Hypertension plays a dominant role in the development of left ventricular (LV) remodeling and heart failure, in addition to being the main risk factor for coronary artery disease. In this review, we focus on the focal geometric and functional tissue aspects of the LV septal base, since basal septal hypertrophy (BSH), as the early imaging biomarker of LV remodeling due to hypertensive heart disease, is detected in cross-sectional clinic studies. In addition, the validation of BSH by animal studies using third generation microimaging and relevant clinical observations are also discussed in the report. Finally, an evaluation of both human and animal quantitative imaging studies and the importance of combined cardiac imaging methods and stress-induction in the separation of adaptive and maladaptive phases of the LV remodeling are pointed out. As a result, BSH, as the early imaging biomarker and quantitative follow-up of functional analysis in hypertension, could possibly contribute to early treatment in a timely fashion in the prevention of hypertensive disease progression to heart failure. A variety of stress stimuli in etiopathogenesis and the difficulty of diagnosing pure hemodynamic overload mediated BSH lead to an absence of the certain prevalence of this particular finding in the population. Heart failure (HF) is a progressive process and associated with the left ventricular (LV) remodeling . HyperteIt is known that LV segmental remodeling could be the case in early-stage hypertension described as borderline hypertension, and the septal wall is speculated to be the first LV wall to become hypertrophic in clinical practice according to cross-sectional studies ,11,12. IOur earlier reports showed a high heart rate–pressure product and high LV outflow tract blood flow as well as basal septal hyperdynamic tissue under stress in BSH patients with hypertension ,18,19,20In the animal validation studies, we also detected a remarkable velocity increment in the early time points after transaortic construction in pathologic stress, which was consistent with the findings in cross-sectional clinic studies . HoweverBP monitorization under stress is insufficient in patients with LV septal hypertrophy during clinical practice. In fact, no attempt was made for BP recording during exercise even in the comprehensively planned CMR study in which physiologic exercise in a healthy population was speculated to be the reason for septal hypertrophy . We emphBSH plays a role as a common denominator for variety of stress stimuli beyond basic hemodynamic stress-mediated LV remodeling. Due to this complex nature of BSH, we previously described this morphological finding as the ‘stressed heart morphology’ (SHM), which was documented as an imaging figure in both acute and chronic stress-mediated heart conditions such as acute stress cardiomyopathy  and hypeIn fact, while a smooth curvature is the case in some patients , anotherSympathetic overdrive more dominantly involves the LV base compared to the midapical myocardial segments. However, despite the fact that it is a potentially possible etiologic mechanism, there has not been any chronic mental or emotional disorder documented or described except acute stress cardiomyopathy in the development of SHM. Heterogeneity involved in remodeling in humans produces a dilemma not only in a certain diagnosis of pure hemodynamic overload-mediated BSH in hypertensive patients, but in the certain determination of BSH prevalence in the population.On the other hand, years later, we have determined LV segmental remodeling in an animal model that is associated with a very regular distribution a,b underHF with preserved ejection fraction (HFPEF) is a relatively new clinical entity and the number of HFPEF patients is increasing worldwide. As the majority of the HFPEF patients have systemic hypertension, HFPEF is usually accepted as a hypertension-mediated phenomenon. The preserved global systolic function has been documented by freehand three-dimensional echocardiography at rest in HFPEFpatients . HoweverThe efficacy of preventive measures to slow the progression of hypertensive heart disease supports the concept that hypertrophy is possibly a reversible stage of LV remodeling . HoweverHypertension-mediated HF describes a mild LV remodeling mostly observed in female patients . It is eIt has been mentioned that myocardial fibrosis is associated with diastolic HF in hypertensive heart disease . The accAge-related myocardial fibrosis may adversely affect the contractile reserve, especially in elderly hypertensive individuals. Recent data have shown that contractility may become blunted by stress induction in patients older than 70 . InteresThe collected data showed that blood pressure control is an essential step in patients with hypertension-mediated consequences leading to vascular mortality ,51. The According to another comprehensive study from the Johns Hopkins Medical Institutions, HFPEF patients who are on an effective medical therapeutic regimen (68% use of an ACE inhibitor) have similar endocardial and mid-wall fractional shortening compared to that of hypertensive LVH . This prAtrial fibrillation (AF) is an important problem during follow-up in hypertensive patients. HFPEF with AF is associated with a greater mean LV mass compared to systolic HF patients with AF, which supports the special importance of long-standing hypertension as the risk factor in HFPEF patients . It may As a result, since LV remodeling leading to HF is a progressive process, an LV segmental evaluation seems important, not only in the determination of BSH as the early imaging biomarker, but in a severity assessment of LV myocardial regions in advance hypertensive cases with global LV remodeling. It is documented in the literature that precise patientmonitorization using novel cardiac imaging can successfully contribute to differentiating the stages of disease course and successful, widespread long-term medical management.


