Towards a unifying mechanism for CCM disease pathogenesis and treatment.CCM proteins play pleiotropic roles in distinct redox-sensitive pathways by modulating the fine-tuned crosstalk between redox signaling and autophagy. Effective autophagy removes ROS-generating cellular trash, including damaged mitochondria, to rejuvenate cell environment, thus serving a cytoprotective function for the maintenance of endothelial cell monolayer integrity and functionality and blood–brain barrier (BBB) stability even under adverse stress conditions. Loss-of-function of a CCM protein  causes defective autophagy and altered redox signaling, affecting BBB stability and sensitizing endothelial cells to local oxidative stress and inflammatory events, which may act as key pathogenic determinants of focal formation and progression of CCM lesions. The common capacity to modulate the interplay between autophagy and redox signaling reconciles the distinct pharmacological approaches proposed so far for CCM disease prevention and treatment. •CCM proteins play pleiotropic roles in various redox-sensitive signaling pathways.•CCM proteins modulate the crosstalk between redox signaling and autophagy that govern cell homeostasis and stress responses.•Oxidative stress and inflammation are emerging as key focal determinants of CCM lesion formation, progression and severity.•The pleiotropic functions of CCM proteins may prevent vascular dysfunctions triggered by local oxidative stress and inflammatory events.•The distinct therapeutic compounds proposed so far for CCM disease share the ability to modulate redox signaling and autophagy. de novo formation of CCM lesions in susceptible individuals.Cerebral Cavernous Malformation (CCM) is a vascular disease of proven genetic origin, which may arise sporadically or is inherited as an autosomal dominant condition with incomplete penetrance and highly variable expressivity. CCM lesions exhibit a range of different phenotypes, including wide inter-individual differences in lesion number, size, and susceptibility to intracerebral hemorrhage (ICH). Lesions may remain asymptomatic or result in pathological conditions of various type and severity at any age, with symptoms ranging from recurrent headaches to severe neurological deficits, seizures, and stroke. To date there are no direct therapeutic approaches for CCM disease besides the surgical removal of accessible lesions. Novel pharmacological strategies are particularly needed to limit disease progression and severity and prevent Useful insights into innovative approaches for CCM disease prevention and treatment are emerging from a growing understanding of the biological functions of the three known CCM proteins, CCM1/KRIT1, CCM2 and CCM3/PDCD10. In particular, accumulating evidence indicates that these proteins play major roles in distinct signaling pathways, including those involved in cellular responses to oxidative stress, inflammation and angiogenesis, pointing to pathophysiological mechanisms whereby the function of CCM proteins may be relevant in preventing vascular dysfunctions triggered by these events. Indeed, emerging findings demonstrate that the pleiotropic roles of CCM proteins reflect their critical capacity to modulate the fine-tuned crosstalk between redox signaling and autophagy that govern cell homeostasis and stress responses, providing a novel mechanistic scenario that reconciles both the multiple signaling pathways linked to CCM proteins and the distinct therapeutic approaches proposed so far. In addition, recent studies in CCM patient cohorts suggest that genetic susceptibility factors related to differences in vascular sensitivity to oxidative stress and inflammation contribute to inter-individual differences in CCM disease susceptibility and severity.This review discusses recent progress into the understanding of the molecular basis and mechanisms of CCM disease pathogenesis, with specific emphasis on the potential contribution of altered cell responses to oxidative stress and inflammatory events occurring locally in the microvascular environment, and consequent implications for the development of novel, safe, and effective preventive and therapeutic strategies. LesionsDiagnosis is commonly made by magnetic resonance imaging (MRI) , althoug116860) that may arise sporadically or is inherited as an autosomal dominant condition with incomplete penetrance and variable expressivity (KRIT1 (CCM1), MGC4607 (CCM2) and PDCD10 (CCM3), which account for about 50%, 20% and 10% of the fCCM cases, respectively. The remaining 20% of cases have been attributed either to other so far undetected genetic alterations in the three known CCM genes or to mutations of a fourth as yet unidentified CCM gene  is found in descendants of Hispanic-Americans who settled in the southwestern United States and northern Mexico states  complex involving VE-cadherin, p120-catenin and β-catenin, and the discovery that loss of this protein promotes the weakening of VE-cadherin-mediated cell-cell adhesion and consequent dysfunction of the endothelial barrier, led to the original hypothesis that loss of blood-brain barrier (BBB) function contributes to the formation of CCM . Though More recently, it has been established that CCM proteins may also regulate integrin-based focal adhesions, which connect endothelial cells to the underlying extracellular matrix, and integrin-mediated signaling . SpecifiBesides the direct regulation of cadherin- and integrin-mediated cell adhesion, a recurring theme dominating the recent scientific literature is the causal link between loss-of-function of CCM proteins and hyperactivation of the small GTPase RhoA and its effector Rho kinase (ROCK). RhoA activation increases cellular contractility and destabilizes endothelial AJs, thereby reducing endothelial barrier function and increasing vascular permeability . Indeed,In addition, there is evidence that CCM proteins ensure the quiescence of endothelial cells and inhibit angiogenic responses by either activating the Delta-Notch signaling axis , inhibitTaken together, these results raise the intriguing possibility that CCM proteins orchestrate the signaling crosstalk between integrins and cadherins that coordinately regulates cell–matrix and cell-cell interactions and actin cytoskeleton dynamics involved in the control of vascular morphogenesis and homeostasis, thereby promoting the maintenance of vascular integrity and barrier function. Consistently, the small GTPase Rap1, a major KRIT1 molecular interactor , has beeLoss-of-function of CCM proteins has also been shown to trigger β-catenin and transforming growth factor beta/bone morphogenetic protein (TGFβ/BMP) signaling-driven endothelial-to-mesenchymal transition (EndMT) , as wellsee Sections below for details).In this intricate mechanistic scenario, a further level of complexity is added by the discovery that CCM proteins modulate distinct redox-sensitive signaling pathways and mechanisms, including pro-oxidant and antioxidant pathways and autophagy , and areIn sum, while the overwhelming majority of mechanistic studies have enhanced our understanding of the molecular mechanisms affected by loss-of-function mutations in CCM proteins with consequent implications for the development of distinct potential pharmacological approaches for CCM disease , the ful3Structural and functional alteration of brain capillaries, a pathologic hallmark of CCM disease, may reflect both physical and biochemical changes involving all components of the neurovascular unit (NVU) . This un2•−), hydrogen peroxide (H2O2) and organic hydroperoxides, and the ability of cellular antioxidant mechanisms to readily detoxify the reactive intermediates or repair the resulting damage (2•−) is the key determinant of the overall effects of ROS, being the precursor of all other major reactive oxygen species found in biological systems, including the powerful oxidants hydroxyl radical (•OH), hydrogen peroxide (H2O2), and peroxynitrite (OONO−) , such as superoxide anion (Og damage . In part (OONO−) . Within  (OONO−) . On the  (OONO−) . Thus, t (OONO−) .2 to O2•−. In addition, ROS are produced by the activity of NADPH oxidase, xanthine oxidase (XO), cytochrome p450 monooxygenase (CYP), uncoupled NO synthase (NOS), myeloperoxidase (MPO), lipoxygenase (LOX), and cyclooxygenase (COX) enzymes, which can be induced by a variety of endogenous and exogenous chemical and physical stimuli  exhibit an enhanced sensitivity to inflammatory stimuli  , fasudilRecent findings have also linked defective autophagy to enhanced endothelial cell sensitivity to oxidative stress, which suggests a pathogenetic mechanism that reconciles both the pleiotropic functions of CCM proteins and the distinct therapeutic approaches proposed so far . Indeed,Taken together, these considerations indicate that CCM proteins are new players in redox biology, and suggest that oxidative stress may contribute significantly to the development and progression of CCM disease by influencing molecular and cellular mechanisms underlying its major phenotypic hallmarks, including destabilization of endothelial cell-cell junctions, increased β1 integrin activation, increased vascular permeability, and enhanced angiogenic and inflammatory responses. In addition, oxidative stress is also a likely candidate to drive progression and severity of CCM disease. Indeed, several genes encoding proteins involved in ROS metabolism and vascular responses to oxidative stress are characterized by single nucleotide polymorphisms (SNPs) that confer substantial inter-individual variability in susceptibility to various oxidative stress-related pathologies, including vascular diseases . ConsistOverall, the evidence accumulated so far weighs heavily in favor of a unifying pathogenic mechanism whereby the loss-of-function of CCM proteins sensitize vascular cells to local oxidative stress events, and raises the possibility that inter-individual variability in susceptibility to oxidative stress may contribute to CCM disease pathogenesis.4The idea that susceptibility to microenvironmental elements and oxidative stress can be conferred to cells by loss-of-function mutations in CCM proteins suggests that these proteins may also play a role in limiting the endothelial response to inflammation. Indeed, as stabilizers of endothelial AJs, CCM proteins are optimally placed to regulate the vascular response to inflammation, as the stability of endothelial cell-cell contacts is a key component of vasogenic edema and leukocyte extravasation. Specifically, destabilization or increased turnover of endothelial cell-cell contacts increases the net flux of fluid across the endothelial barrier. This, in turn, carries with it small molecules and proteins that disrupt the osmotic balance between blood and tissue, causing further fluid flux across the vessel wall. At the tissue level, once the flux of fluid into the tissue exceeds the ability of the lymphatic vessels to compensate, fluid accumulates in the tissue, causing edema . KRIT1 hThe role of CCM proteins in the vascular response to inflammation has only recently been investigated, and is one of the only functions for CCM proteins described under non-pathological conditions. Existing data points to an anti-inflammatory role for CCM proteins, in which they function to suppress the activation of, or response to, pro-inflammatory signals. As an effector of Rap1, KRIT1 mediates the ability of this GTPase to stabilize endothelial cell-cell contacts, as has been shown in response to thrombin  and acut5The pathogenesis of CCM is thought to require genetic loss of both alleles of a single CCM protein, which leads to abnormal endothelial responses, including changes in cell adhesion, cytoskeletal rearrangement, transcriptional activity, and oxidative stress. This is supported by genetic animal models, in which loss of both alleles of KRIT1, CCM2, or CCM3 is required for the formation of CCM-like vascular lesions . HoweverFirst, partial loss of CCM proteins increases intracellular ROS levels and oxidative stress , which cin vivo for their