It is the only species cultivated for turf among the eight species in Eremochloa. The center of origin for this species is southern to central China. Although centipedegrass is an excellent lawn grass and is most widely used in the southeastern United States, China has the largest reserve of centipedegrass germplasm in the world. Presently, the gene bank in China holds ~200 centipedegrass accessions collected from geographical regions that are diverse in terms of climate and elevation. This collection appears to have broad variability with regard to morphological and physiological characteristics. To efficiently develop new centipedegrass varieties and improve cultivated species by fully utilizing this variability, multiple approaches have been implemented in recent years to detect the extent of variation and to unravel the patterns of genetic diversity among centipedegrass collections. In this review, we briefly summarize research progress in investigating the diversity of centipedegrass using morphological, physiological, cytological, and molecular biological approaches, and present the current status of genomic studies in centipedegrass. Perspectives on future research on genetics and genomics and modern breeding of centipedegrass are also discussed.Genetic diversity is the heritable variation within and among populations, and in the context of this paper describes the heritable variation among the germplasm resources of centipedegrass. Centipedegrass is an important warm-season perennial C Eremochloa ophiuroides (Munro) Hack.] is a perennial warm-season (C4) grass that originated in China3. It is indigenous to Southeast Asia and is now widespread, with its distribution, including China (in the Yangtze River Basin and its southern area), Southeast Asia, the eastern and southern United States4, some parts of South America, the West Indies, and even parts of Africa5 and tropical northern and eastern Australia6. It has highly developed stolons during growth in the field and can form a dense canopy that provides continuous ground cover  provides an opportunity for plant breeders to develop new and improved cultivars with desirable characteristicsHere, we present overviews of the results of major studies on the genetic variation in centipedegrass and of the recent progress made in describing centipedegrass diversity, mainly in the United States and China. The information summarized in the present article is of potential value not only for understanding the drivers of genetic variation in centipedegrass, but also for promoting the breeding and improvement of centipedegrass varieties using modern genetic and genomic tools.Eremochloa in the family Poaceae or Gramineae, subfamily Panicoideae, tribe Andropogoneae, and subtribe Rottboelliinae18. It is the only species in the Eremochloa genus that is used as turfgrass12. Centipedegrass is a C4 plant, similar to maize and sorghum20.Centipedegrass belongs to the genus n = 2x = 1824 and a genome size of ~800 Mb25. Cytological observations of this species revealed that metaphase I of meiosis was mostly regular, with nine bivalents, but 1 to 15% of the microsporocytes had eight bivalents and two univalents due to a precociously dividing bivalent2. Centipedegrass is a sexually reproducing species with high-pollen stainability and normal sexual development involving megasporogenesis and an embryo sac, but it is self-incompatible9. An artificially induced tetraploid accession of centipedegrass can be generated by colchicine treatment, with an induction rate of 0.2%26. As polyploidization often results in the induction of chromosomal aberrations at the mitotic and/or meiotic level, such ploidy changes through artificial factors contribute to creating new centipedegrass germplasms, which are of high value in terms of sampling for cultivar improvement. However, cytogenetic information for natural accessions, as well as artificial lines of centipedegrass is currently limited. In addition, the above-mentioned findings were based on only a portion of centipedegrass samples, and such a small sample size might lead to an underestimation of the genetic diversity in this species. Therefore, it is necessary to use current cytogenetic approaches to carry out ploidy identification and karyotype analysis of more centipedegrass germplasms derived from different provenances or multiple breeding sources.Centipedegrass is a diploid species with a somatic chromosome number of 224. Currently, the Institute of Botany, Jiangsu Province and Chinese Academy of Sciences, which is one of the most important turf research institutes in China, has the only Engineering Research Center for Germplasm Innovation and Utilization of Warm-season Turfgrasses in the National Forestry and Grassland Administration (NFGA) and has the largest National Main Warm-season Turfgrass Gene Bank (NMWTGB) in China. The NMWTGB preserves centipedegrass genetic resources collected from different geographical regions in China and plant materials imported from the United States. To the best of our knowledge, the NMWTGB maintains the richest centipedegrass resources in the world, with ~192 accessions, including 11 cultivars initially registered and conserved ex situ 31, seed yield32, and phenological phases, which mainly include the regreening stage, booting stage, blossom stage, maturity stage, wilting stage, and green period34. The narrower genetic base of centipedegrass collections in the United States than in China is likely because most of the centipedegrass accessions in the United States originated from a single collection introduced from China9. In addition, variations in some morphological characteristics related to lawn appearance, such as leaf length, plant height, and internode length and diameter, were also detected in centipedegrass hybrid generations36  and DNA markers Table , respect22. For centipedegrass collections or populations in China, several studies were also carried out on the variation in isozymes. Ren et al.39 tested peroxidase isozymes and esterase isozymes in five native centipedegrass samples from different areas of Sichuan and found that all five samples showed variations in the two enzymes. Bai et al.40 clustered 15 centipedegrass accessions collected from six geographical regions in China into two categories and four groups based on peroxidase isozyme analysis. By comparing peroxidase isozymes, esterase, and malate dehydrogenase isozymes among six populations of centipedegrass derived from geographical regions of mainland China, Xuan, and Liu41 evaluated the genetic diversity in centipedegrass populations and drew the conclusion that the genetic diversity of centipedegrass in China was more abundant within populations than among populations. Liu and Liu42 also revealed abundant genetic diversity in 16 centipedegrass accessions sampled from East China by electrophoretic analysis of peroxidase and esterase isozymes. However, the genetic diversity in centipedegrass revealed by these isozyme markers still needs to be further verified by more accurate DNA markers. In fact, portions of these research findings have already been validated or corrected in subsequent studies using DNA markers.Isozymes were among the most widely used markers for genetic variation analysis within and between populations before DNA markers were applied. Although they have now been largely superseded by more informative DNA-based markers, they were an excellent choice for projects that sought only to identify low levels of genetic variation. Early studies on isozymes showed different isoenzyme patterns of esterase and peroxidase among 12 U.S. centipedegrass accessions43. Similarly, genetic variations among accessions and populations of centipedegrass that were collected from different geographical regions in China were also analyzed in subsequent studies using AFLP44, RAPD45, ISSR46, SRAP48, and SSR markers49. The Nei’s genetic distances between nine centipedegrass collections derived from different geographic regions in China ranged from 0.135 to 0.994 for AFLP markers44, indicating broad genetic variation among these accessions. Significant variation was also detected in six centipedegrass populations consisting of 50 accessions by RAPD analysis45 and among 60 centipedegrass collections from 13 different geographical regions by ISSR analysis46, with a much higher level of genetic variation within populations than among populations. However, it is worth mentioning that a higher level of diversity in U.S. cultivars than in Chinese collections was revealed using SRAP and SSR markers; meanwhile, a lack of overlap in the ranges of diversity between the U.S. and most Chinese groups were found, and genetic diversity did not differ quantitatively between the U.S. and Chinese materials but did differ qualitatively11. Recently, Li et al.49 developed a large number of SSR markers based on the next-generation sequencing (NGS) approach and detected considerable genetic diversity among centipedegrass accessions by systematically analyzing the genetic variation among accessions in one core collection of 43 centipedegrass accessions. All the accessions were clustered into six groups according to genetic variation, while the genetic relationship among the 43 accessions did not correspond exactly to their geographical locations, which suggested that centipedegrass experienced outward expansion from its origin site, leading to a complex genetic background and evolutionary history. These analyses depicted a high level of polymorphism within cultivars and a dramatic difference in diversity between/among centipedegrass populations.Molecular markers are short sections of DNA that differ among genotypes, and they are widely used for the identification of germplasm, assessment of genetic variation within and among populations, and determination of genetic relationships between various populations. The genetic relationships among five centipedegrass accessions (or cultivars) in the United States were assessed based on DNA amplification fingerprinting (DAF), and the relatively low levels of polymorphism among them suggested that these accessions are closely related and may share a common origin1 progenies of a cross between two centipedegrass ecotypes (E102 and E092-1). The maps consisted of a female linkage map with 89 loci (85 SRAPs and 4 EST-SSRs) and a male linkage map with 71 assigned SRAP loci50. The same research group subsequently produced another set of genetic maps using the same molecular markers from a population of 87 F1 plants derived from crossing two different ecotypes (E142 and E022) and detected a total of 14 QTLs on the nine linkage groups of the maps; the QTLs were associated with seed yield, vegetative traits and cold