fewer potential seed dispersers than in the tropical belt. Likewise, many animals that may seem like candidates for a dispersal guild either ignore or only selectively consume sugary fruits, such as ruminants (see Fig. Malus spp. fruits. They were also the only large arboreal animals. Ripe apples often remain on the tree even after the leaves fall due to a lack of function in pedicle abscission zones, a typical adaptation for megafaunal-dispersed fruits that helps them avoid rodent seed predation.The rose hip is small and red, in most cases small enough for birds, which do not masticate their food. The apple is clustered with other mega-rosaceous fruits, including the pear (see Fig. . HominidComprehensive studies of the fossil record of Miocene Eurasia suggest that fleshy-fruit-based endozoochory was rare overall on a landscape dominated by grazers and open woodlands (Fortelius et al. Asimina triloba of North America or related Annona fruits of Central and South America are good examples, with large hard seeds, soft sweet flesh, and remaining green when ripe. Additionally, many, such as the cucurbits and Maclura pomifera, do not possess high sugar concentrations. Wild apples contain red morphotypes, have high sugar levels, and they contain small easily crushed seeds. Fruits that were likely dispersed by elephantine or xenarthran species often contain large seeds or pits, easily mashed fruit coats, muted colors, and oily or low-sugar fruits. Smaller fruiting members of Rosaceae attract avian dispersers; however, the fruits of many Maloideae and Prunoideae are too large for frugivorous birds to swallow. It is probable that red fruits of M. sylvestris and M. sieversii, which are too large for avian dispersal, evolved to attract a megafaunal disperser that possessed trichromaticism, likely one that cannot swallow large pits. Additionally, there were fewer frugivores on the pre-Holocene landscape of Europe than in the Americas, where gomphotheres and other proboscideans, and xenarthrans likely drove the evolution of larger fruits. Ruminant dispersers and other grazing animals avoid sweet fleshy fruits and tend to be destructive of larger seeds.Most examples of endozoochoric megafruits have muted colors, often yellow, green, or brown. Malus trees. Large primates were prominent on the European landscape during the Miocene. Fossil evidence seems to suggest that these primates evolved new traits to adapt to ecological changes during the late Miocene, including dental features that suggest specialized frugivory. The limited availability of other large-fruiting trees in late Miocene Europe points to a strong focus on Rosaceae. Similarly, studies of fruit consumption among both extant and extinct apes further supports the present hypothesis. Identifying the exact drivers of evolution is always difficult, and organisms often evolve in a complex milieu of selective forces, many of which are complementary. Likewise, seed dispersal often relies on guilds rather than a specific species; however, humans appear to have been the main dispersers for M. sylvestris in Europe since at least the Mesolithic and of M. sieversii and M. orientalis during the past few millennia. Given the close relationship between people and the apple over the past few hundred thousand years, as evidenced in the archaeobotanical record, it is reasonable to assume a deeper time depth for this mutualism. Further paleontological research, especially targeting rare fleshy fruit fossils, may validate or refute the theories that we present here, but in either case, it is clear that collaborations between domestication scholars and evolutionary ecologists can prove to be fruitful. Ultimately, this study demonstrates that the coevolutionary process of human-driven evolution that we colloquially call “domestication” has deeper roots in our hominin lineage.A fleshy fruit dispersal guild in late Miocene Europe likely included bear, rhinoceros, proboscideans, equids, and suids, all of which would have selected for larger fruiting hybrid examples of