effects on lesion development, none have been able to provide more than 50% relief of lesion burden, suggesting that each pathway is only partially responsible for the CCM phenotype. Notably, significant crosstalk between the inflammatory response and many of these pathways is already suggested by findings in other fields. Down-regulation of cell-cell contacts and activation of RhoA signaling and cytoskeleton contractility , and requires the remodeling of the endothelial cytoskeleton, cell-matrix adhesion, and cell-cell contacts . InflamIn vitro, studies using isolated endothelial cells have yielded somewhat contradictory findings. While some studies have shown that loss of KRIT1 or CCM2 inhibit the ability of human umbilical vein endothelial cells (HUVEC) to form tube-like structures  and E12.5 (PDCD10) . The sevructures , others ructures . Knockdoructures . PDCD10 ructures , furtherWhile these studies support the idea that CCM proteins are important regulators of angiogenesis, many of these studies failed to address the mechanism for CCM protein involvement in angiogenesis. Nonetheless, increased expression of several pro-angiogenic growth factors have been found in human CCM lesions, including VEGF, PDGF, and TGF-β , and incTaken together, this data strongly suggests that the CCM complex is a key regulator of angiogenesis as well as postulates a role for angiogenesis in the formation of CCM lesions. The formation of new lesions, may occur via a hijacking of the angiogenic process in which new vessel formation is subverted to form dilated cavernous vessels. The increase in expression of angiogenic growth factors in human CCM patients, and the correlation of VEGF expression with disease progression, certainly supports the idea that these mechanisms may be active during CCM formation. However, the work done to date has not defined exactly how this complex regulates the angiogenic process. More studies will be required to sort out the relative contributions of KRIT1, CCM2, and PDCD10 to the angiogenic process, and of neo-angiogenesis to the etiology of CCM.7Because of the diversity of molecules and molecular mechanisms that can be modulated by CCM proteins, it is not a surprise that these proteins influence almost all aspects of endothelial biology, including vascular development, maintenance of endothelial cell homeostasis, and barrier function . On the Consistent with this possibility, growing evidence demonstrates that indeed an intricate, reciprocal relationship exists between these processes, especially in human pathologies . SpecifiThe potential existence of a unifying mechanism that connects both the pleiotropic functions and the dysfunctional effects of CCM proteins has clearly emerged from recent discoveries in cellular and animal models and surgical CCM samples. In particular, the discovery that defective autophagy is a common feature of loss-of-function of the three known CCM genes and may underlie the major phenotypic hallmarks of CCM disease suggests a potential unifying pathogenic mechanism that reconciles both the broad spectrum of signaling abnormalities and consequent pathologic effects linked to CCM protein dysfunctions, and the distinct therapeutic approaches proposed so far . Indeed,In this light, it is also possible to provide an alternative interpretation for recent findings suggesting that CCM arise from endothelial gain of MEKK3-KLF2/4 signaling . Indeed,Future studies are required to pave the way along the novel and intricate research avenues traced out by the potential interconnections among recent findings, including the emerging evidence that a fine-tuned crosstalk between redox signaling and autophagy plays a pivotal role in modulating both the pleiotropic functions of CCM proteins and the interplay between oxidative stress, inflammation and angiogenesis in CCM disease pathogenesis. Nonetheless, the novel therapeutic perspectives that recent scientific discoveries are opening up justify the commitment to address these difficult but exciting new research challenges.8The scientific advances and breakthroughs into the physiopathological functions of CCM proteins outlined in this review bring into view a new mechanistic landscape in which defective autophagy and altered redox signaling emerge as the major molecular mechanisms that underlie the pleiotropic effects of CCM protein dysfunctions, whereas oxidative stress and inflammation loom large as the key pathogenic determinants of CCM disease onset and progression. Consistently, emerging evidence suggests that autophagy, oxidative stress and inflammation are inextricably linked, and play major roles in the onset and progression of other vascular diseases . FurtherIn view of this new mechanistic scenario, it is also possible to speculate that the loss-of-function of CCM genes may affect mainly low-blood-flow capillary beds due to their enhanced susceptibility to oxidative stress events. Consistently, it is now well understood that endothelial cells display remarkable heterogeneity in structure and function , and resFinally, the mechanistic landscape outlined in this review brings to the forefront distinct therapeutic perspectives, barely dreamt a decade ago, which now seem legitimately attainable. However, given that most of the emerging potential therapeutic compounds influence redox-sensitive mechanisms, both their low and high concentration thresholds for physiological vs. pathological effects should be carefully considered. Indeed, the existence of a physiological role of specific ROS concentrations can explain some of the negative results from clinical trials in which large doses of exogenously administered antioxidants or hyperactivation of antioxidant pathways with electrophilic therapeutics failed to improve outcomes of vascular diseases or resulted even deleterious .In conclusion, this review highlighted current evidence for a major involvement of oxidative stress and inflammation in CCM disease, arguing that the interplay between these potential determinants should be considered and examined using an integrative systemic approach in order to better understand the complexity of the underlying molecular mechanisms. Such an approach may provide novel valuable insights into CCM pathogenesis, facilitating the development of novel targeted, safe and effective therapeutic strategies to counteract disease progression and clinical severity, including drug combination and personalized medicine strategies.


Despite abundant evidence that socio-economic status (SES) is a fundamental determinant of health, there is a dearth of research examining association between SES, measured at the individual and community levels, and cardiovascular risk factors and morbidity among indigenous populations.To examine the influence of individual-level and community-level SES on systolic and diastolic blood pressure among Greenlandic Inuit.Multilevel analysis of cross-sectional data from the Inuit Health in Transition – Greenland Survey, to which 3,108 Greenlandic Inuit aged 18 years and older participated. Blood pressure is measured using an automatic device, according to standardized protocol. Individual SES is measured by education. Community socio-economic conditions are measured using combined information on average disposable household income and settlement type.Education was not significantly associated with blood pressure. There was an inverse U-shape association between community socio-economic conditions and blood pressure with significantly lower SBP and DBP among participants living in remote traditional villages characterized by lower average disposable household income and in affluent more urbanized towns. Sex-stratified analyses demonstrate the salience of community conditions for men.The association observed between blood pressure and community-level socio-economic conditions suggests that public health and social policies, programmes and interventions aiming to improve living conditions might improve cardiovascular health in Greenland. Studies are required to further examine social gradients in cardiovascular risk factors and morbidity among indigenous populations using different measures of SES. Despite abundant evidence that socio-economic status (SES) is a fundamental determinant of health, there is a dearth of research examining association between SES, measured at the individual and community levels and cardiovascular risk factors and morbidity  among indigenous populations ,2. A recHigher education, income, employment and housing statuses, often used as individual measures of SES, are often shown to be associated with better health outcomes in non-indigenous populations. In indigenous populations, studies examining socio-economic inequalities in health outcomes have reported mixed results. Shepherd et al. discussed the possibility of different associations between “traditional” SES indicators and health outcomes among indigenous populations because of persistent issues of exclusion, marginalization and discrimination leading to less pronounced social gradient in health . Other fIn Greenland, higher degrees of social transition  was associated with increased prevalence of clinical and biochemical risk factors for cardiovascular diseases (CVD) . Among ITo better understand the SES–health relationship in indigenous context, Shepherd et al. pointed to the importance of multilevel studies to document SES simultaneously across different levels, that is, individual, household and community. This is in accordance with indigenous worldviews, which recognize the intertwining of peoples’ health to that of their family and environment . FramewoAmong non-indigenous and mostly urban populations, several systematic literature reviews have documented associations between community socio-economic deprivation, built environment features, and urban–rural location and CVD ,16 and rSocial (between people) and geographic (between communities/regions) inequalities in cardiovascular risk factors and morbidity highlight the heterogeneity in living conditions experienced by indigenous populations worldwide. Still, relatively little is known about the multilevel and joint influence of individual-level and community-level SES on cardiovascular health and risk factors . For pubThought to be traditionally protected from CVD because of particular genetic endowment, high dietary intake of marine mammals and fish, and vigorous physical activity , Inuit pGreenland was under Danish colonial system between 1721 and 1953. It attained Home Rule in 1979 and has a self-governing status since 2009. Urbanization started in the early 20th century and increased rapidly since the 1950s. In 1951, 68% of the population lived in villages with less than 500 inhabitants; by 2010, this proportion decreased to 15%. Today, the total population of Greenland is about 56,400 of whom 90% are Greenlanders (Inuit) living in one of 80 communities located on a narrow coastal strip ,32. TherInuit Health in Transition – Greenland Survey. A full description of the study methods is available elsewhere  and diastolic blood pressure (DBP) were measured on the right arm of the sitting participant after at least 5 min of initial rest, using an automatic measuring device (Kivex UA-779) with appropriate cuff size. SBP and DBP were read to the nearest mm Hg three times, with at least 1-min interval between measurements. The last two measurements were averaged for the analyses.Individual SES was measured using information on education. Participants reported their highest level of schooling, which was grouped in three categories: high school or less, vocational training after high school and higher education .www.stat.gl/default.asp?Lang=en). The 22 communities were categorized in tertiles of equivalized average disposable household income . Communities were further categorized by settlement type, where towns, including larger and smaller towns, were contrasted to villages. As settlement type and community socio-economic conditions are strongly correlated , we created a composite measure categorizing towns and