tolerance, and could explain 8.71–23.61% of the phenotypic variation51. With the rapid development of high-throughput sequencing technology, additional specific molecular markers for centipedegrass can be rapidly developed at low cost. Therefore, constructing high-density genetic maps in centipedegrass will be an important goal for future research and has the potential to identify the genes responsible for traits of interest.Owing to the high level of heterozygosity of centipedegrass plants, research progress on genetic map construction and quantitative trait locus (QTL) mapping of major economic traits in centipedegrass has been slow. The first genetic linkage maps of centipedegrass were constructed using SRAP and SSR markers and were based on 89 F52. For the cold-tolerant variety “TifBlair”, a normalized transcriptome library was prepared and sequenced from leaves of seedlings, resulting in a transcriptome with 45,575 unigenes and 84,781 contigs52. A second normalized library was constructed from various centipedegrass tissues, including leaf, stolon, and spike tissues, resulting in more gene clusters49. Furthermore, a comparative RNA-seq study revealed 329 putative gene products differentially expressed between red-purple and green stolons and 829 differentially expressed genes between red-purple and yellow-green spikes49. Owing to various environmental adversities during lawn growth, future research endeavors should be devoted to the transcriptomic analysis of centipedegrass in response to cold and drought stresses and of its tolerance to barren and acidic soils, among other environmental stressors.To date, the transcriptomes from one cultivar and two accessions of centipedegrass have been sequenced53 and perennial ryegrass54 via NGS techniques.With the rapid development and wide applications of NGS technologies, genomic research on several grass species has recently moved from small-scale analysis of genetic polymorphisms toward whole-genome sequencing and genome-wide polymorphism surveys. The availability of genomic sequences for a turfgrass species will greatly increase the number of genome-scale investigations of fundamental mechanisms of resistance to biotic and abiotic stresses. However, to date, there have been no reports on centipedegrass whole-genome sequencing or related genome-sequencing projects, while a few such studies have been performed in zoysia60 to studies of physiological traits related to turf quality66. However, systematic studies on genetic variability in drought tolerance among centipedegrass genotypes have rarely been performed, which severely restricts the breeding of drought-tolerant centipedegrass varieties. Nevertheless, there have been a few successful attempts to produce drought-resistant mutants by radiation-induced mutation in centipedegrass seeds69 and by culture-induced variation in somatic embryogenesis70. These mutant plants showed greater tolerance to drought stress and thus could be potential germplasm resources for breeding drought-tolerant centipedegrass. Hence, it will be important to understand genetic variability in drought tolerance within the centipedegrass gene pool in the future.Drought stress often occurs during the process of lawn growth and management, and it results in a decline in the quality and productivity of turfgrasses. Studies investigating the effect of moisture deficits on the performance of centipedegrass plants ranged from studies of variability in key morphological characters and responses72. Generally, however, centipedegrass is a salinity-sensitive species, in contrast to other warm-season turfgrasses77.Salinity is a detrimental abiotic stressor for turfgrass plant growth in salt-affected soils. Some artificially bred cultivars of centipedegrass show intraspecific variations in morphological characteristics and turf quality related to salinity tolerance; for example, there is a difference in salt tolerance between “TifBlair”  and “Common” . Studies on physiological responses to salt stress have revealed significant differences between salt-tolerant and salt-sensitive cultivars/accessions80. A preliminary genetic analysis of aluminum tolerance revealed that aluminum tolerance in centipedegrass is not controlled by a single major gene81. Root exudation of citric acid is one of the key mechanisms for Al tolerance in centipedegrass82.Aluminum (Al) toxicity is a major limiting factor for plants growing in acidic soils. Wild centipedegrass is mainly distributed in acidic soils in tropical and subtropical regions, so investigating and documenting the effect of such soil conditions on centipedegrass production and productivity is worthwhile. It has been widely assumed that centipedegrass is well adapted to acidic soils and has excellent Al resistance. A high degree of genetic variation in Al tolerance in centipedegrass collections in China, as well as in the cultivars “TifBlair” and “Common”, was found based on plant growth and physiological responses to Al83. In contrast, several centipedegrass accessions in China showed great differences in cold tolerance85. The freezing tolerance of centipedegrass was positively correlated with the levels of polyamines (Pas) and antioxidants, the levels of proline and soluble carbohydrates, and the ratio of soluble carbohydrates to starch89. The inheritance of cold tolerance in centipedegrass is additive and dominant with epistatic effects and is controlled by two major genes90. To date, one QTL for cold tolerance has been identified by constructing a group of genetic linkage maps of centipedegrass91. Recently, several centipedegrass mutants have been produced by radiation86 and by somaclonal variation92, and the resultant mutants show good cold resistance. These mutants are valuable materials for both centipedegrass research and centipedegrass breeding purposes.Centipedegrass is sensitive to low temperatures, is vulnerable to freezing injury, and has a poor overwintering ability. Thus, its adaptation is limited to areas with mild winter temperatures. An early study revealed no measurable differences in cold resistance among centipedegrass plants from different sources in the United StatesThe value of germplasm resources is determined by their genetic diversity, availability, and utility. The wide spectrum of genetic diversity in growth phenotypes and stress-related traits in centipedegrass implies great opportunities for genetic improvement through either direct selection or hybridization between parental lines with desirable traits. Cytological and molecular methods have provided powerful tools for a deeper analysis of genetic variation in centipedegrass. Some mutagenized materials have been developed to supplement the natural diversity present in centipedegrass. As in the many studies that were reviewed here, many efforts have been made over the past few decades to estimate and utilize the genetic variation in centipedegrass populations grown in the United States. Nevertheless, due to the limited populations and genotypes of U.S. accessions, the actual diversity is not reflected in the available centipedegrass germplasm. Although wild resources of centipedegrass are abundant in China and have many unique and useful characteristics, such as a diversity of turf performance and levels of stress tolerance, the exploitation and utilization of resources based on their genetic diversity are still limited. Therefore, it is necessary and valuable to further explore the diversity of centipedegrass germplasms that are currently growing in China and other places in South Asia. Such further germplasm exploration and evaluation may lead to the identification of additional improved centipedegrass materials, which could be conducive to the expanded production of high-value turf. Molecular cytogenetic and new sequence-based approaches will provide opportunities for in-depth studies of the genetic variation and phylogenetic relationships among global collections of this species. In view of the above facts, future research should emphasize four aspects: (1) further collection of centipedegrass germplasm from all of its distribution areas, and especially from regions not sampled during previous collection trips, in order to construct a richer and more complete germplasm bank and an updated core collection; (2) cytogenetic studies on the chromosome structure and function of centipedegrass both for breeders and for other scientists interested in the analysis and manipulation of breeding material at the chromosomal level; (3) studies of genomics, transcriptomics, proteomics, and metabolomics in centipedegrass using high-throughput sequencing techniques; and (4) mining and functional research on the genes responsible for desirable traits such as strong aluminum tolerance and good tolerance to infertile soils, which will ultimately aid in cultivar improvement. With this article, the authors hope that the concerted efforts of all stakeholders in research, development, and funding can be united globally to promote the healthy development of the turf industry.Table S1


Older adults, including those with dementia and other types of cognitive decline, often report a desire to remain in their homes. Over 50 million informal caregivers in the US provide needed in-home assistance to those in need, and there are well-documented disparities in informal caregiving responsibilities by sociodemographic factors , yet little is known about “unmet need” in informal caregiving. Therefore, the study’s objective is to examine discrepancies in unmet caregiving-related need by race/ethnicity, gender, and employment status. We abstracted data about caregivers from the 2017 National Study of Caregiving and linked these data to participants in the National Health and Aging Trends Study on caregivers of older adults (n=993). Generalized linear models were used to model the discrepancies between the number of activities of daily living for which the care recipient required assistance and the number of tasks caregivers provide, by race/ethnicity, gender, and employment status, accounting for confounders and complex sampling. Care recipients whose primary informal caregivers were employed were 69% more likely than those whose informal caregivers were not employed to experience unmet caregiving need . A similar association between employment and unmet caregiving was observed among White caregivers , while the association was not significant among Black caregivers (p=0.228). These findings suggest potentially addressable disparities in informal caregiving duties between Black and White caregivers, and can be used to inform and develop of policies and programs designed to improve caregiver health and reduce undue strain on caregiver health and wellbeing.