In recent years, millions of citizens all over the world have used digital dating services. It remains unknown to what extent human sexuality will be changed by this. Based on an evolutionary psychological perspective, we assume that sexual selection shaped behavioural tendencies in men and women that are designed to increase the reproductive fitness. These tendencies are referred to as sexual strategies. Males and females sexual strategies differ according to sex-dimorphic reproductive investments. We assume that this inheritance will affect human sexuality also in a digital future. To evaluate this assumption, we conducted a selective review of studies on digital dating services. Based on sexual selection theory, we derived a number of hypotheses regarding how men and women will use digital dating services typically and how the use of digital dating services might affect sexual wellbeing. Out of an initial data set of 2,568 records, we finally reviewed a set of 13 studies. These studies provided support for the notion that men and women act in the digital dating area according to sex-typical strategies. However, sometimes the circumstances of digital dating affect communication flow, e.g., in that men are even more active in establishing contacts than they are in real world conditions. Overall, women appear to accomplish their sexual goals in digital dating arenas more than men do given a surplus of male demand. Our results suggest that future human sexuality will be impacted by an interaction of both: sex-dimorphic ancient sexual strategies and new technologies. Digital applications have widely influenced everyday life in most human societies. Moreover, there is good reason to assume that this holds true for the sexual life histories of many citizens in modern societies as well. For example, dating platforms have millions of users. Thirty percent of German adults have used a digital dating service at some point . About 4It is possible that online sexual activities diverge from offline sexual behaviour. Dating platforms offer highly differentiated services addressing a growing variety of sexual contacts. People engage in long-distance sexual activities like cybersex via webcam, chatting with sex bots or interacting with sex robots. The division between porn users and porn producers has also vanished since platforms that broadcast users’ own sexual activities are provided. In light of these new developments, one might argue that digital sexual services will change human sexuality in the future. Some observations, however, call this assumption into question. In modern gender-equal societies, gender-stereotyped personality traits and gender-stereotyped job careers are more frequent in comparison to more traditional gender unequal societies . These fIn the following, first we will outline some basic ideas of sexual selection theory , and secSexual selection, as one specific case of natural selection, operates on variance in reproductive success. If individuals differ in mating success, traits that aid their reproductive success will find their way to subsequent generations more frequently. Hence, adaptions will follow sexual selection. Traits that aid reproductive success differ between the sexes. Given that the more investing sex, i.e., females in mammals, needs more time for any reproductive act (because of gestation and lactation), sexually receptive females become scarce relative to males. Because of female scarcity, males more than females are selected for their ability of effectively compete for mates. In consequence, in males variability in reproductive success is higher than in females, not only in mammals , p. 147 Numerous studies across various cultures have provided empirical support for the assumption that sexual strategies of men and women follow the predictions of sexual selection theory. Women show a higher preference than men for mates who possess resources and are willing and interested in investing in children; men, in contrast, show a higher preference than women for physically attractive and young mates . Same seIn natural environments, the operational sex ratio  influences the sexual strategies of males and females. If there is a surplus of females, sexual competence between women increases and women tend to lower the preconditions for sex. Women engage more in short-term sex when there is a surplus of women – sex becomes cheap. In the opposite case, women’s willingness to engage in short-term sex decreases . The impGiven the absence of some natural restraints in digital encounters  we furthermore expect that using digital dating tools can lead to an amplification