villages by their socio-economic conditions. Communities are thus categorized in one of four types: town with average SES , town with high SES, village with low SES or village with average or high SES. There were no towns within lower tertiles of average disposable income.Community socio-economic conditions were measured using information on average disposable household income for 2008 “equivalized” to account for the total number of person per household (2008 was selected as it is the mid-point in the survey data collection). This information was retrieved from Statistics Greenland and appended to the survey file based on community identifier , fluency in speaking Danish  , treatmeData were analysed using multilevel linear models. This type of analysis allows partitioning the variation in outcome variables, here SBP and DBP measured at the individual level, into two (or more) sources: variation attributable to differences between individuals and variation attributable to differences between communities. In doing so, multilevel models account for the clustering of similar individuals within communities (non-independence of observations within groups) and allow for the assessment of the relative contribution of both individual-level and community-level characteristics to health variation . For thiDescriptive statistics of the study sample appear in 2=26.96; p<0.001) and 5.2% of total variation in DBP  were attributed to differences between communities (results not tabulated). To illustrate this variation, There was a significant variation in participants’ blood pressure between communities in Greenland, as indicated by results of the unadjusted multilevel models. About 2.2% of the total variation in SBP  are presented in There was a direct and statistically significant association between community socio-economic conditions and blood pressure model 2; . CompareIn sex-stratified analysis , there wWhile social determinants are recognized as key factors leading to health  in the scientific literature and public policy, less attention has been given to individual-level and community-level SES among indigenous populations. This article contributes to the multilevel study of the social determinants of indigenous peoples’ health. Findings show that blood pressure significantly varied between communities in Greenland. Although small, the extent of geographic variation was similar to that observed in multilevel studies conducted among non-indigenous (and mostly urban) populations . It undeAmong participants to the Greenland survey, education was not significantly associated with blood pressure. This absence of association could be due to low variability in the distribution of education, with an overrepresentation in less favourable categories. In this study, 60% of participants had a high school education or less. As indicated by Shepherd et al.'s review of SES and health studies among indigenous populations in Australia, observing social gradient in health is often contingent upon the SES measure used and the health outcome observed. Different measures of SES, such as personal income or occupational status, should be examined for their association with blood pressure and with cardiovascular risk factors and morbidity more generally.As observed in studies conducted among non-indigenous populations –17, therMeasures of community conditions used in this study were limited by available data. More work is needed to better characterize the social, economic and built environment conditions of indigenous communities to understand the relevance of community context for cardiovascular health and risk factors, but also for other health outcomes. Observing association between health outcomes and community-level socio-economic conditions, but not with individual SES, perhaps reflects the role the community plays in nurturing health and wellness among indigenous populations, beyond individual idiosyncrasies.Although the cross-sectional design prevents analysing processes of causation, findings nonetheless contribute novel evidence about the social determinants of CVD among indigenous populations. More research is needed to understand how socio-environmental determinants “get under the skin” to influence health ,14. DaniThere was a tendency for SES measured at the individual and community levels to be more strongly associated with blood pressure among men than in women. This possibly indicates differential gender effects, with men's blood pressure being more influenced by the conditions of their surrounding environment, expressed by lower blood pressure in more traditional or more urban, and affluent, communities. It is possible that women may have other health responses to being exposed to adverse socio-economic conditions. Future studies should examine gender-based health inequalities in relation to SES.Findings of this study show that blood pressure varies significantly between communities in Greenland and are consistent with studies among general populations where higher community-level SES is associated with better health. However, our findings also indicate the protective role of remote and more traditional settlements in relation to this risk factor for CVD in Greenland. As such living in communities at both end of the “spectrum” of settlement type and socio-economic conditions, that is, in remote traditional villages and affluent and more urbanized towns, seems to be associated with healthier blood pressure among Greenlanders.In this large representative sample of Greenlanders, the unadjusted prevalence of hypertension is high (38%), suggesting that it is an important population health challenge in relation to CVD in this country. Ecological interventions targeting community conditions that shape the distribution cardiovascular risks and diseases are required to yield population-wide health benefits. Results of this study suggest that public health and social policies, programmes and interventions aiming to improve living conditions might improve cardiovascular health in Greenland. These interventions could be first directed to communities “in the middle” of social and cultural transition, where the population appears to be more at-risk for high blood pressure. These interventions should be developed alongside individual level health promotions efforts to encourage the pursuit of traditional lifestyles.


A number of natural and chemical compounds that exert anti-oxidative properties are demonstrated to be beneficial for brain and cognitive function, and some are reported to reduce the risk of dementia. However, the detailed mechanisms by which those anti-oxidative compounds show positive effects on cognition and dementia are still unclear. An emerging body of evidence suggests that the integrity of the cerebrovascular blood-brain barrier (BBB) is centrally involved in the onset and progression of cognitive impairment and dementia. While recent studies revealed that some anti-oxidative agents appear to be protective against the disruption of BBB integrity and structure, few studies considered the neuroprotective effects of antioxidants in the context of cerebrovascular integrity. Therefore, in this review, we examine the mechanistic insights of antioxidants as a pleiotropic agent for cognitive impairment and dementia through a cerebrovascular axis by primarily focusing on the current available data from physiological studies. Conclusively, there is a compelling body of evidence that suggest antioxidants may prevent cognitive decline and dementia by protecting the integrity and function of BBB and, indeed, further studies are needed to directly examine these effects in addition to underlying molecular mechanisms. As a consequence of rapidly aging populations, particularly in developed nations, dementia has become a major health and medical issue imposing an extraordinary economic burden. As reported by the World Health Organization and Alzheimer’s disease International, the global cost of dementia-related healthcare was estimated to be $604 billion in 2010, which was equal to 1% of world gross domestic product, indicating a significant socioeconomic impact [2 [Major subtypes of dementia are Alzheimer’s disease (AD), vascular dementia, Lewy body dementia, and frontotemporal dementia, which accounts for approximately 43%, 15%, 5% and 1% of all dementia cases, respectively [In recent clinical and animal model studies, agents with anti-oxidative properties are reported to exert therapeutic effects on cognitive impairment and dementia ,7,8. HowThe brain is a vital organ, yet extremely vulnerable to various endogenous and exogenous insults such as viral and bacterial pathogens, inflammatory cells, pro-inflammatory cytokines, reactive oxygen species (ROS), and macronutrients . TherefoA dysfunctional BBB may occur via (i) impaired transcellular transport, mainly due to dysregulation of endothelial receptors and intracellular transporters; (ii) impaired paracellular unspecific extravasation of molecules due to a loss of tight junction complex; and/or (iii) loss of endothelial cells per se due to apoptosis or traumatic injury. Persistent disturbances of BBB allow substantial cerebral extravasation of blood-borne potentially neurotoxic molecules, which thereby promote the synthesis and release of pro-inflammatory cytokines resulting in the activation of microglial phagocytes and production of ROS . ChronicDespite decades of attempts in Alzheimer’s research, anti-amyloid strategies have failed to consistently deliver positive results in the prevention and treatment of AD ,15. In fEmerging evidence substantiates the involvement of cerebrovascular dysfunction in the pathogenesis of AD and other dementias. In vivo and in vitro studies demonstrated that the transport of β-amyloid across the BBB is mediated by receptor for advanced glycation endproducts ,19. ThusThere has been rigorous debate on whether the breakdown of BBB is a primary causative factor of neurodegeneration and dementia or whether it occurs as a downstream response . An incrOxidative stress is a state that arises from an inappropriate redox balance where the production of ROS exceeds the conversion/neutralization of ROS into less toxic derivatives by antioxidants such as glutathione and superoxide dismutase (SOD). ROS may be generated by several pathways, such as conversion of oxygen into superoxide by enzymatic activities of oxidase or altered metal homeostasis  and ensuing metal catalyzed free radical production through classic Fenton chemical pathways. Superoxide is frequently converted into hydrogen peroxide, the most bioactive and stable form of ROS, however, superoxide may also react with nitric oxide generating additional free radicals. In addition, hydrogen peroxides can also be generated directly by some enzymes such as NADPH oxidase. Therefore, oxidative stress can occur by an overproduction of ROS by enzymes including NADPH oxidase, and/or from lowered antioxidant levels or activity including SOD. Studies report that elevated oxidative stress may have direct and indirect effects on the integrity of BBB .An involvement of oxidative stress in the regulatory mechanisms of BBB integrity is supported by a number of studies ,30,31,32Overall, the current literature implicates the substantial involvement of oxidative stress in BBB dysfunction , and henStudies report that oxidative stress is positively associated with impaired cognitive function ,40. ConsA number of studies report that diet and nutrients have a strong association to the risk of dementia including AD ,42. VitaIt has been suggested that anti-oxidative vitamins may prevent cognitive decline also by protecting BBB integrity. However, only a few studies have directly investigated the effects of anti-oxidative vitamins on dementia through cerebrovascular axis. A study by Kook et al. recently reported that high dose supplementation of Vitamin C reduced amyloidosis in the cortex and hippocampus of AD mice (5XFAD) via attenuation of BBB disruption and mitochondrial alteration . VitaminAlthough the underlying mechanisms by