Millennium Development Goal 4 (MDGs) mobilised countries to reduce child mortality by two thirds the 1990 rate in 2015. While India did not reach MDG 4, it considerably reduced child mortality in the MDG-era. Efficient and targeted interventions and adequate monitoring are necessary to further progress in improvements to child health. Looking forward to the Sustainable Development Goal (SDG)-era, the Indian Council of Medical Research and The INCLEN Trust International conducted a national research priority setting exercise for maternal, child, newborn health, and maternal and child nutrition. Here, results are reported for child health.The Child Health and Nutrition Research Initiative (CHNRI) method for research priority setting was employed. Research ideas were crowd-sourced from a network of child health experts from across India; these were refined and consolidated into research options (ROs) which were scored against five weighted criteria to arrive weighted Research Priority Scores (wRPS). National and regional priority lists were prepared.90 experts contributed 596 ideas that were consolidated into 101 research options (ROs). These were scored by 233 experts nationwide. National wRPS for ROs ranged between 0.92 and 0.51. The majority of the top research priorities related to development of cost-effective interventions and their implementation, and impact evaluations, improving data quality; and monitoring of existing programs, or improving the management of morbidities. The research priorities varied between regions, the Economic Action Group and North-Eastern states prioritised questions relating to delivering interventions at community- or household-level, whereas the North-Eastern states and Union Territories prioritised research questions involving managing and measuring malaria, and the Southern and Western states prioritised research questions involving pharmacovigilance of vaccines, impact of newly introduced vaccines, and delivery of vaccines to hard-to-reach populations.Research priorities varied geographically, according the stage of development of the area and mostly pertained to implementation sciences, which was expected given diversity in epidemiological profiles. Priority setting should help guide investment decisions by national and international agencies, therefore encouraging researchers to focus on priority areas. The ICMR has launched a grants programme for implementation research on maternal and child health to pursue research priorities identified by this exercise. Globally, 5.4 million children die every year, many due to preventable causes . One fifThe Millennium Development Goal era (MDG) resulted in large reductions in child mortality in numerous countries worldwide; the MDGs were a powerful advocacy tool as they provided an agenda with succinct, measurable goals . MDG 4 aThe mortality reductions have not been uniform across the country ,5. A recIn the beginning of the MDG-era, criticisms included the poor correlation of research funding with the conditions resulting in the greatest mortality and disability, and with the types of research that could have the most immediate impact. The so-called 10/90 gap showed that 90% of research funding went to conditions that accounted for 10% of the global disease burden -10. AdvoWith the knowledge that India was unlikely to meet MDG 4, looking forward to the Sustainable Development Goal (SDG) era, and being aware of the importance of targeting and prioritising research options, especially in a context of resource constraints, the Indian Council of Medical Research (ICMR) and the INCLEN Trust International (INCLEN) began a national research priority setting exercise using the CHNRI method in 2012 . In thisThe CHNRI method is the dominant method of health research priority setting . It capiA multidisciplinary and multi-stakeholder national steering group (NSG), comprised of policy makers, academics, program managers, civil society representatives, and donors was assembled to oversee the exercise. The NSG finalized 12 areas of concern (AOC) for the child health theme that together accounted for 75% of child mortality and morbidity. A child health research sub-committee (RSC) was set up and included 26 experts that further developed the technical details for this theme, including the iterative refinement and consolidation of the research options. Further information on their involvement is published elsewhere .A nation-wide network of 186 experts was established ; they weFive criteria were selected for scoring: (i) relevance; (ii) answerability; (iii) equity; (iv) innovation and investments in research resolving complex and refractory challenges; and, (v) investment in research. Experts were assigned to score two of the five criteria to reduce scorer fatigue . ScorersIn tandem with the scoring phase of the CHNRI exercise, a Larger Reference Group (LRG), which contained diverse stakeholder groups including politicians, policy makers, funding agencies, and senior researchers was created and tasked with weighting the criteria against one another. This exercise is described fully elsewhere . The resIndia is a large country with diverse population and heterogeneous governance status. We, therefore presented national research priorities, as well as regional priorities. The states were grouped into the following regions: (i) EAG (Empowered Action Group) and North-Eastern (NE) states; (ii) Northern states and Union territories (UTs) ; and, (iii) Southern and Western states and UTs (Box 1The three regions were:Empowered Action Group (EAG) States  and North–Eastern (NE) States ; ;Northern states and Union territories ; andStates and Union Territories in Southern and Western part of the country .4 domains: description, discovery, development, and delivery). The description domain included 32 ROs (31.7%), 27 ROs (26.7%) were within development and another 27 ROs (26.7%) within delivery and only 2 (2%) within the discovery domain. The remaining 16 (15.8%) were classified within multiple domains, the majority of which including delivery (n = 13) or development (n = 8).Of the 212 experts requested to contribute RIs, 90  contributed 596 RIs. These were refined onto 648 RQs and finally consolidated as 101 ROs. ROs spanned across the four domains of research , monitoring and evaluation or surveillance , program delivery and cost-effectiveness , and communications (number 6).) development of low cost, environment friendly, and innovative interventions for vector control (number 7) and community engagement (number 9) were the novel and contextually important priority research areas.Among the top 10 research priorities for the Southern and Western States , but the content of the research options was different between regions. The EAG and North-Eastern states are among the least developed and was also the only region that prioritised a policy analysis reflecting the need for reviewing, refining and aligning programs and interventions to local requirements if they have to achieve SDGs in time. The other high priority RO from this region was the need for strengthening administrative data (number 2). Valid and high quality administrative data encourages timely decision making for rational and specific action in addition to bringing accountability across the health system ,18. The Prioritising health research and aligning these with program interventions will be important to make progress to reach the SDGs. Indeed, the recent Global Burden of Disease Study for India found that not only there were differences between states at different levels of economic transition, states that were further along in economic transition had higher burden of non-communicable diseases in contrast to rest of the states with persistence of higher burden of communicable diseases. However, grouping states simply due to economic status might miss some nuances. For example, Odisha and Jharkhand had the highest DALYs due to diarrhoea but lowest due to LRTIs as compared to rest of India . The resIn our exercise, researchers gave most ROs high scores against the ‘answerability’ and lower score to “innovation” criterion. The LRG on the other hand allocated greater weight to relevance and innovation. Thus, the LRG weights were impactful in discriminating between ROs and helped in deciding the final priority listing. The vast majority (>70%) of CHNRI exercises have not employed a LRG, which has the benefit of including wider stakeholder values in calculating research priorities ,19. YoshThe EAG and North-Eastern states was the only region to prioritise conducting a policy analysis in-line with the SDGs in their top 10; this was their top priority. It was important to note that while this exercise was conducted thinking forward to the SDGs, the SDGs had not yet been released during the first round of the CHNRI (generating the ideas), and had been released in the middle of the second round (scoring the ideas). Therefore, while the exercise had the lens to look forward to the SDGs, it was not informed by the wider SDG agenda, which unlike the 8 MDGs, are much broader, and are comprised of 17 goals with 169 targets . Many ofMoreover, one major cause of mortality was missing from the regional and national prioritised lists. The Million Deaths Study had demonstrated that India had shown accelerated declines in pneumonia and diarrhoea, though these were still major contributors to child deaths. However, deaths from injuries, including falls and drowning, have risen to the third most common cause of death in children, and is responsible for almost 70 000 deaths . In an a4 domains were independently assigned to every RO by three reviewers  and matched; disagreement was sorted by a senior researcher (NA) and through consensus with the reviewers. However, the domains overlapped and therefore, categorization of some of the research options was liable to subjective variation in interpretation of domains.The dThis research priority exercise mobilised hundreds of researchers, funders, program managers from central and state governments, and policy makers and was part of a larger research priority setting exercise for maternal, child, newborn health, and maternal and child nutrition. Simply having research priorities are not enough; they must be implemented. The ICMR launched a grants programme for Implementation Research on Maternal and Child Health in spring 2017 to pursue the research priorities identified by this umbrella exercise. Ultimately, we hope that the outcome of this exercise and the joint ICMR grant programme shall positively impact child health in India, and accelerate India’s journey towards achieving the SDGs.