of sexual benefits as well as harm. Possible benefits might be an increased probability of finding a good mate in consequence of having access to a wider mating pool. Psychological harm can be the result of sexual conflicts. In evolutionary psychology sexual conflicts refer to those instances in which one individual tries to realise its sexual strategies  at the cost of its partners sexual strategies (respectively the partners fitness) . There afemale mating preferences will shape the online mating market as follows: (i) a high level of education will be demanded more in men than it is in women; (ii) if there are men of different races, white men will be more eligible than males of colour; (iii) high-status men will look for younger women more than lower status men do; and finally; (iv) men will show in their personal ads more signs of physical strength than women do. Men’s mating preferences for numerous, young and physically attractive women will shape the online mating market as follows; (v) men will use dating platforms, hoping to extend the number of sexual partners, more than women do; and (vi) being of an older age is for women less favourable than for men.In detail we hypothesise that interaction of male and female sexual strategies will have the following consequences in the online dating market; (vii) women will receive more requests than men do, and (viii) will receive more responses to their own requests than men do; (ix) women will be more self-centred in their profiles and communication than men; (x) highly attractive women will give fewer responses to requests than less attractive women; (xi) compared to men, older women will use dating services more frequently than younger women do.The increased sexual wellbeing, we expect that; (xii) couples who meet in online settings will be more satisfied with their relationship than offline couples are (given the higher number of choices). With respect to sexual conflicts and risks to sexual wellbeing, we expect that; (xiii) women to be more frequently subjected to sexual deception because men are expected to display more emotional commitment than they actually feel (and a less possibilities for women to detect deception). We furthermore expect that; (xiv) using digital sexual dating services can be associated with or driven by psychological problems, such as feelings of loneliness or low self-esteem and finally; and (xv) that people who use online dating services show risky sexual behaviour more than others, e.g., unprotected sex.With respect to To evaluate these hypotheses, we conducted a selective review of recent studies on digital sexual dating services.We first conducted an extensive literature research. We performed the literature research using the PubMed database. Given that online dating services constitute a rapidly changing market, we limited our literature research to studies with a publication year from 2015 to 2021. The search was restricted to publications written either in English or German. We used the following search terms: online dating (525 hits); infidelity, online (24 hits); sexual risk behaviour, online dating (51 hits); dating applications ; relationship, satisfaction, and online (910 hits). Our search string was as follows: Online Dating OR (Infidelity AND online) OR  OR Dating applications OR (Relationship AND satisfaction AND online). Every string was searched alone, there were 7 duplicates. In total, we found 2,568 publications in this initial step.Using several additional selection procedures and excluding criteria, we consecutively reduced the sample . First, Given that our review is focussed on sexual strategies in online dating, articles dealing with sexuality in the context of social media  were excluded. Although social media use in many cases leads to sexual interactions, social media are first designed for other purposes, making it more complicated to study sexual strategies in this area. Furthermore, articles that focussed on only one aspect of online dating  were excluded as well. Furthermore, we were forced to exclude some articles because they were not available online. After applying these selection procedures, 13 articles remained. In a second step, we then reviewed the remaining 13 studies according to our study hypotheses.All the studies included in the review were exclusively cross-sectional studies. In the following, we report the findings of the reviewed studies with respect to the hypotheses as stated in the introduction see also .female mating preferences:Findings related to (i) A high level of education will be demanded more in men than it is in women. Applying a detailed network analysis of messaging patterns and demographic variables in a data set of a huge dating platform, (ii) If there are men of different races, white men will be more eligible than males of colour. In the same study  High-status men will look for younger women more than lower status men do. In a subsequent analysis, the same authors ( authors  found th(iv) Men will show in their personal ads more signs of physical strength than women do. One study analysed more than 900 self-portraits (“selfies”) that male and female Tinder users chose for their personal profiles  Men will use dating platforms, hoping to extend the number of sexual partners, more than women