which anti-oxidative vitamins protect BBB integrity are largely unknown, these studies collectively suggest that these vitamins may ameliorate neurodegenerative changes and cognitive decline by preserving the function and structure of BBB. More direct experimental and clinical evidence would provide further strength to such hypotheses.Melatonin is a neurohormone found in animals, plants and bacteria, reported to exhibit strong anti-oxidative properties through protecting the mitochondrial membrane potential and thereby suppressing the production of superoxides ,92. Melaα-Lipoic acid (ALA) is known to chelate transition metals and ROS, thus inhibiting hydroxyl radical formation. A clinical trial involving 43 AD patients over an observation period of 2 years demonstrated that subjects receiving ALA showed constant scores in two neuropsychological tests, while the untreated subjects showed significant decline in cognitive function . ConsistAnother emerging potentially neuroprotective antioxidant is garlic. An extract of garlic contains a mixture of biologically active compounds such as S-allylcysteine (SAC) and S-allylmercaptocysteine, which are known to exert strong anti-oxidative effects. These compounds have repeatedly been shown to provide antioxidant action by scavenging ROS, enhancing SOD, catalase glutathione peroxidase, and increasing glutathione. A number of studies demonstrated the neuroprotective effects of garlic . AlthougThere are other natural antioxidants that are recently reported to exhibit potent BBB protective effects. These include apocynin ,67,68, bMany clinical drugs for treatment of cardiovascular disease exert antioxidant effects. Statins, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, are reported to show anti-oxidative properties by inhibiting the increase of 8-isoprostane and suppressing the activity of nitric oxide synthase ,114. Whi1-40, probucol prevented hippocampal lipid peroxidation and attenuated loss of hippocampal-dependent learning and memory [Probucol is a conventional cholesterol-lowering drug that possesses potent anti-oxidative properties, which attribute to attenuation of ROS by inhibiting the expression of Nox2 , and by d memory . Similard memory . Consistd memory ,88. Thesd memory .Fenofibrate is another lipid-lowering drug reported to lower cholesterol and triglycerides and increase HDL-cholesterol . BesidesThese studies suggest that the lipid-lowering pharmacological agents with anti-oxidative properties exert positive effects on neurodegeneration and cognitive deficits, at least in part, through protective mechanisms via the BBB. Further studies to identify more detailed molecular and cellular mechanisms to strengthen this evidence are required.There are several other pharmacological agents with anti-oxidative properties exerting vascular protective effects, and some are demonstrated to be beneficial for BBB. Ibuprofen is a widely utilized nonsteroidal anti-inflammatory drug (NSAID) reported to non-selectively attenuate the activity of cyclooxygenase and is reported to exert substantial oxidative effects . A numbePrevious studies suggest that natural and chemical compounds with anti-oxidative properties have beneficial effects on neuroprotection and cognitive performance, although the underlying mechanisms are largely unknown. As summarized in the current review, clinical evidence suggests the therapeutic effects of antioxidants on dementia and cognitive impairment and findings from animal and in vitro studies support this evidence. Furthermore, a substantial body of evidence from animal and in vitro studies suggests that such neuroprotective effects of antioxidants may be entirely or partially attributed to the BBB protective effects of antioxidants. However, the number of studies directly considering the therapeutic effects of antioxidants on cognitive impairment through the axis of cerebrovascular BBB integrity remain limited. Further investigations should focus on simultaneously testing the neuroprotective effects as well as the BBB protective effects of antioxidants. Furthermore, the elucidation of such mechanisms may lead to the development and search for new agents to specifically target the protection of BBB, conferring neuroprotection.


Social interaction is stressful and subordinate individuals are often subjected to chronic stress, which greatly affects both their behavior and physiology. In teleost fish the social position of an individual may have long-term effects, such as effects on migration, age of sexual maturation or even sex. The brain serotonergic system plays a key role in coordinating autonomic, behavioral and neuroendocrine stress responses. Social subordination results in a chronic activation of the brain serotonergic system an effect, which seems to be central in the subordinate phenotype. However, behavioral effects of short-term acute activation of the serotonergic system are less obvious. As in other vertebrates, divergent stress coping styles, often referred to as proactive and reactive, has been described in teleosts. As demonstrated by selective breeding, stress coping styles appear to be partly heritable. However, teleost fish are characterized by plasticity, stress coping style being affected by social experience. Again, the brain serotonergic system appears to play an important role. Studies comparing brain gene expression of fish of different social rank and/or displaying divergent stress coping styles have identified several novel factors that seem important for controlling aggressive behavior and stress coping, e.g., histamine and hypocretin/orexin. These may also interact with brain monoaminergic systems, including serotonin. The development of a dominance based social hierarchy is common among vertebrates, including teleost fish  serves multiple functions in the vertebrate brain , different paralogs of 5-HT specific genes are expressed in these different 5-HT populations. One example is the divergent expression of tryptophan hydroxylase (TPH) paralogs. This is the rate-limiting enzyme in 5-HT biosynthesis. The isoform TPH2, which has a Km for its substrate, L-tryptophan (Trp) that is close to the in vivo concentrations of Trp , slc6a4a (serta), and slc6a4b (sertb), again with divergent expression  is becoming an increasingly popular model also for studies on effects of agonistic interaction on behavior, stress responses, and brain monoamines . However, some of these 5-HT related effects are mediated in concert with other neuromodulators. Especially, two neuropeptides are of interest based on their involvement in the stress axis, namely arginine vasotocin  and corticotropin-releasing factor (CRF). Both are involved in the hypothalamic-pituitary-interrenal axis    did not affect brainstem 5-HT neither in isolation nor under social interactions within 1 h  in male bluehead wrasse (Oncorhynchus tshawytscha)          and high (HR) responding strains , there was a difference in hindbrain serotonergic activity with late emerging salmons having a higher serotonergic activity  with a larger black (melanin-based) stripe area defended their territory more vigorously  with darker manes are more aggressive  are darker although cortisol was not tested , social signaling and stress have recently been investigated in Arctic charr  major players responsible for shaping the behavioral profile of individual fish according to its social experience. However, behavioral effects of social interaction are complex, including effects on aggression, boldness, arousal etc. Thus, multifactorial control mechanisms are to be expected. Moreover, effects of social interaction may vary between individuals depending on genotype, context and previous experience , also known as spiegel danio, is bolder and show elevated aggressive behavior as compared to wild type fish  is important for our understanding of how divergent life history trajectories are controlled. It is also highly relevant for welfare and applied research on aquaculture. Effects of social interaction in zebrafish also provide a useful and relevant model for biomedical studies on drug addiction and affective disorders in humans.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Whole exome and gene panel sequencing are increasingly used for oncological diagnostics. To investigate the accuracy of SCNA detection algorithms on simulated and clinical tumor samples, the precision and sensitivity of four SCNA callers were measured using 50 simulated whole exome and 50 simulated targeted gene panel datasets, and using 119 TCGA tumor samples for which SNP array data were available.On synthetic exome and panel data, VarScan2 mostly called false positives, whereas Control-FREEC was precise  at the cost of low sensitivity (<40% detected). ONCOCNV was slightly less precise on gene panel data, with similarly low sensitivity. This could be explained by low sensitivity for amplifications and high precision for deletions. Surprisingly, these results were not strongly affected by moderate tumor impurities; only contaminations with more than 60% non-cancerous cells resulted in strongly declining precision and sensitivity. On the 119 clinical samples, both Control-FREEC and CNVkit called 71.8% and 94%, respectively, of the SCNAs found by the SNP arrays, but with a considerable amount of false positives (precision 29% and 4.9%).Whole exome and targeted gene panel methods by design limit the precision of SCNA callers, making them prone to false positives. SCNA calls cannot easily be integrated in clinical pipelines that use data from targeted capture-based sequencing. If used at all, they need to be cross-validated using orthogonal methods.Scripts are provided as supplementary information.Bioinformatics online. Although copy number variation only represents about one tenth of a percent of an individual patient’s genetic variation, it affects more base pairs than single nucleotide polymorphisms or short indels . Copy nuIn clinical laboratories, well-studied, recurrent SCNAs are traditionally identified using immunohistochemistry or fluorescence in situ hybridization, which are highly sensitive and specific to the queried biomarker .Despite its theoretical and practical appeal, the detection of SCNAs from massively parallel sequencing methods is far from straightforward. Ideally, SCNAs are determined from whole genome sequences with uniform coverage across all positions, yet currently such comprehensive sequencing remains beyond the means of most clinics and patients. Whole exome and targeted panel approaches offer higher coverage at a much reduced cost, but suffer from several drawbacks caused by (i) non-homogeneous coverage, (ii) unequal distribution of targeted sites across the genome, (iii) the inability to find CNV breakpoints falling outside covered regions, and, particularly for panel data, (iv) sometimes extreme GC bias  find all copy number variants in all of the sequenced genomic segments (sensitivity), (ii) reliably detect breakpoints and (iii) avoid falsely calling sequencing errors, spurious fluctuations in coverage, or other systematic biases (precision). These challenges have spurred a rich body of research that has produced a wide variety of CNV tools, only a few of which were specifically designed to deal with the vagaries of tumor genetics  and targeted gene panel (panel) data. First, we use simulated datasets with known mutations (gold standard), which allows comprehensive analysis of both false positive and false negative rates. Here, we specifically test the influence of low frequency variants that can be the consequence of tumor admixture, impurity, or clonality (heterogeneity). Second, to gain more realistic insights into clinical data, we also evaluate the performance of the methods on 119 whole exome endometrial cancer datasets for which SNP array data were available as a gold standard.The construction of realistic tumor samples consisted of several steps, each of which is explained in more detail in the next paragraphs. First, to mimic realistic human genomes, a diploid normal (control) and five