This study aimed to provide a summary of all online available literature of published clinical and histopathological data regarding tumors affecting the reproductive tract of female sheep and goats. In addition, a detailed description of the clinical history, clinical findings, and gross and histopathological findings of one case of vaginal fibroma in an adult Awassi sheep is provided for the first time.Internet search engines such as PubMed, ResearchGate, Scopus, ScienceDirect, and Google Scholar were used to collect all published articles in refereed journals from 2000 to 2018 regarding tumors and tumor-like lesions involving the reproductive tract of ewes and does.There are six published papers in sheep and nine in goats reporting various malignant and non-malignant tumors involving different parts of the reproductive tract. The most commonly diagnosed tumors of the reproductive tract were leiomyoma (six cases), adenocarcinoma (six cases), leiomyosarcoma (three cases), adenoma (one case), squamous cell carcinoma (one case), and metastatic signet ring cell carcinoma (one case). The most common sites of tumor formation were the uterus (10 cases), vulva/vagina (five cases), ovaries (four cases), cervix (four cases), and Bartholin’s gland (one case). All affected animals were aged females (older than 3 years of age). In both ewes and does, the most frequently reported clinical symptoms were chronic weight loss, pyometra, hydrometra, vaginal bleeding, abnormal vaginal discharges, straining, pollakisurie, ascites, and abdominal distension.Tumors of the reproductive organs in sheep and goats are not uncommon and should be considered in the differential diagnoses in cases with poor reproductive function. Malignant and non-malignant tumors of the female reproductive tract in small ruminants are not uncommon and rank in frequency only second to skin tumors . ApproxiThese tumors could lead to a significant economic loss due to infertility, production losses, and the death of the affected animals in advanced cases -3. Neverst time.This study aimed to summarize the clinical and histopathological data regarding tumors affecting the reproductive tract of female sheep and goats that have been published in scientific and refereed journals. In addition, a detailed description of the clinical history, clinical findings, and gross and histopathological findings of one case of vaginal fibroma in an adult Awassi sheep is provided for the 1Written owner consent was obtained before the use of the clinical case described here in this article. Institutional Animal Ethic Committee approval was not required as the study was based on clinical case.A review of recent literature regarding malignant and non-malignant tumors involving the reproductive organs in female sheep and goats was carried out using internet search engines such as PubMed, ResearchGate, Scopus, ScienceDirect, and Google Scholar. Only published papers in scientific and refereed journals after the year 2000 to 2018 were considered. Keywords that were used in the search included “tumors of the reproductive tract in sheep,” “tumors of reproductive tract in goats,” “tumors of the vulva and vagina in sheep and goats,” “tumors of the cervix and uterus in sheep and goats,” and “tumors of the ovaries in sheep and goats.” To avoid missing any papers, the references of all selected articles were also searched.Data extracted from selected articles included the species, breed, gender and age of affected animals, histopathological diagnosis, location of the lesion, and clinical history wherever specified.Review of recent literature revealed five published papers in sheep -9 Table and eighIn goats, the most frequently diagnosed tumors of the reproductive organs were leiomyoma (five cases), adenocarcinoma (six cases), leiomyosarcoma (two cases), adenoma (one case), choriocarcinoma (one case), SCC (one case), thecoma (one case), leiomyofibroma (one case), and signet ring cell carcinoma (one case). All goats were females older than 3 years of age. The most frequent clinical symptoms were weight loss, vaginal bleeding, abnormal vaginal discharge, pollakisurie, hydro pyometra, and abdominal distension.Adenocarcinoma of the reproductive organs is rarely diagnosed in ruminants . HoweverLeiomyoma is a non-invasive benign tumor of the smooth muscles which has been rarely reported in ruminants, especially sheep and goats ,4,17. LeLeiomyosarcoma is locally invasive malignant tumor of smooth muscles that are capable of metastasis to distant locations in the body ,17. MostGastrointestinal stromal tumors (GISTs) that are mostly arise from the gastrointestinal tract can mimic leiomyomas and leiomyosarcomas . GISTs hGCT is one of the most common ovarian tumors in domestic animals -3. The tSCC is a common cutaneous malignant tumor in all domestic animals that are characterized by tumorous epithelial cells with variable degrees of differentiation toward keratinocytes . In one Tumors of the Bartholin’s gland are rare in animals . Tumors Fibroma and leiomyofibroma are benign tumors of the fibrous connective tissue and smooth muscles, respectively . FibromaMetastatic signet ring cell carcinoma is extremely rare in animals. In humans, only few cases have been reported . These tst time.Although rarely diagnosed in small ruminants, tumors and tumor-like lesions still can be encountered in veterinary practices worldwide and should be considered in the differential diagnoses of infertility and abnormal reproductive function in sheep and goats. This review indicates that goats are more likely to suffer from tumors involving the reproductive tract than sheep. In addition, a case of vaginal fibroma in a non-pregnant Awassi sheep is described here for the 1WMH diagnosed the case and wrote the pathology part of the manuscript. ZBI completed the rest of the manuscript. MHD did the clinical and surgery part. All authors read, finalized, and approved the manuscript.