Drosophila melanogaster possesses a highly conserved and comparatively simple innate immune system. Intriguingly, recent studies have shown that Drosophila plasmatocytes, the macrophage-like blood cells, adopt comparable metabolic remodeling and signaling pathways to achieve energy reassignment when challenged by pathogens, indicating the conservation of such metabolic strategies between insects and mammals. Here, focusing on Drosophila macrophages (plasmatocytes), we review recent advances regarding their comprehensive roles in local or systemic metabolism under homeostasis or stress, emphasizing macrophages as critical players in the crosstalk between the immune system and organic metabolism from a Drosophila perspective.Macrophages are well known for their phagocytic functions in innate immunity across species. In mammals, they rapidly consume a large amount of energy by shifting their metabolism from mitochondrial oxidative phosphorylation toward aerobic glycolysis, to perform the effective bactericidal function upon infection. Meanwhile, they strive for sufficient energy resources by restricting systemic metabolism. In contrast, under nutrient deprivation, the macrophage population is down-regulated to save energy for survival.  Drosophila comprises two major arms, the humoral immune response and the cellular immune response, in response to bacterial and fungal infections  in the body cavity , is an essential transcription factor for crystal cell specification and development during both waves of hematopoiesis  is an early marker defining hemocyte precursors in both embryos and larvae  and gcm2, which are critical lineage-specific transcription factors that direct the specification and terminal differentiation of embryonic plasmatocytes  usually in low-oxygen environments—to quickly provide adequate energy for phagocytosis  also undertake a dramatic shift toward aerobic glycolysis upon infection by pathogens   macrophages, a recent study indicates that  macrophaDrosophila, mitochondrial fission–fusion events contribute to blood progenitor differentiation and the eventual blood cell count  in humans  is able to facilitate the over-production of macrophages, a phenomenon that is conserved from s Straub . InsulinListeria monocytogenes, a facultative intracellular bacterial pathogen found in the cytosol of Drosophila phagocytic cells, acquires nutrients from the host cell to support its growth and replication  located in fat body cells transduces Pvf signaling to mediate lipid storage in the fat body (Hoch and Soriano pvf3 deficient larvae (Cox et al. It has been reported that Drosophila muscles, macrophage-derived Upd3 is required as a metabolic regulator via activating JAK/STAT signaling (Kierdorf et al. In healthy Drosophila larvae infected by parasitoid wasps, sessile macrophage populations are up-regulated and released into the circulation via a fat body-secreted peptide known as Edin (Vanha-Aho et al. As described above, upon infection, energy is reallocated to the immune system to support a rapid and efficient response to kill pathogens. The increased number of macrophages secret more Upd3 or adenosine, which systemically activates JAK/STAT signaling and adenosine-associated signaling, respectively, to inhibit metabolic processes (Kim et al. Similar to the infection situation, blood cells tend to amplify rapidly when a subtype of plasmatocyte is specifically ablated, to maintain a sufficient number of immune cells. In response to this expansion demand, the remaining plasmatocytes produce more Upd3, which activates JAK/STAT signaling and decreases insulin signaling in the fat body, leading to less lipid storage in fat body cells (Shin et al. Drosophila macrophages under chronic lipid-rich conditions has yet to be investigated. However, it has been found that a chronic lipid-rich diet in Drosophila induces the production of Upd3 by macrophages causing insulin insensitivity and a reduced lifespan via activation of the JAK/STAT pathway (Woodcock et al. In addition to stimulation by pathogenic organisms, the nutrient condition is another critical factor affecting the immune system. Similar to conditions when infected by pathogens, mammalian macrophages also remodel their metabolic strategy to aerobic glycolysis under lipid-rich conditions (Bajgar et al. Drosophila is a powerful model organism to investigate immunity and metabolism due to its comparatively simple immune/hematopoietic or metabolic systems and the conservation of functional mechanisms throughout the evolution (Graham and Pick Drosophila. During homeostasis, macrophages are maintained in a basal number and at a basal metabolic level, playing essential roles in metabolism and growth control. However, under stress conditions, for example due to infection or nutrition deficiency, the immune system and other tissues compete for energy and nutrients. When a sudden infection occurs, the number of macrophages is rapidly amplified to defend the host organism against the pathogen (P et al. P et al. . In thisP et al. , Table 2Macrophages are highly plastic cells that play multiple roles in organisms. They are also closely associated with many human diseases (Wynn et al. Drosophila ovary (Lebo et al. Macrophages, however, are not the only cell type to perform the phagocytic function. Epithelial follicle cells may serve as phagocytes in the