tumor genome reference sequences were generated by implanting germline SNPs and somatic SNVs, germline and somatic indels and germline CNVs and tumor SCNAs. Second, to simulate the heterogeneity of tumor samples, the five tumor clones were mixed at random proportions. Finally, to simulate admixture of tumor samples with normal (control) samples, each subclone mixture was further mixed with reads sampled from the control samples. This entire process was repeated five times.In step one, a control genome was created by implanting 3 894 338 germline SNPs and indels  into thein silico probe capture by hybridization. In addition, it reproduces known biases resulting from GC-content and fragment length variation, and platform-specific errors. Read simulations were conducted once for a whole-exome approach using the Agilent SureSelect Human All Exon kit v5 probes, and once for a targeted gene panel, using the Molecular Health Cancer Gene Panel containing 619 genes  proportions of 0.27, 0.29, 0.36, 0.06 and 0.02.In the third and last step, this clonal mixture was used to create ten admixed tumors, by adding 0% to 90% of reads from the control sample. The entire process, starting from the construction of the genome sequences, was repeated five times, such that in total we obtained 50 admixed tumor-control sample pairs with a total of 5800 SCNAs.www.novocraft.com), and realigned around indels using GATK IndelRealigner 2.2  project . SamplesBecause our focus was on the evaluation of SCNA callers in the context of cancer, we only included callers that were designed to call SCNAs from tumors, and that could deal with targeted (exome and gene panel) capture data. We included CNVkit . Parameter optimization was not performed for CNVkit, as the approach of this tool relies on off-target reads which were not present in the simulated data. Parameters included base and mapping quality thresholds, choice of segmentation algorithm, and several tool-specific modulations. In ONCOCNV, we also tested the option to use three non-matched controls, which greatly increases precision by adding more non-cancer samples (that do not need to be from the same patient). These three non-matched controls were randomly chosen from the control samples not used to simulate that sample. A complete overview of the parameters tested for each tool is provided in For the synthetic data, SCNAs obtained from the caller were compared with the known ‘gold standard’ variants that were implanted into the datasets. For TCGA cases, the output of the bioinformatic tools was compared with the variants determined by the SNP array, which for our purposes can be considered the ‘gold standard’.Using sparsely and unequally distributed targeted genome regions to call copy number variants creates several technical difficulties. For example, it can lead to oversegmentation due to experimentally inherent coverage inhomogeneity, and can cause larger CNVs encompassing several target regions to be missed or falsely considered separate by the caller. Moreover, the highly variable size of SCNAs, which can range up to a full chromosome arm, renders simple interval comparisons difficult and inaccurate. Given these complexities, all comparisons between predicted and gold standard SCNAs were done using three metrics: nucleotide-based, gene-based and interval-based agreement. For the gene panel analysis, the latter was only done for genes covered in the target panel. In the manuscript we will concentrate on the nucleotide-based approach, which avoids setting an arbitrary threshold on the fraction of overlap, and also accounts for complex cases where several smaller predicted SCNAs are contained within a larger gold standard SCNA. In our experience, nucleotide-based and gene-based approaches yield similar values for sensitivity and precision, while an interval-based approach with an 80% overlap criterion leads to strongly decreased sensitivity and precision estimates.Using the definitions listed in First, we investigated the reliability of SCNA calling algorithms for whole exome and targeted gene panel data across a range of known tumor admixture levels. Simulated data offer the advantage that the exact size, position and copy number of each SCNA is known; therefore true positives, false positives and false negatives can be directly determined. Nevertheless, whether a given copy number variant is indeed identical to the one that is known to be present in the data can be determined in different ways (see methods). The interval-based estimates led to significantly decreased precision estimates across all simulated datasets, whereas the nucleotide-based and gene-based approaches yielded higher, more similar estimates of precision. For clarity and simplicity we therefore further concentrate on the nucleotide-based approach—the other measures lead to the same conclusions see .On the 50 exome datasets we tested VarScan2, Control-FREEC and CNVkit, and on the 50 gene panel datasets we additionally evaluated ONCOCNV, which was developed specifically for deep-targeted amplicon sequencing data. Because our simulated data did not contain off-target reads (outside of the capture regions), CNVkit was hampered in its performance, as it uniquely exploits such off-target reads to establish a genome-wide coverage baseline. For that reason CNVkit could not be fairly appraised using our synthetic data; the results are nevertheless included in Across all of our experiments, VarScan2 showed surprisingly poor performance. Compared to Control-FREEC or ONCOCNV it called far more SCNAs, but most of these were false positives. Moreover, VarScan2 found almost none of the known SCNAs . In contTo further explain the low sensitivities of Control-FREEC and ONCOCNV, we investigated sensitivity with regard to the allele fractions at which the variants occurred in the tumors. As shown in The precision and sensitivity of ONCOCNV (on panel data) and Control-FREEC (on gene panel and exome data) were relatively robust up to 60% contamination with normal cells, but both measures dropped off steeply at higher admixtures , presumaNext we analyzed deletions and amplifications separately . Both onFig. 3C, D;Finally, we compared the length distribution of detected SCNAs across the different methods . The 50 Taken together, these analyses show that both Control-FREEC and ONCOCNV are conservative methods with good sensitivity and precision for deletions, but limited sensitivity to low-frequency amplifications. This applied to both exome and panel data. Nevertheless, Control-FREEC and ONCOCNV generated few false positives on the simulated data, although this could be the result of the relative ‘cleanliness’ of simulated data (simulation cannot capture the full complexity of heterogeneous tumors).To evaluate the performance of SCNA detection algorithms on realistic clinical data, we obtained exome sequencing data of 119 endometrial cancer samples from TCGA. For these samples, SNP array data were also available as an independent proxy for ‘true’ SCNAs. The TCGA samples used in this study exhibit a wide range of SCNA numbers, and it has been established previously that the presence of SCNAs in endometrial tumors correlates with progression-free survival: most endometrioid tumors have few SCNAs, whereas serous and serous-like tumors have many . On averOur analyses showed that Control-FREEC reached median precision of 29% and median sensitivity of 71.8% across the 119 clinical samples, although these values varied greatly depending on the patient Fig. 5A;. In contContrary to the simulation results, in half of the samples Control-FREEC detected at least 60% of the amplifications, although with many false positives (20% median precision). However, it identified few deletions  control samples were pooled, which enables better GC and library size normalization (et al. found around 30% Jaccard concordance between Control-FREEC calls and SNP arrays on four breast cancer samples (A different, even worse, picture emerged when we analyzed the 119 clinical endometrial carcinoma exome samples. Control-FREEC produced many more false positive amplifications and deletions on real than on simulated data, but found only 30% of deletions and only about 60% of amplifications determined by SNP arrays. CNVkit tended to correctly identify more gold standard amplifications and deletions than Control-FREEC, but at the cost of close to zero precision. Control-FREEC was biased to mostly medium-sized amplifications, while CNVkit preferentially produced medium-sized and large deletions. These data suggest that all of the tested algorithms called too many spurious SCNAs. This confirms an earlier study on 50 kidney chromophobe tumor exomes (The discrepancy between our simulated data and the TCGA cases can be explained by several factors. First, clinical datasets feature the full biological complexities of the tumor environment and potential sample preparation and processing biases, which cannot be captured by simulations. The much-reduced precision in the TCGA data may thus be partially explained by confounding complexity, or by the presence of artifacts such as sequencing errors or differential coverage at GC-rich regions. Second, Control-FREEC had much lower sensitivity for amplifications in the simulated exome data than in the tumor samples, presumably because the real data also contained more high-copy number amplifications, which are easier to detect than duplications. On the other hand, detection of deletions was easier in the simulated than in the real data. Deletions, as an absence of signal, are expected to be easier to find. It is therefore puzzling that the precision of the tools on deletions in the TCGA data was low. Possibly this effect was negligible compared to the alltogether high number of false positives. Third, the use of SNP arrays as gold standard also introduces important limitations compared to the absolute ground truth in the simulated data. A comprehensive comparison of array-based CNV calling methods found less than 50% concordance among algorithms, and less than 70% reproducibility among replicates when the same raw data was processed multiple times with the same array platform and CNV calling algorithm (Because with simulated data we were able to rely on an absolute gold standard, we investigated how low allele fractions of SCNAs affect the sensitivity and precision of the SCNA discovery algorithms. Low allele fractions are common in clinical tumor samples, for two related reasons. First, they are caused by the presence of non-cancerous cells such as stromal cells, immune cells and blood cells present in the tumor , or can Whole exome and targeted gene panel sequencing are increasingly finding their way into clinical practice. Their focus on a smaller and presumably more cancer-relevant part of the genome at higher coverage offers a compelling alternative to whole genome sequencing, at a much reduced price. Although these methods are primarily used in precision medicine to detect single nucleotide variants and small indels, they offer the opportunity to simultaneously call somatic copy number aberrations. This is an attractive option considering that the presence of SCNAs such as ROS or MET amplifications offers clear therapeutic options. However, our analysis of SCNA callers using 50 simulated datasets and 119 endometrial tumors clearly shows that considerable caution is needed with targeted sequencing approaches. On such data, SCNA methods are error-prone: they both missed a considerable portion of SCNAs known to be present in our test datasets, and called a large number of false positives, especially in the TCGA data. Therefore copy number aberrations called from WES or targeted gene panel sequences should be considered hypotheses that require cautious interpretation and cross-validation with more reliable methods such as FISH, PCR, or SNP arrays. In cases where SCNA discovery is explicitly desired, researchers are recommended to contemplate appropriately powerful experimental alternatives.Supplementary DataClick here for additional data file.