Early and late onset post-stroke cognitive impairment (PCI) contributes substantially to disability following stroke, and is a high priority within stroke research. The aetiology for PCI is complex and related to the stroke itself, brain resilience, comorbid brain diseases, prestroke vulnerability and complications during the hospital stay. The aim of the Norwegian Cognitive Impairment After Stroke study (Nor-COAST) is to quantify and measure levels of cognitive impairments in a general Norwegian stroke population and to identify biological and clinical markers associated with prognosis for cognitive disorders following incident stroke. The study will be organised within five work packages: 1) Incidence and trajectories 2) Pathological mechanisms 3) Development of a risk score 4) Impact of physical activity and 5) Adherence to secondary prevention.Nor-COAST is an ongoing multicentre , prospective, cohort study with consecutive inclusion during the acute phase and with follow-up at three and 18 months, and at three years. Inclusion criteria are stroke defined according to the WHO criteria. During the recruitment period from 18.05.2015 to 31.03.2017, 816 participants have been included. Cognitive impairment will be classified according to the DSM-5 criteria using a consensus group. Cognitive function is assessed by a standardised neuropsychological test battery, the Montreal Cognitive Assessment, Trail making A and B, ten-word immediate and delayed recall test, the Controlled Oral Word Association, Global Deterioration Scale and proxy based information by and the Ascertain Dementia 8 item informant questionnaire. Biomarkers include magnetic resonance imaging, routine blood samples and bio-banking. Clinical assessments include characteristics of the stroke, comorbidity, delirium, frailty and tests for cognitive and physical function, sensor based activity monitoring and adherence to secondary prophylaxis.Nor-COAST is the first Norwegian multicentre study to quantify burden of PCI that will provide reliable estimates in a general stroke population. A multidisciplinary approach aiming to identify biomarkers and clinical markers of overall prognosis will add new knowledge about risk profiles, including pre-stroke vulnerability and modifiable factors such as physical activity and secondary prophylaxis of relevance for clinical practice and later intervention studies.NCT02650531. Retrospectively registered January 8, 2016. First participant included May 18, 2015.ClinicalTrials.gov:  Stroke and cognitive impairment are common in old age. One in three persons will develop stroke, dementia or both , and theCognitive function is therefore defined as a top priority for stroke research, especially studies of the links between cerebrovascular and degenerative disease are requested –7. The tReported rates for PCI varies considerably between studies. Many studies reports dementia but not MCI, and in studies that include MCI the operational definition has a large impact on the reported rate . Pooled A complex interplay of vascular pathology, neurodegenerative and inflammatory processes contributes to the progression of PCI , 14–16. Early and late-onset PCI is probably driven by somewhat different mechanisms, with brain resilience and characteristics of the stroke lesion being the dominant driver for early-onset PCI, while small vessel disease, Alzheimer pathology and recurrent strokes are more pronounced in late-onset PCI , 23, 24.Prevention of recurrent strokes is important in preventing PCI  and can There is evidence that physical activity enhances cognitive function after stroke , and espThe aim of the Norwegian Cognitive Impairment After Stroke study (Nor-COAST), is to quantify and measure levels of cognitive impairments in a Norwegian general stroke cohort and to identify biomarkers and clinical markers associated with overall prognosis for early and late onset PCI.The Nor-COAST study is organised within five work packages (WP). The aim of WP 1 is to describe incidence and distinct trajectories of PCI. In WP 2, the aim is to increase knowledge concerning the pathogenesis of early and late-onset PCI by analysing brain imaging, APOE ε4 typing and blood markers, and to explore associations between neurodegenerative disease, underlying vascular disease, inflammation and stroke characteristics. In WP 3, we aim to identify predictors for PCI in order to develop a novel risk score consisting of a few clinical markers that will enable planning of individualized prevention and treatment. The aim of WP 4 is to study the impact of physical activity and sedentary behaviour on PCI in the short and long term, and to explore associations between motor function measured by performance based tests and progression of PCI. WP 5 aims to explore the impact of cognitive function on adherence to secondary prevention and evaluate whether optimal secondary prophylaxis is protective against decline in cognitive function over time Fig. n = 400); Ålesund Hospital, Møre and Romsdal Health Trust, Ålesund (n = 33), Haukeland University Hospital, Bergen (n = 142); Bærum Hospital, Vestre Viken Hospital Trust, Drammen (n = 142) and Oslo University Hospital, Ullevål, Oslo (n = 99). All patients admitted to the participating stroke-units were consecutively screened for eligibility and approached as soon as the diagnosis was confirmed. Informed consent was given prior to data collection by the participant or by proxy if the participant lacked capacity to give informed consent. All participants received treatment and routine follow-up as usual in accordance with national and international guidelines [The Nor-COAST study is a multicentre, prospective, cohort study following participants for three years from the stroke incident. Recruitment started successively at the different sites between 18.05.2015 and 01.09.2016 and was ended as preplanned 31.03.2017, with 816 participants included. Participants were recruited from five Norwegian stroke units at the following hospitals; St. Olavs University Hospital, Trondheim  Admittance to one of the five centres within seven days after symptom debut. 2) Acute stroke diagnosed according to the World Health Organisation (WHO) criteria or with findings of acute infarction or intra-cerebral haemorrhage on MRI. 3) Scandinavian speaking 4) over > 18 years and 5) living in the catchment area of the recruiting hospitals. Exclusion criteria were expected survival less than three months.Assessments during the hospital stay are performed at discharge or the seventh day of the stay for participants with longer hospital stay. Study related follow-ups are performed at the outpatient clinic three and 18 months, and three years’ post-stroke. Participants unable to attend the outpatient clinic are assessed by telephone interview and/or proxy information is collected. Assessments and interviews are performed by trained research assistants, using a standardised paper Case Report Form (CRF), and then plotted in web-based CRF developed by the Unit for Applied Clinical Research, NTNU. Table Sociodemographic characteristics are registered based on medical records and interviews with patients and/or caregivers. Information of health history, premorbid function and life style habits are recorded using standardised questionnaires from the Norwegian stroke registry and the North-Trøndelag Health (HUNT) Study. Charlson comorbidity index identifies comorbidity,  and a meStroke symptoms and severity is assessed by National Institutes of Health Stroke Scale (NIHSS). Strokes are classified according to the Oxfordshire Stroke Classification Project (OSCP)  and the MCI and dementia are diagnosed according to the DSM-5 criteria , an expeScreening of global cognitive function is performed using the Montreal Cognitive Assessment (MoCA) . MoCA evNeuropsyciatric Inventory (NPI-Q)  is a 12-Lower extremity function is measured by Short Physical Performance Battery (SPPB) consisting of three subtasks: 4-m gait speed, balance and chair rise . AdditioPhysical activity is measured using a three-axial accelerometer, ActivePAL monitors , attached to the front of the unaffected thigh during the hospital stay and for a minimum of four days at three and 18 months’ and three years’ follow-up. The inertial sensor produces a signal related to thigh inclination and can thus identify posture (sitting/lying from upright activity) . This meBlood samples are analysed during the index stay and at three and 18 months and three years for haemoglobin, low density lipoprotein (LDL), high density lipoprotein (HDL) and total cholesterol, glucose, glycosylated haemoglobin (HbA1c), creatinine, high sensitive CRP and troponin T. In addition, blood has been sampled in BioBank 1, Central-Norway Regional Health Authority, at baseline, three and 18 months and three years for analyses regarding genetics and inflammation. If full blood can not be sampled, saliva is collected in order to make genetic analyses (APOE ε4 carrier status).All patients undergo an acute CT scan to establish the stroke diagnosis and the majority have a brain MRI scan as part of routine diagnostic work-up. In addition, participants are recruited for a study specific MRI brain scan within the first 14 days after stroke. The MRI study protocol consists of 3D-T1, axial T2, 3D-FLAIR, DWI and SWI sequences. A follow-up scan with identical MRI protocol is performed after 18 months and at three years. Protocols were harmonized between centres after scanning of the same healthy volunteer and stroke volunteer in all scanners.A standardized assessment of the MR findings includes systematically scoring for global atrophy, focal atrophy and vascular disease. For evaluation of white matter hypertensities (WMH) we will use the Fazekas scale . For parAdditional information on diagnosis, treatment, and cause of death will be obtained from the Norwegian Stroke Register, the Norwegian cardiovascular disease registry, the Norwegian Prescription Database, the Norwegian Patient Registry and the Norwegian cause of death registry. Administrative permission to access data from registries will be obtained within each workpackage according to the specific research questions.Demographics and participant characteristics will be presented using descriptive statistics. Prevalence and incidence of dementia will be presented by crosstabs. Statistical analyses for trajectories will be performed with group-based trajectory modelling, which uses maximum likelihood to identify groups of individuals with statistically similar trajectories Two primary outputs of the estimations in group-based trajectory modelling are 1) shapes of trajectories of each group as specified by group-specific polynomial functions of time and 2) estimated percentages of the population following each identified trajectory . Both reThe current paper describes the protocol of the Nor-COAST study, an ongoing prospective, cohort study following 816 participants for three years after incident stroke. This will be the first study to quantify and report levels of cognitive impairment in a large Norwegian stroke cohort. The study will focus on the diagnosis, incidence and clinical entity of PCI, and provide estimates for the burden of both early and late onset PCI in a general stroke