do. By means of an online survey with more than 700 participants, it was found that men use dating platforms, hoping to extend the number of sex partners, more than women do; however, they do not succeed in this as much as they expected to (vi) Being of an older age is for women less favourable than for men. The above-cited network analysis of messaging patterns revealed in addition that being older is for women less favourable than for men  Women will receive more requests than men do. Two studies that analysed online communication patterns in huge samples reported that women receive more requests than men do (n men do . In part(viii) Women will receive more responses to their own requests than men do. This was also reported by the study of (ix) Women will be more self-centred in their profiles and communication than men. The study of Davis and Fingerman analysed 4,000 profiles of two popular websites by means of a linguistic inquiry and word count software. The authors found that women are more self-centred in their profiles than men are ( men are .(x) Highly attractive women will give fewer responses to requests than less attractive women do. (xi) Compared to men, older women will use dating services more frequently than younger women do. Bruch and Newman found in their subsequent analysis that in younger people, more men than women use online dating services; however, in older people this difference decreases  Couples who meet in online settings will be more satisfied with their relationship than offline couples are. Contrary to our hypothesis (xiii) Women are more frequently subjected to sexual deception than men are. Similarly, we did not find evidence that women are more at risk of being sexually cheated than men are in digital contexts as revealed by an online survey with more than 600 individuals  Using digital sexual dating services can be associated with or driven by psychological problems, such as feelings of loneliness or low self-esteem. Performing an online survey on more than 1,000 Tinder users, one study reported a “high level of problematic use” in nearly 1/3 of the sample. In these individuals, using sexual dating services is associated with psychological problems, such as feelings of loneliness or low self-esteem in some cases (me cases .(xv) Users of online dating services show risky sexual behaviour more than others. There is conflicting evidence concerning whether people who use online dating services show risky sexual behaviour more than others. Whereas (particularly in men) than in controls, This selective review evaluated a total of 13 cross-sectional studies on digital dating services. Evolutionary psychological reasoning and some hypotheses, which we drew from this, drove our analysis. Taken together, our selective review supports the notion that human sexuality is not going to change fundamentally on account of the rising popularity of digital dating services. The hypotheses that led our review covered four broader topics: (a) female mating preferences, (b) male mating preferences, (c) interactions between male and female mating preferences and finally, and (d) sexual wellbeing. The reviewed studies provided supporting evidence particular to hypotheses regarding mating preferences (a–c), which were derived from evolutionary psychological reasoning. Our hypotheses regarding sexual wellbeing received only partial support.Some of the reviewed studies provided findings that are in accord with evolutionary psychological reasoning. These studies report that women in the digital mating market appreciate men of higher education and of white colour. Both attributes are associated with higher socio-economic status in many countries. High-status men in turn look for younger women, as one study reported. This indicates that high-status men in digital mating markets are aware of female mating preferences. Both findings  have previously been found in non-digital mating markets . One of We assume that female mating preferences  are shaped by sexual selection and modulated by culture and actual conditions of the mating marked (in terms of demand and supply). The findings discussed so far indicate that humans act according to female mating preferences in (sometimes anonymous) digital dating arenas more or less similar to real-world encounters.According to sexual selection theory, males have more fitness benefits from having numerous sexual partners than females do. Therefore, males are predicted to pursue more sexual partners than females. In humans, this is particularly evident when looking at gender differences regarding interest in short-term sex . This haA striking gender difference was reported by the study of Bruch and Newman in that 80% of first messages were sent by men . Given tHowever, it is not self-evident that a surplus of male demand in the digital  market is only driven by male’s (ancient) strategy to find as quickly as possible as many mates as possible. In a seminal review, Contrary to our expectations, we found no studies that reported high numbers of persons being victims of sexual deception (as described above). However, we found no study that investigated this topic from an evolutionary psychology viewpoint directly. Taken together, the reviewed studies provided mixed information about whether using digital