Herbal medicines or remedies are applied to treat renal disorders and most of them have been proved to be useful. The medical management of nephrolithiasis is either costly or not without side effects. However, there is a common belief that using medicinal plants is safer than synthetic drugs, even though medicinal plants and other natural compounds may also result in adverse effects and the safety of these remedies under question. Urinary diseases have affected humankind since ancient time and can persist, with serious medical consequences, throughout the world. Additionally, the incidence of renal disorders especially kidney stones have been enhanced in western countries in the last decades, in relation with economic development. It seems that acute and chronic renal failure and lithiasis (stone formation) occurred due to both nephrolithiasis (stone formation in kidney) and urolithiasis (stone formation in ureter or bladder even both places). Nowadays, alongside synthetic drugs, herbal medicines play a prominent role in treatment and prevention of various diseases. A number of herbal medicines and remedies have been reported for its significant nephroprotective activity, which is probably due to the presence of flavonoids and other effective secondary metabolites in those medicinal plants. Furthermore, literature reveals that the extracts from the leaves and aerial parts of some plants exhibit good potentials to improve kidney damages. Actually among different kidney disorders, there are two main urologic indications for application of herbal drugs as follows -3:Inflammatory urinary tract diseases including renal gravel and more severe types of lithiasis, in which herbal remedies mainly of kidney & bladder teas have been used. As a matter of fact, urinary tract inflammation can be treated mainly by medicinal teas that possess a diuretic activity because of the consumption of the water that is ingested by drinking the teas. Actually, in patients with urinary tract infections or stone-related (and other) inflammatory irritations of the urinary tract, increasing the output of a hypo-osmolar urine is observed to be an effective way to clear ascending bacteria, crystallization nuclei, and other inflammatory agents .Benign Prostatic Hyperplasia (BPH), for which there are three pathogenic hypothesis as below:A. Increase in the prostatic synthesis of dihydrotestosterone (DHT) & estrogen:androgen ratioB. Elevation in the binding capacity of sex hormone-binding globulin (SHBG)C. Elevation in the levels of inflammatory mediators (prostaglandins & leukotrienes).However, in BPH, saw palmetto berries, nettle root and pumpkin seeds are widely employed .Arctostaphylos uva-ursi (Ericaceae) with chemical composition of arbutin (5-12%), hydroquinone and tannins (10-20%) is well known for treatment of bacterial inflammatory diseases with three gram of the dried herb, or 400-800 mg of hydroquinone derivatives, four times daily (Ammi visnaga (Apiaceae) has been traditionally used to relieve the pain of renal colic and spastic urinary tract disorders  is a native plant in USA and consists of lipophilic composition like saturated and unsaturated fatty acids, which has been administered in micturition difficulties associated with stage I-II in BPH with 1-2 g of the crude drug or 320 g dried herb, as daily dosage  is another famous herbal drug, with composition of phytosterols, triterpenic acids, lignans, polysaccharides and simple phenol compounds, employed in micturition difficulties associated with stage I-II of prostatic adenoma. Its mechanism of action is defined by interacting (competitive displacement) with SHBG and multiple inhibitory effects on inflammatory mediators (acid polysaccharide fraction). The daily dosage of this plant is 4-6 g of crude drug, although some adverse effects such as gastrointestinal disturbances have been reported (Cucurbita pepo (Cucurbitaceae) with chemical composition of fatty acids , phytosterols, tocopherols and carotenoid is a useful plant in urinary tract diseases. Micturition difficulties associated with stage I-II of prostatic adenoma can be one of its indications with daily dose of 10 g of ground seeds , phytosterols (from Hypoxis rooperi), and pygeum (Prunus africana) are also mentioned in literature for their effectiveness in renal diseases. Some other plants as corrective herbs are used in kidney teas formulations including fennel seed, licorice root, calendula flowers and peppermint leaves  have been completely observed by the authors.None.


Purpose of review The purpose of this review is to assess the evidence behind treatment regimens for cerebellar ataxias occurring in the context of systemic disease. We will address systemic conditions which are associated with specific involvement of the cerebellum (rather than widespread nervous system involvement) and those conditions for which some degree of evidence of treatment response exists.Recent findings We have divided systemic disorders affecting the cerebellum into systemic immunological disorders, endocrine and metabolic disorders and paraneoplastic. Recent studies have increased understanding of the range of cerebellar disorders associated with a systemic immunological condition. The identification of newer pathogenic antibodies has improved diagnosis in conditions which would have previously been labelled as idiopathic. However, their rarity and phenotypic variability makes defining optimal immunomodulatory treatment regimens challenging. There is some evidence for beneficial effects of immunomodulation, particularly in anti-GAD ataxia and Hashimoto’s encephalopathy, although, at this time, specific treatment regimens cannot be defined. Immune-mediated paraneoplastic cerebellar disorders show response to therapy dependent, to some extent, on the underlying pathogenic antibody. Much is still to be understood concerning treatment regimens for the ataxic manifestations of metabolic disorders, notably alcohol-induced cerebellar injury, which are common and which are associated with significant disability.Summary Despite their rarity, cerebellar ataxias occurring in the context of systemic disease cause significant morbidity and better therapies are required to improve outcomes associated with these conditions. Dysfunction of the cerebellum can occur either as a result of localised injury or in the context of a number of systemic diseases. Systemic disorders often affect the central nervous system diffusely, but, in a number of situations, may specifically cause cerebellar dysfunction. Within this review, cerebellar ataxia in the context of systemic diseases will be considered. Broadly, systemic disorders affecting the cerebellum may be divided into systemic immunological disorders, endocrine and metabolic disorders and paraneoplastic. While some of the conditions discussed have no specific treatment, there are emerging studies suggesting specific conditions may respond to particular treatments.Non-paraneoplastic autoimmune cerebellar ataxia was first defined some 20 years ago with the identification of antibodies, in both serum and CSF, directed against the enzyme glutamic acid decarboxylase (GAD) . Since tWith the expectation that most patients with anti-GAD cerebellar ataxia will accumulate significant disability , conside. These patients, however, had an existing diagnosis of gluten ataxia suggesting therefore an overlapping spectrum of cerebellar autoimmunity. This neurological syndrome is infrequently the presenting clinical feature of coeliac disease, antibodies to gliadin and/or transglutaminase are accordingly detectable in between 10 and 50% of sporadic ataxia patients, depending on the background population [Anti-GAD antibodies have also been detected in 40% of a well-defined cerebellar ataxia cohort curated in Sheffield, UK . These ppulation . Coeliacpulation  and othepulation .While randomised trial data concerning treatment of gluten ataxia is lacking, the broader necessity for systemic control of coeliac disease applies equally to this subgroup . Strict 1) deficiency is well-recognised; however, it remains unclear to what extent chronic alcohol-induced cerebellar damage is caused by the effects of thiamine deficiency or directly attributable to the toxic effects of alcohol on the brain [Chronic excessive alcohol ingestion is a common cause of cerebellar degeneration. Clinically, patients present with ataxia predominantly affecting legs and gait, and typically occurs in association with features of malnutrition. Some patients may present acutely with Wernicke encephalopathy (WE), which has the added features of delirium, cognitive impairment and oculomotor deficits. The association of WE and thiamine  is a neurological condition associated with elevated anti-thyroid antibodies (anti-thyroglobulin or anti-thyroid peroxidase (TPO)), often occurring in euthyroid individuals . Since aParaneoplastic syndromes within the central nervous system (CNS) refer to non-metastatic involvement of the brain and/or spinal cord, most likely occurring as a result of an immune reaction to cancer cells generating antibodies which cross-react with CNS antigens . They ocFifty to 60% of patients with paraneoplastic cerebellar degeneration (PCD) have identifiable antibodies in serum and/or CSF, of which anti-Yo  is the commonest, representing approximately 50% of antibody-positive PCD . PCD typIn general, PCD responds poorly to treatment. The rarity of the condition, coupled to the multiple antibodies that may cause the phenotype, has meant that randomised controlled trials of PCD therapies are lacking. In addition, the rather rapid disease onset followed by plateau renders determination of treatment efficacy challenging.Treatment or removal of the underlying tumour, if possible, is important, although even if successful, often, the symptoms of PCD do not improve and the majority of patients with PCD will remain severely disabled , 54. ProStudies have assessed the utility of additional immunotherapy in PCD. The outcomes are generally disappointing although some small case series have reported benefit (class IV evidence). Immunotherapies such as corticosteroids, IVIg and PEx have been most studied. PEx has been reported to cause improvement in some cases, although the majority of reported cases do not appear to improve . SimilarNewer therapies including tacrolimus and rituximab have been studied in case reports or small case series in PCD. Rituximab has been reported to induce partial remission in individual cases –69. TacrThere is some evidence concerning treatment regimens for cerebellar ataxias occurring in the context of systemic disease. Cerebellar ataxia occurring in the context of a systemic immunological disorder is often amenable to a range of immunomodulatory therapies, although the rarity of these disorders and the phenotypic variability makes defining optimal treatment regimens challenging. The commoner ataxic manifestations of metabolic disorders, notably alcohol-induced cerebellar injury, have been the subject of several studies, although there is a paucity of evidence concerning optimal treatments for chronic alcoholic cerebellar degeneration. Despite their rarity, cerebellar ataxias occurring in the context of systemic disease cause significant morbidity and better therapies are required to improve outcomes associated with these conditions.