population.The neuropsychological test battery used in the study is sensitive to the mild cognitive impairments including non-amnestic deficits  that areUsing registry data from the Norwegian stroke registry allow us to account for some of the methodological challenges associated with bias, drop-outs and testability in a heterogenic population –78. ThisBy neuroimaging and identification of genetic, vascular and inflammatory response-factors, we hope to achieve insight of stroke as a trigger for degenerative brain processes and the relevance of pre-existing risk factors, including brain pathologies, for development of PCI. Both results from visual and volumetric brain analyses will be used to identify MRI predictors of early or late onset cognitive impairment. The longitudinal design of Nor-COAST enables us to look for the contribution of vascular and degenerative changes to delayed onset PCI, and to study the characteristics of patients with augmented and prolonged inflammatory response.We aim to develop a reliable and accurate tool to identify patients at risk of developing PCI based on clinical markers in early phase after stroke. This will provide insight into the relative importance of patient vulnerability in terms of frailty, comorbidity, pre-stroke function and cognition, and the relation between cognitive outcome and stroke and non-stroke factors such as location and severity of stroke, specific treatment and complications including delirium. Further, we aim to explore whether inclusion of biomarkers will increase the predictive value of the score. Identifying stroke survivors at high risk at an early stage would enable early, personalized and appropriate intervention for prevention.Physical activity will be measured by use of body worn sensors. This will make it possible to monitor physical activity continuously for up to one week at inclusion and at each follow-up, and thereby avoid some of the methodological challenges, such as recall bias and overestimation of activity, associated with the most commonly used self-reported measures –82. ThesThe concept of adherence, will be assessed by combining information from subjective and objective sources. With supplementary information and evaluation of follow-up routines in primary health care, this sub-study constitutes a valuable approach to a challenging and sparsely studied research area where further data are warranted , 85. SecThe results of our comprehensive approach, combining assessment of biomarkers and clinical markers along with modifiable factors including physical activity and adherence, holds potential to reveal knowledge that could inform routine clinical practice and be easily applicable in clinical practice. We aim to develop a tool for the early identification of persons at risk and to improve knowledge about modifiable factors such as physical activity and secondary prophylaxis important for prevention, treatment, rehabilitation and overall prognosis. Increased knowledge of adherence to a healthy lifestyle and pharmacological treatments will enable us to give realistic and feasible individualised advice to prevent recurrent stroke and PCI.Combination of biomarkers and clinical markers allow us to explore the relationship between inflammation and APOE status, chronic inflammation, sedentary behaviour, stroke recurrence and cognition. Brain MRI analyses will be combined with advanced statistical techniques to find combinations of MRI findings and clinical variables associated with the development of PCI. The multidisciplinary approaches applied in the present study unite dementia, geriatrics, stroke and physiotherapy research. This gives us an opportunity to extend existing perspectives for cooperation and to exploring the impact of for example frailty and neurodegeneration on long-term outcome after stroke.There are some limitations of the Nor-COAST study. Although the neuropsychological test battery contains most of the cognitive domains in the DSM 5, symptoms related to behavior and social cognition are not extensively assessed. Further, some selection bias may have occurred despite the inclusive nature of the study: potential participants may not have been included because of worse health status. Also the recommended neuropsychological battery is cited as taking up to 30 min to perform, but many patients needed longer or testing had to be abandoned. In addition, some assessments, eg the MRI study and parts of the cognitive testing, were not feasible for all participants because of severe illness or specific impairments.The Nor-COAST study will provide reliable estimates of the burden of PCI in a general Norwegian stroke population. Further, the study will add new and important knowledge on the early detection of individuals at risk for progression of PCI, extend understanding of the underlying pathophysiology and the impact of pre-stroke vulnerability, early physical activity and adherence to secondary prevention on prognosis. The results will contribute to the development of new guidelines for routine clinical practice in stroke and better understanding of mechanisms underlying PCI allowing the development of more specific hypotheses and the design of future intervention studies.


Economic, physical, built, cultural, learning, social and service environments have a profound effect on lifelong health. However, policy thinking about health research is dominated by the ‘biomedical model’ which promotes medicalisation and an emphasis on diagnosis and treatment at the expense of prevention. Prevention research has tended to focus on ‘downstream’ interventions that rely on individual behaviour change, frequently increasing inequalities. Preventive strategies often focus on isolated leverage points and are scattered across different settings. This paper describes a major new prevention research programme that aims to create City Collaboratory testbeds to support the identification, implementation and evaluation of upstream interventions within a whole system city setting. Prevention of physical and mental ill-health will come from the cumulative effect of multiple system-wide interventions. Rather than scatter these interventions across many settings and evaluate single outcomes, we will test their collective impact across multiple outcomes with the goal of achieving a tipping point for better health. Our focus is on early life (ActEarly) in recognition of childhood and adolescence being such critical periods for influencing lifelong health and wellbeing. Children growing up in these areas are more exposed to stress, chaos, violence and household instability2. These wider determinants and inequalities in these, damage child health and cause an accumulation of multiple environmental risks and clustering of unhealthy behaviours, that impair life opportunities and increase longer term non-communicable disease (NCD) risk1. Addressing them can improve health outcomes3, but too often NCDs have been attributed to bad choices rather than framed as emergent properties of complex systems. Public health interventions seek to directly influence behaviours rather than addressing the conditions that drive them and directly and indirectly affect health4. There is robust research on how upstream factors affect NCD risk but little around how to address these at a local level where action is needed. There is also poor linkage between academics, those with broader interdisciplinary expertise, and the statutory, voluntary, cultural and commercial sectors, despite them all having a role in improving public health.Areas with high levels of child poverty tend to have increased rates of obesity, polluted roads with low walkability, poor quality green spaces for play and exercise, high fast food outlet density and food poverty; poorer levels of child development, school readiness and educational attainment, higher school exclusion rates, poor performing schools and lower entry into further education; unsafe neighbourhoods, higher levels of youth crime, physical decay, poor public services and poor quality, overcrowded unfit, temporary/rented and unaffordable housing5, shifting the emphasis from deficits to harnessing of community assets, recognising the lived experiences and resourcefulness of disadvantaged communities, working ‘with’, rather than delivering ‘to’ people, and applying systems thinking principles to examine poor and unequal health “as outcomes of a multitude of inter-dependent elements within a connected whole”7. Components of factors influencing health, interact in complex and dynamic ways8. A complex systems approach requires bringing together all stakeholders from across the system to understand how, when and where to intervene. This means taking account of the key concepts of complex adaptive systems - emergence, feedback loops and adaptation, and using systems-focused interventions which may be partner-led, natural experiments or simulation studies that make use of data whilst also identifying what information is needed to support replicability9. It also means using more credible methods of economic evaluation to inform social policy decisions, based on careful modelling of interacting social, fiscal and health outcomes and accounting for budget constraints and opportunity costs for different social groups. Across Europe, there are just a few examples of systems initiatives that have achieved reductions in child obesity prevalence and inequalities11, or that have delivered city-wide system change in ecology, technology, mobility and urban design to improve equity in the social determinants of health12. UK transdisciplinary research is now needed that can change broader environments to improve the lives of our most vulnerable communities5, focusing on children to yield high returns across the entire lifecourse1.There is increasing focus on how to reduce inequalities in wider determinantsCities are an ‘immense laboratory of trial and error, failure and success”13 and our city approach will provide real world opportunities to scope, deliver and evaluate sustainable and replicable population prevention interventions.In 2017, the UK Prevention Research Partnership (UKPRP), launched a novel model of public health funding to support research into the primary prevention of NCDs that could develop innovative and interdisciplinary approaches, and deliver upstream interventions to improve population health and reduce unfair health inequalities. We have been awarded 5-year UKPRP consortium funding to develop ActEarly City Collaboratories. “Our long-term vision is to promote a healthier, fairer future for children living in deprived areas through a focus on improving environments that influence health and life chances.Our objectives are:1) To establish a prevention research consortium that unites broad transdisciplinary expertise including economics, geography, urban design, transport, education, housing, arts and culture, social justice and welfare , with the public, policy leaders and practitioners from across our populations to develop shared understanding and priorities.2) To identify, co-produce and implement system-wide early life upstream prevention solutions.3) To provide efficient data platforms and methodological expertise enabling robust population-scale