dating services might lead to increased sexual wellbeing or not. In Tinder users, feelings of loneliness or low self-esteem were found quite often ; others The findings of this selective review are limited by the fact that the studies included in our review were not designed to test evolutionary psychological hypotheses. This has led to a type of methodological cherry-picking in the sense that we just looked at the reviewed studies for evidence that seemed to match with (or contradict) our expectations. One problem with this approach is that the samples of the reviewed studies were of quite different origins. Some studies were based on representative samples of the general population, whereas others focussed on particular individuals, e.g., Tinder users or individuals in committed relationships. Moreover, our review covers different types of dating services; some of them offer opportunities for short-term dating, whereas others focus on long-term dating. These aspects also influence the operational sex ratio. There is ample evidence in evolutionary psychology that people experience different sexual preferences and apply different strategies depending on whether they are looking for a short-term mate or a long-term mate and depending on whether there is a surplus of males or females in a given mating arena. This leads to some limitation in the reported findings given that our hypotheses were found to be proved sometimes in one sample type but not in another sample, and vice versa. In most cases this was influenced by the fact that not all studies we reviewed provided information regarding all our hypotheses.Digital sexual services go far beyond pure dating platforms: cybersex via webcam, chatting with sex bots, sex robots and self-broadcasted sexual content are recent developments in a fast-developing digital market. In the light of the findings reviewed here so far, we assume that these developments and future digital sex services will be driven by both, new technologies and ancient sexual strategies of men and women; however, it is hard to predict how both factors will interact in future. It should be subject of an ongoing research. To circumvent the limitations of the present selective review we recommend that future studies should directly test hypotheses that are derived from evolutionary psychology in samples that engage in different types of digital sexual services.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.JP, KD, and AS contributed to conception and design of the study and wrote sections of the manuscript. KD and JP organised the database. JP wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Across millennia and societies, the aesthetic diversity of human imaginative culture appears stunning. This tendency is especially pronounced today, where the arts seemingly manifest unprecedented variety. It is appealing to regard human artistry as literally unbounded in its creative potential.In this opinion piece, I argue that this unbounded view of human aesthetics is illusory. The contingent evolutionary basis of our humanity implies that our aesthetic and creative capacities are biologically constrained in fundamental ways  development of artistic styles themselves represent a neglected line of evidence that can further support and inform art's biological basis. I then discuss how biological or evolutionary views might address the challenges posed by contemporary modernism and postmodernism, two culturally prominent anti-traditional movements which undergird the contemporary ‘crisis' of the fine arts Pinker, . I closeThe degree to which human aesthetics are constrained by our evolutionary past has strong implications for artistic traditions' trans-historical unfolding. An exclusively culture-driven, “blank-slate” aesthetic mode has few built-in constraints and should yield a history with minimal systematic long-term trends. In contrast, an evolutionary view, constrained by basic psychobiological mechanisms, implies significant structure in the development of the arts in historical times, as these mechanisms play out in predictable ways. la Elkins show clear directionality and are thus perhaps more promising targets for evolution-informed analysis. Life history trajectories are typically arch-shaped, tracing the development then decline of a tradition, but other paths—like a linear or accelerating increase over time—are possible.How aesthetic traditions unfold has long been of interest in the humanities. For instance, Elkins  discusseStyle trends can be parsimoniously understood via psychobiological processes deployed by individuals to achieve their creative and aesthetic goals Kozbelt, . Such prMartindale's  visionarFor instance, one provocative question is how Martindale's  trans-hiAnother challenging issue involves the later stages of artistic traditions. This has special relevance in today's artworld, which—despite its variety—is sometimes regarded as exhausted Danto, . Over thOne might approach this issue by asking if documented trends from the past—like Martindale's  trajectoThe fundamental endgame bottleneck is the inability of the fine arts in their late stages to meaningfully communicate to audiences. On this note, Martindale  describepost-hoc socio-cultural account the best we can do?Keyser's  notion oDisentangling these