Here, we review current data elucidating the role of red blood cell derived microparticles (RMPs) in normal vascular physiology and disease progression. Microparticles (MPs) are submicron-size, membrane-encapsulated vesicles derived from various parent cell types. MPs are produced in response to numerous stimuli that promote a sequence of cytoskeletal and membrane phospholipid changes and resulting MP genesis. MPs were originally considered as potential biomarkers for multiple disease processes and more recently are recognized to have pleiotropic biological effects, most notably in: promotion of coagulation, production and handling of reactive oxygen species, immune modulation, angiogenesis, and in initiating apoptosis. RMPs, specifically, form normally during RBC maturation in response to injury during circulation, and are copiously produced during processing and storage for transfusion. Notably, several factors during RBC storage are known to trigger RMP production, including: increased intracellular calcium, increased potassium leakage, and energy failure with ATP depletion. Of note, RMP composition differs markedly from that of intact RBCs and the nature/composition of RMP components are affected by the specific circumstances of RMP genesis. Described RMP bioactivities include: promotion of coagulation, immune modulation, and promotion of endothelial adhesion as well as influence upon vasoregulation via influence upon nitric oxide (NO) bioavailability. Of particular relevance, RMPs scavenge NO more avidly than do intact RBCs; this physiology has been proposed to contribute to the impaired oxygen delivery homeostasis that may be observed following transfusion. In summary, RMPs are submicron particles released from RBCs, with demonstrated vasoactive properties that appear to disturb oxygen delivery homeostasis. The clinical impact of RMPs in normal and patho-physiology and in transfusion recipients is an area of continued investigation. Genesis of small membrane-encapsulated vesicles  from activated and/or apoptotic cells was first reported ~40 years ago  MPs act as circulating modules for complex signaling, activating receptors on target cells by presenting organized clusters of membrane-associated bioactive molecules . MP levels, in particular: for platelet-, leukocyte-, and endothelium-related MPs, are known to increase in the setting of vascular injury, pro-thrombotic and pro-inflammatory states that complicate a broad array of health conditions, such as diabetes    appears to regulate circulating MP availability for target-cell fusion; however, less is known about this process than about MP formation   the changes RBCs undergo during storage. These include:Little is known about the specific signaling that regulates RBC vesiculation, both during RBC aging Increased cytosolic calcium (Ca2+) is the most well-characterized trigger for activation of Ca2+ dependent proteases, leading to cytoskeletal damage and activation of Ca2+ dependent scramblase; both processes are result in PS exposure and MP shedding  responsible for maintaining cell membrane asymmetry; loss of asymmetry promotes MP budding and shedding  leakage has also been linked to disturbed erythrocytic membrane transporter activity, disturbing maintenance of membrane structure and leading to MP formation  pathway, the Jak-STAT  pathway and the Raf-MEK (mitogen-activated protein kinase)-ERK  pathway    is a vasodilator effector component of physiologic reflexes that subserve dynamic matching between regional blood flow and tissue respiration  is a recognized, but poorly characterized, complication of transfusion. Given the known increase in RMP generation with storage duration, a role for RMPs in TRIM pathobiology (which appears linked to RBC unit age) has been postulated  as means to prevent premature RBC clearance, by shedding membrane proteins that would otherwise signal RBC senescence  is characteristic and is associated with a significant acidosis, decrease in 2,3-diphosphoglycerate and failure of the membrane Na2 delivery is a function of blood O2 content and regional blood flow, with the latter being the principle determinant. As such, the volume and distribution of regional blood flow is actively regulated to maintain dynamic coupling between O2 delivery and tissue respiration   transduce regional pO2 gradients into NO bioactivity, thereby effecting vasodilation to resolve perfusion insufficiency   preferential streaming in the cell free zone of the microcirculation and (2) acting as an NO sink. Specifically, animal studies demonstrate greater increase in mean arterial pressure (MAP) upon infusion of cell-free supernatants of longer stored RBC units (39 days) vs. fresher units (4 days) , a novel non-invasive means to monitor hypoxic vasodilation (Creteur et al., Our goals are to further elucidate the impact of RMPs on vasoregulation in critically ill subjects. We are currently examining the AS: performed experiments and analyzed data and drafted the manuscript. SR: performed experiments and analyzed data. AD: supervised experiments and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Globally, anthropogenic environmental change is exacerbating the already vulnerable conditions of many people and ecosystems. In order to obtain food, water, raw materials and shelter, rural people modify forests and other ecosystems, affecting the supply of ecosystem services that contribute to livelihoods and well-being. Despite widespread awareness of the nature and extent of multiple impacts of land-use changes, there remains limited understanding of how these impacts affect trade-offs among ecosystem services and their beneficiaries across spatial scales. We assessed how rural communities in two forested landscapes in Indonesia have changed land uses over the last 20 years to adapt their livelihoods that were at risk from multiple hazards. We estimated the impact of these adaptation strategies on the supply of ecosystem services by comparing different benefits provided to people from these land uses , using forest inventories, remote sensing, and interviews. Local people converted forests to rubber plantations, reforested less productive croplands, protected forests on hillsides, and planted trees in gardens. Our results show that land-use decisions were propagated at the landscape scale due to reinforcing loops, whereby local actors perceived that such decisions contributed positively to livelihoods by reducing risks and generating co-benefits. When land-use changes become sufficiently widespread, they affect the supply of multiple ecosystem services, with impacts beyond the local scale. Thus, adaptation implemented at the local-scale may not address development and climate adaptation challenges at regional or national scale . A better understanding of the context and impacts of local ecosystem-based adaptation is fundamental to the scaling up of land management policies and practices designed to reduce risks and improve well-being for people at different scales. Many societies around the world are facing major environmental challenges that are increasingly complex, uncertain, and interconnected . Global Nature provides benefits to people from ecosystem services, including the mitigation of impacts of natural hazards and strengthening social capacity to respond to environmental change ,3. ProviEcosystems can help people achieve multiple development objectives simultaneously, including adaptation to climate change and other hazards, but the contribution ecosystems can make depends on how lands are managed and benefits are shared . Land usDespite the importance of trade-offs and off-site effects in relation to making ecosystem service assessments useful and operational ,21, therIn order to understand how land-use changes affect interactions within social-ecological systems, we used a modification of the ecosystem services cascade of Haines-Young and Potschin . This frThe framework highlights how land-use decisions by local actors can spread through reinforcing loops via the ecosystem service flow , we identified the drivers of change that impacted peoples’ lives and the responses to these changes since 1994. Among the adaptation strategies reported by communities, we selected those that led to changes in land uses applied by most people over a large part of the landscape. Rural communities and their leaders who participated in this study agreed by oral consent. The field work was permitted by the pertinent Indonesia authorities and approved by CIFOR Ethics Review Committee.We assessed the impact of land-use changes on multiple benefits provided by ecosystems in order to understand the effects on adaptation and well-being of people at different scales. Ecosystem services can support peoples’ adaptations by reducing impacts of climate hazards or other risks and strengthening capacities to respond ,5. In paWe used four indicators to assess selected ecosystem services and their evolution with land-use changes : values In focus group discussions, we identified why and how local people have adjusted land uses to respond to drivers of change since 1994. To guide discussions, we used rural appraisal techniques of participatory mapping, historical timelines, seasonal calendars, and problem-trees exercises ,39. For To assess clean water, due to lack of historical hydrological data, we asked 40 local adults per village to score their satisfaction with current and past availability of clean water, i.e. quality and quantity for domestic and agricultural purposes. They scored water conditions on a 5-point scale (from very unsatisfied to very satisfied), for the current situation, 10 years ago, and 20 years ago . Scores were drawn on a graph and the trends discussed with the interviewees. Their explanations helped us check the reasons for changes in water conditions . People assessed the water benefits at landscape scale rather than between land uses. However, land-use changes were widespread, so we assumed they influenced perceived trends in clean water availability.To estimate the value of harvested products from each land use, we asked key informants about harvesting frequencies, quantities, and local market prices. Crop yields per hectare per year were taken from official provincial statistics . For for2, we measured tree diameters (>2 cm) at breast height (DBH at around 1.3 m height), estimated their height, and identified species with the help of parataxonomists and databases of previous studies in the region [Carbon stocks in aboveground biomass and tree species richness were assessed using field inventories and their mean values were used for each land-use type. We inventoried 81 plots selected using stratified random sampling based on the land-use types previously identified by remote sensing and participatory mapping . Sample e region .Carbon stocks were calculated using the improved allometric equation for tropical trees . Dry wooAt all four study sites, livelihoods were mostly based on land-use activities. In West Kalimantan (L1-2), most people interviewed harvested rubber (90%), practiced traditional gold mining (50%), and cultivated rice for subsistence (30%). They cited extreme fluctuations in rainfall, leading to floods or drought among the drivers of change that had the most severe impact on livelihoods in the last 20 years . These hA range of adaptations to maintain livelihoods were evident in the study population. In West Kalimantan, interviewees repaired flood-damaged houses, fields and fishponds or relocated them, harvested forest products such as fruit, birds, and deer, or borrowed money. In Central Java, they bought water and food, worked off-farm, temporarily migrated to cities for jobs, sold livestock or plantation timber, and changed diets . In both provinces, farmers changed crop varieties, reduced harvest times, and used fertilizers and pesticides. Other technical adaptations included building irrigation channels and wells, pumping or transporting water, stabilizing slopes with terracing  or protecting vegetation .Local people reduced livelihood risks through land-use changes , L1-4. Iavoid that our next generations experience difficulties in finding natural and forest resources and face intense floods and hot weather”.Another change was the introduction of a new village rule to preserve forests in 2011 , L2, whiLembaga Ekolabel Indonesia (LEI 2004 village certification book). According to the head of the certified forests group in L3: “at the beginning we planted trees to complement income from