evaluation of the impact of interventions on environments, health related behaviours and interlinked health, educational, social and economic outcomes.4) To evaluate, refine, replicate and disseminate our City Collaboratory approach as a model for addressing upstream determinants of health and inequality.14. Researchers working with policymakers have built strong networks across health care providers and schools, connecting multiple systems and developing whole-system information and analytic capacity. We have worked closely with our communities to promote a strong public voice in the focus and delivery of research and now have a population based, system wide research infrastructure with committed investment to support the delivery of interdisciplinary preventative interventions.City Collaboratories in areas of high child poverty will provide research-ready, people-powered and data-linked test beds to co-produce, implement and evaluate multiple novel early life interventions to prevent disease and reduce inequalities. Our City Collaboratory approach will provide a whole-system environment where the public, scientists, policy leaders and practitioners work with each other to develop and test system-wide early life upstream prevention solutions, supported by efficient platforms for robust evaluation. We will create City Collaboratories first in Bradford , and then in Tower Hamlets (a London borough) to support the identification, implementation and evaluation of upstream interventions in areas with high levels of child poverty. Our initial focus will be in Bradford, which provides a research-ready population laboratory for prevention research due to: its level of need, research track record, strong data linkage, pipeline of interventions and deep engagement with the community and local policymakers. Bradford, the fifth-largest city in the UK, has high levels of poverty and ill-health. It is ethnically diverse, with a large South Asian community and an accelerating prevalence of diabetes and cardiovascular diseaseTower Hamlets, the London ActEarly Collaboratory site, will help explore replicability of the model and generalisability of interventions. Similar to Bradford, this East London borough is ethnically diverse and has some of the highest rates of child poverty in the UK, but it also has a strong foundation of community-developed research, in particular through the Communities Driving Change programme and transformative community health models developed by the Bromley-by-Bow Centre. The local authority has demonstrated enthusiasm and commitment for ActEarly and offers an existing platform of linked routine data through the Whole Systems Data Integration programme.15, c) co-producing prioritised intervention strategies using internal and external experts, d) implementation  and e) evaluating impact. Our evaluation will explore process (of the Collaboratory model itself and of interventions) and outcome .The Collaboratory model consists of a multistep interactive cycle that places local communities at the heart of decision making and active participation in both shaping and using the research, and connects academic expertise with real-world policymakers see. This cyWe will apply our ActEarly Collaboratory model to work programmes of three inter-linked themes that were identified collectively during the development phase of our programme: Healthy Places, Healthy Learning and Healthy Livelihoods . These t16 to sustainable community-driven change, building on work already started. Evidence shows that interventions engaging community members in delivery are effective, but no particular model of engagement appears superior17, so we will test multiple approaches to support co-production ranging from robust consultation and dialogue, to complete multidisciplinary community and stakeholder led co-production. We are committed to genuine co-production with users in order to achieve acceptable, feasible, replicable, and sustainable systems interventions with real impact. We will engage policymakers, third sector organisations and our public  using citizen science methods of community engagement and prioritization in an asset-based community development approach18, extreme citizen science)19 and traditional methods for consultation, dialogue and priority setting (e.g. open space). We will then refine and adapt existing co-production methods (e.g. experience-based co-design)20 to unite communities, policymakers and researchers in focused co-production groups. We will evaluate the impact and effectiveness of our co-production activities on processes, outputs and impacts using mixed qualitative and quantitative methods. This will help develop and deliver appropriate engagement models across our sites and inform implementation of co-production activities within ActEarly.We have started our co-production activities, developing, refining and prioritizing the suite of activities outlined in each work programme with all key user groups. We have already identified synergies between community needs, policy and decision maker, and other user group priorities across our programmes and sites, for example: safer streets (places), healthy vending options in school (learning), easier access to welfare advice (livelihoods). Within each theme, we will start by eliciting user insights and experiences around prioritised topics using a tool kit of citizen science approaches .Outcomes of novel methods in turn will increase the scale and scope of evaluation (yellow arrow). Promoting awareness of our outputs will enable ActEarly to influence decision making. Decision makers’ responses will also influence intervention development & evaluations (yellow arrow). The underpinning data infrastructures enables examination of longer-termimpacts.ActEarly’s logic model  builds o21), and healthy eating (fast food outlets22). These are compounded by factors such as fear of crime and hostile traffic23, lack of well-connected routes to work and leisure activities24, low levels of social cohesion25 and unfit and overcrowded housing. Research shows links between poorly designed neighbourhoods and obesity, mental health and cardiovascular health29, as well as poor social connectedness with community assets . Social networks and social capital are weakest in the most deprived areas30. Thus, modifying local ‘places’ to make it easier for disadvantaged families to live better lives may offer gains across a range of outcomes.The spaces we live in affect how we travel, exercise, eat, socialise and interact. Deprived areas are often unhealthy obesogenic environments for children and young people, with physical infrastructure that increases barriers to healthy living such as physical activity  Living Well programme which includes a healthy charter for businesses and communities, and a Tower Hamlets-based Community Engagement Campaign programme to encourage use of social, cultural and community assets. We will also evaluate natural experiments, for example Bradford’s Clean Air Zone, which is due to be implemented in 2020. All these interventions should impact on key lifelong health outcomes including prevalence of obesity, mental wellbeing and social outcomes, such as opportunity and social mobility. In the short term, we expect impact at an individual level , at the community level  and at an environmental level . From a systems perspective, changing the attributes of place will change how communities move and thrive in that place thus creating interconnections between the ActEarly themes and delivering change across the whole system.We aim to increase the health and social potential of local places for children and young people by both changing physical infrastructure and by promoting connected communities. Improvements to physical environment will be based on the ‘healthy streets’ approachSome examples of our Healthy Places research questions include the following: Can ActEarly Healthy Places interventions:1) Reduce child obesity and improve child mental wellbeing?2) Increase active travel?3) Increase the use and quality of open spaces for play and recreation?4) Increase social connectedness?5) Improve air quality?6) Reduce health inequalities?7) Increase uptake of housing related services  and maximise benefits of new housing?32, maintaining intergenerational cycles of inequality33. Learning environments can play a critical role in encouraging children to adopt healthy lifestyles and nurturing the social and emotional wellbeing critical to good health34. Learning is linked to place, and can provide powerful settings for community interactions which can support good parenting , and opportunities for wider health and social care (e.g. access to services and welfare advice). Previous attempts to introduce health programmes to schools , the National Healthy Schools programme) have often produced minimal change35. A new approach is needed that can move beyond a collection of individual health-promoting activities and deliver a real step change. Bradford is a UK Department for Education Opportunity Area with a delivery plan to improve opportunities for children and young people in the city. Via this initiative, we have established an ‘evidence active network’ (EAN) involving all learning environments across Bradford. The EAN will enable schools (n = 206) and pre-schools to adopt evidence-based practice in teaching and learning and empower staff and children to participate in research as citizen scientists. ActEarly offers an opportunity to widen the EAN’s remit to include health and wellbeing, and develop and deliver large scale evaluations - first in Bradford, with later extension and evaluation in Tower Hamlets. We will work with Evidence Champions on schools’ senior management boards to co-produce, deliver and evaluate health initiatives within local trailblazing sites, share learning across the network and develop an intervention ‘menu’. We will engage staff and students to create profiles of their environments as a baseline for monitoring progress against key indicators, such as absenteeism, attainment, child and adolescent mental health (CAMHS) referrals, exclusion, primary and secondary healthcare episodes.Literacy and educational status are major upstream determinants of health, but educational opportunities are often poor for those living in disadvantaged areasSome examples of our Healthy Learning research questions include the following:1) Does the EAN increase uptake of evidence-based interventions within early years and school settings?2) Does the EAN increase participation of children, families, teachers, professionals and the community in research?3) Which interventions have the greatest impact on physical and mental health, social wellbeing and educational attainment?36. Demands are higher and resources lower at two critical stages: during the transition to parenthood and in early childhood37, and during young people’s transitions from school into adulthood38. Our aim is to develop and evaluate interventions and initiatives to address child, young person and family wellbeing and opportunities through increasing income, skills and control over community resources. The interventions will be co-produced with communities and include promoting take up of existing policy measures , pioneering interventions  and skills) and scaling-up promising interventions in new contexts (participatory budgeting). Outcomes we anticipate being affected in the short term are both child/adolescent/young adult/family-centred and place-based: i) child ; ii) young person ; iii) family ; iv) community , all of which affect the risk of NCDs.People’s livelihoods are important for both their mental and physical health, partly due to higher levels of education, income and social class providing material benefits for health at all ages, but also through psychosocial mechanisms – dignity, sense (and locus) of control and self-worth, engagement in meaningful activity, social networks/social capital, social statusSome examples of our Healthy Livelihoods research questions include the following:1) What are some of the obstacles to the uptake of early childhood education and care, what interventions might increase appropriate uptake and what is their effect on key outcomes? 