crops, but later on we also realized the positive impact on water springs”.In Central Java, a new land use involved planting trees on private lands near settlements which helped diversify farmers’ livelihoods and income opportunities , L3. In Another widespread land-use change in Central Java was the abandonment of less productive croplands of rice, soya, and peanut . Although some rice fields are close to the river and cultivated up to three times per year, most are on rain-fed terraced slopes. Farmers reported that these less productive croplands were cultivated with rice only if enough rain was expected and were otherwise planted with other crops or left fallow. However, due to rainfall variability, harvest failures were frequent. Farmers reforested some less productive fields by allowing natural regeneration to occur or planting teak and mahogany , L4. ThiShorea spp., Syzygium spp., and Turpinia spp.) (Havea braziliensis) were mixed with fruit trees, such as mango or durian, which led to an average of around 3 species in this land use. In Central Java, croplands and gardens had low tree species richness (0–3). Gardens, mostly planted with cassava, maize, and medicinal herbs, were sometimes mixed with coconut, banana, and bamboo trees. The tree species richness was higher (up to 5) in forest gardens and mostly included teak (Tectona grandis) or mahogany (Swietenia macrophylla). The same species were used to reforest less productive croplands in addition to some natural regeneration with shrubs and other trees such as Acacia spp. and Pterocarpus spp.Logged-over or protected forests in West Kalimantan hosted similar tree species richness (mostly ia spp.) . A few rEusideroxylon zwageri); however, it was becoming increasingly rare according to the forest users in the focus group discussions (L1-2). People extracted timber for an estimated value of 180 USD/ha/y and collected NTFPs worth 30 USD/ha/y . The main timber species harvested for building or trade was the Bornean ironwood . During the first planting season, farmers explained that they preferred to cultivate the rain-fed fields with red rice (an early-maturing drought-resistant variety). When the least productive croplands were abandoned and trees planted, the harvested product value fell to 40 USD/ha/y. Food (vegetables and cassava) and medicinal plants in gardens were worth 80 USD/ha/y, and when mixed in with agroforestry in forest gardens, reached 110 USD/ha/y.shifting cultivations and gold mining activities are decreasing the soil fertility and water quality” (L1) or “in the future the water might get better because of the new regulations that prevent the mining” (L2). In Central Java, interviewees mentioned that “water conditions are improving because the community forest grows very well” (L3) and that “there are many reforestation activities that if they continue will help us to have more secure sources of fresh water” (L4).The perception by local people of clean water availability evolved differently in the two regions over the last 20 years . In WestCarbon stocks in aboveground biomass were highest in the semi-natural protected forests (198 t C/ha) and in old logged-over forests (130 t C/ha) in West Kalimantan . In rubbSelected land-use changes increased most ecosystem services, but some trade-offs occurred . In WestOver the last 20 years, local people in the study sites have changed land uses by adjusting their management of trees to reduce risks to livelihood linked to natural resource scarcity, low agricultural productivity, and climate hazards. Similar to the Indonesia cases, other rural communities in tropical landscapes have started local initiatives to manage forested areas to improve ecosystem services and adaptation benefits. For example, farmers in Southeast Asia adapted land uses by mixing plantations of rubber, coffee, or cacao with crops in agroforestry systems ,47. FarmChanges in land uses to increase local benefits from ecosystems have consequences for other services that span spatial scales. In the Indonesia case studies, local people modified forest and agroecosystems to change supply of products, diversify livelihoods and reduce risks, but these changes impacted regulating services that benefit people in other areas. Land-use decisions that increased provisioning services for local benefits, like in the case of conversion of forests to rubber plantation, led to trade-offs with regulating services that were then reduced, providing fewer benefits at larger scales. Conversely, restoration of regulating services for water by reforesting cropland or protecting forest patches led to a decrease in local benefits from provisioning services). Similar trade-offs or synergies between provisioning and regulating services have been reported ,15, as wLocal strategies for adaptation based on land-use changes result in co-benefits and trade-offs at the global scale. Three of four land-use strategies (L2–4) increased local and regional benefits (more products and cleaner water), but also global benefits for climate mitigation (more carbon stocks). Such strategies met the converging interests of local and global stakeholders for solutions to climate change. However, local strategies can also result in trade-offs for carbon sequestration, as for conversion of forests to rubber plantations (L1), where interests of local people to strengthen livelihoods diverged from the global priority to reduce carbon emissions. Understanding the impact of local adaptation strategies on ecosystem services that can have benefits at the global scale, can help implement successful actions for climate change that account for different stakeholders’ interests. International policy initiatives on climate change mitigation  that consider local ecosystem benefits are more likely to be legitimate and long-lasting –54. At tWhen local actors perceive that strategies based on small-scale land use changes are successful, they can expand strategies and spread change at landscape scale. As our analysis showed, a single-farmer initiative or a rule made by a village chief may be followed by others. The ecosystem services framework helps highlight how perceived increases in certain benefits from ecosystems can be reinforced through land management decisions. Attempting large-scale change without preliminary small-scale change is difficult and risky . HoweverPerception by local actors that land-use changes improve livelihoods and reduce risks creates a reinforcing loop that increases the spread of such changes: supply of more ecosystem services leads to broader adoption of change in land-use . SeveralThe introduction of new land uses by local actors to improve livelihoods and reduce risks is facilitated by the states of or changes in social or ecological systems, which create “windows of opportunity” ,63. As sLand-use changes that lead to improved livelihoods may not spread automatically because reinforcing loops that can promote certain ecosystem services depend on human actions and contextual factors. Dominant rules and power relations, values, and knowledge can hinder or facilitate people’s adaptation decisions and actions –70. ThesLocal adaptation strategies can introduce novel ways of managing ecosystems that then spread at the landscape scale through reinforcing loops in the ecosystem services flow and have impact beyond the local scale. Such responses have been described as transformative adaptations ,74,75, aTransformative adaptations are generally collective strategies, undertaken at large scale or intensity, novel to the prevailing social-ecological system, and that cause major system changes . In addiSuccessful bottom-up land-based strategies offer the prospect of promising pathways for development that can be replicated and scaled up. Landscapes can provide multiple ecosystem services that support the livelihood needs of those managing them and provide co-benefits for people located more distantly. Whoever controls access to the land usually derives benefits from provisioning services, but people further away also benefit from regulating services via off-sites effects. Certain land-use practices are already suited to, and embedded in, local contexts, thereby increasing the chances of sustainability and success. As shown in the case studies, people may have local initiatives in place to protect or increase tree cover in the landscape.Land-based approaches that build on local initiative with inclusive benefits and minimized trade-offs can contribute to achieving several development objectives simultaneously while having greater impact. This is particularly relevant with the increase in international initiatives on climate change, biodiversity and sustainable development such as the UN Sustainable Development Goals and the UNFCCC Paris Agreement. The design of Reduction of Emissions from Deforestation and Forest Degradation (REDD+) initiatives that consider multiple effects of adjustments in land-use strategies could leverage on local co-benefits for adaptation to help spread and scale-up new forest management practices.In this paper, we illustrated four cases of major land-use changes adopted by local people in response to multiple risks in two rural regions of Indonesia. Local people converted, protected, or planted trees in their landscapes to diversify local livelihoods and maintain land productivity under changing conditions such as climate variation and natural resource scarcity. Changes in land use mostly affected provisioning services of forests and agricultural ecosystems and produced local benefits, but also affected biodiversity and the regulating services of water quality and quantity and carbon sequestration, which have impacts beyond the local scale.Our assessment of the impact of local land-use changes on products, water, climate, and biodiversity revealed some multiple benefits, but also trade-offs and off-site effects that were not initially considered by the people who initiated the changes; an important consideration in operationalizing ecosystem assessments. Not all land-use changes simultaneously meet multiple development and climate objectives, because actors at different scales may have diverging interests. Widespread changes in land uses entail shifts in peoples’ priorities, practices, and rules related to ecosystems and their benefits. New perceptions and strategies developed by local communities can arise from learning and experiential knowledge of the effects of change. Positive feedback loops from land-use changes with local benefits, combined with enabling contextual factors, can spread new land uses to different people and places . In this way, some land-use changes can radically modify large areas in novel ways that alter current dominant feedback loops and affect different spatial scales. Changes in social–ecological systems with such characteristics have been associated with transformative adaptations.Ecosystem services assessments that consider feedback loops and multiple impacts on different ecosystem services and beneficiaries can help environmental managers and policy makers design and implement more locally appropriate and sustainable land-use decisions. The complexities and uncertainties of the impact of drivers of global change might require radical changes. However, such changes imply shifts in current values related to social-ecological systems can be challenging because of dominant views, traditions, and the interests of powerful stakeholders. Therefore, building on currently emerging local adaptation pathways that demonstrate multiple benefits across scales can help strengthen and scale up responses to climate change and other sources of vulnerability.S1 TableTop 3 and other unranked drivers of change in each study site identified by local communities (L1-4).(XLSX)Click here for additional data file.S2 TableSummary of statistical information on the sample plots and list of species per land use in each study site (L1-4).(XLSX)Click here for additional data file.S3 TableInformation on land products harvest quantities, frequency, and incomes per land use in each study site (L1-4).(XLSX)Click here for additional data file.S4 TableSummary of statistical information on people’s satisfaction with water conditions and qualitative explanations of trends in the last 20 years in each study site (L1-4).(XLSX)Click here for additional data file.S5 TableSummary of statistical information on carbon estimations of above ground biomass per land use in each study site (L1-4).(XLSX)Click here for additional data file.