2) Can a UBI for young adults improve self-efficacy, mental health & wellbeing and engagement with education, employment, training and entrepreneurship? Is this more or less or cost-effective or effective when combined with life skills training? 3) Does community involvement  improve individual self-efficacy, social support and health, and community wellbeing?Examples of early interventions identified in our three themes are described inComplex systems theory and complexity thinking provide the framework for our analysis of systems focusing on the relational nature of systems, and the resulting emergent properties of those relations. ActEarly aims to evaluate the impacts of interventions in a complex system setting on the health of children in Bradford and Tower Hamlets across the three themes. We will collect and link bespoke and available data at individual and area-level to enable evaluation of multiple initiatives.For all interventions, combinations of interventions, and systems we will be interested in (a) understanding processes of implementation including adaptation, (b) effectiveness and (c) economic impact. We will estimate both average and distributional effects, harnessing our consented cohort and routine linked datasets to follow up our children’s longer-term health and wellbeing outcomes.We will use a variety of methods see, dependicases and use qualitative comparative analysis (QCA)39 as our approach. This algebraic technique will be used to test the extent to which different components of the configuration of the interventions, and their context, seem necessary or sufficient to produce outcomes. It will allow us to examine pathways to both positive and negative (unintended) outcomes across our complex system. Definition of cases can be based on both quantitative and qualitative data, the configurations of which are analysed as either ‘crisp set’ (where data are clearly binary) or ‘fuzzy set’ . We will treat ‘groups of conditions’,  as40, and/or complex networks of systems, related to each of our research themes or related to producing outcomes in, for example, early childhood, school age children or young adults, or systems related to particular stakeholder spheres of influence, e.g., local authorities. Systems will be developed and described through iterative concept mapping, expert input (via Delphi surveys) and then simulated (and refined) via agent-based and/or system dynamic models. Empirical data will then be used to explore the credibility of, and to improve, the system models. We will co-develop complex systems maps41. Simulation methods will explore long-term impact of interventions on health using relationships between early life predictors and later disease.We will simulate long-term policy effects, public costs and inequality impacts of interventions, sets of interventions or systems for our Collaboratory sites and nationally, building on microsimulation methodsWe will adopt a realist context-mechanism -outcome perspective. This will involve multiple components including QCA, a complex systems analysis of the whole Collaboratory, social network analysis of collaborators, qualitative interviews, and tracking of processes, outputs and impact on policymaking.establishing a parallel Whole System Demonstrator-linked dataset, and both settings have well characterized geospatial data on exposures such as pollution, green space, transport, connectivity, walkability and fast food outlets.Our evaluation plans will require efficient use of our bespoke and routine data sources. We benefit from well-established data platforms in both Bradford and Tower Hamlets. Bradford has some of the most richly described populations in the UK with its cohorts and Connected Bradford dataset which includes linked health, social care and education routine data for 700,000 citizens. Tower Hamlets isOur goal is to develop safe and secure data tapestries that unite our cohort, routine data, public health data, consumer data and citizen science, and allow us to evaluate multiple, interdependent outcomes across the life course .We will develop effective KTE activities to promote the uptake of actionable evidence. At the core of our KTE strategy will be the building of trusted and enduring partnerships between researchers, practitioners and policymakers, promoting effective dissemination and communication developed from the best implementation science and drawing on professional communications and marketing expertise (see communication plan). ActEarly will favour an integrated approach that incorporates direct audience engagement with information push, pull, linkage and exchange. The development of specific knowledge mobilisation activities for the consortium’s proposed research outputs will be theory driven and informed by the topic, research findings, and the needs and preferences of the audiences to be targeted. Our goal is to produce evidence that is useful to decision makers.ActEarly partners involved in our KTE include the What Works Network, Centre for Cities, Local Government Association, NESTA, Academy of Urbanism, Sustrans, Royal Society for Arts, Public Health England, National Housing Association and the UK National Institute for Health Research.This is an ambitious research programme that aims to catalyse system-wide transformation underpinned by strong co-production and robust evaluation of multiple and interacting health promoting interventions across two city regions. We face a number of challenges in implementing such a programme. Effective community engagement will be central to the prioritisation and uptake of interventions. Key to this success is being sensitive to the complexity of the setting and understanding the need to reconcile differing agendas. We will use multi-faceted approaches that capitalise on traditional strengths and assets but also develops novel methods of citizen science and participatory research.We will need to embed our research within mainstream policy and practice and work hard to achieve and maintain meaningful engagement between communities, researchers, local authorities and local and national stakeholders in an era of severely constrained resources. We will be required to prioritise our activities to maximise value of limited resources and attract funding to support an ambitious pipeline of interventions. The curation and development of multiple combined data sources will need to be safe and secure but also accessible and more useful for prevention policy than the conventional randomised trial approach to causal inference. We also face methodological challenges in evaluating multiple and interacting population level interventions and natural experiments. Our meta-evaluation will capture and monitor our progress in tackling these challenges.No data are associated with this article. This Open Letter is an important take on a challenging area for chronic disease prevention - namely the ‘how’ of putting prevention research into practice, instead of simply describing the ‘what’ (the problem of chronic disease). This paper sets out an impressive program of work and research which is ambitious and comprehensive. The researchers should be commended for this and for engaging with systems thinking in an applied way. The background, aims and objectives are clearly described, as are the major themes for the project. The challenge for this paper was in outlining and explaining the overall elements of the project with sufficient detail in a way that does not feel like there are lots of bits and pieces. This is where Table 1 on page 9 with intervention examples is particularly helpful, and the data tapestry  is a useful way of identifying all the different data components of the project. However, the evaluation components are included in a separate table, which does make it a little difficult to link the evaluation framework with the broader project.1 have argued a logic model (or a ‘theory of change’) is an essential part of a systems approach. However it was less clear how this rather linear logic model fit within the authors’ definition of a ‘supportive system context’ in terms of the program. The authors have developed a logic model to support the program, which is understandable given others such as Foster-Fishman and Watson2. The researchers have demonstrated how complex systems thinking is informing the intervention but less so for the evaluation framework. This would address the point raised earlier about clearly linking the different evaluation components with the intervention components. The authors briefly explain in the ‘Evaluation framework’ section why complex systems theory and complexity thinking are being used, but it is worthwhile to reflect on complex systems approaches to evaluation, which consider feasibility and appropriateness of complex program evaluations within real world settings3,4 and how this impressive program of work and evaluation will add to it. In the section on co-production, it is necessary to define co-production beyond describing the importance of engaging and empowering citizens through citizen science or participatory action research. For example, given this is an initiative bringing together researchers and policymakers, it is helpful to reflect on why co-production between these two groups is needed, particularly in terms of prevention, or what the existing evidence base is for co-production for preventionWe confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The open letter describes a large and ambitious consortium research project commissioned under the UK Prevention Research Programme. In a similar vein to trial pre-registrations, this letter sets out to pre-register the team's plans to set up two City Collaboratories focused for whole-systems research on influences in childhood and adolescence that shape health outcomes over the lifecourse.  This is clearly a very well thought out project, and it has prevailed through several stages of rigorous selection and peer review, so there is not really anything left for me to critique in terms of scientific quality. The authors present a strong, multi-pronged evaluation framework that allows them to reflect on whether ActEarly is achieving its milestones.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.