threads is challenging but not impossible. If modernism or postmodernism resembles other artistic periods, then similar patterns should be evident in quantitative measures like the strongly positively skewed distribution of creative achievement Murray,  and tranAnother possibility is that the broad-brush picture of the arts today is not so different from the past: a complex cultural system consisting of many niches with different characteristics and dynamics and audiences and selection pressures, but numerically dominant popular forms partaking of humanistic natural aesthetic principles, with hedonic enjoyment of beauty and meaning-making paramount in aesthetic experience Kozbelt, . If the Empirically addressing such issues would constitute a productive, provocative research agenda. Testing the assertion that our biological inheritance remains relevant to the contemporary arts (see Kozbelt, The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Consider that multilateral food aid and regional food security mechanisms may incompletely adapt to the challenges of climate change in future practice. This study proposes a framework of bilateral emergency export reserve mechanism to encourage both participating countries to jointly appoint a transnational agribusiness to manage emergency export reserves as a means of fulfilling its corporate social responsibility (CSR). This mechanism has the features of simplified negotiation, more transparent operating procedures, along with reciprocity in bilateral cooperation, which would provide grain importing countries with a higher degree of safeguarding food security. After the 2007–2008 food crisis, successive droughts in Russia and the United States have reduced grain production, causing the surge in global food prices during the period 2010–2012 , 4, coupGlobal food prices have stabilized over a period of 5 years. This has led many consumers to experience the benefits of affordable food prices and have gradually weakened people’s awareness of the potential of recurring food crises. However, growing public concerns on food shortages spurred panic buying in the first half of 2020 due to pandemic disruptions in food supply chains, such as the suspension of production of food processing factories due to cluster infections and logistics disruptions caused by restrictions or lockdowns  predicteOver the past few decades, global food prices in nominal term have clearly trended upward since the 1970s, inflation-adjusted term began to reverse the downward trend in 2001 to increase steadily in later years. Prices soared during the period 2008–2011, and then maintained a somewhat stable level during the period 2015–2019 —we may eGrain exports from Russia and India have grown markedly in the last decade, increasing both countries’ influence on global food security. In recent history, Russia has sometimes experienced crop shortfalls due to abnormal drought, causing the country to purchase grains abroad in the early 1970s. Nearly four decades later, Russia has imposed a wheat export ban due to poor wheat harvests in 2010, which pushed up international wheat prices and had a profound impact on the economy and politics of North African countries . FurtherGovernments in some food-importing countries took countermeasures, though with limited effects, to reduce the impact of export restrictions imposed by major food-exporting countries, triggering public resentment and political unrest , forcingThe purpose of the regional food reserve mechanism is to improve regional food security by earmarked or stockpiled emergency food reserves of the organization’s member countries. However, earmarked emergency food reserves of the organization’s member countries may be insufficient to cope with large-scale disasters, and political struggles among major donor countries may undermine assistance capability. Further, this may be accompanied by the economic power and political influence exerted by larger participating countries on regional countries. There are additional concerns that some of the organization’s member countries have a free-riding mentality, and that food-exporting countries will be concerned about the impact of regional food reserves on free trade in grains, thus reducing the effectiveness of the mechanism during food crises.Progress in strengthening multilateral agreements on export restrictions has been stagnant since the 2007–2008 food crisis. In addition, major food-importing countries encountered challenges in improving national food security. This study proposes to utilize a bilateral emergency export reserve mechanism with transnational agribusiness as a carrier to address the possible outcomes of climate change. This mechanism would have the properties of bilateral cooperation and mutual benefit with the primary goal of enhancing a safety network through international trade relations between grain importing and exporting countries. The following sections discuss two substantial determinants of food security including climate change and export restrictions, practices and challenges of developing Asian countries in improving their own national food security after the 2007–2008 food crisis, the roles of transnational agribusiness in food security, and the later section proposes a bilateral emergency export reserve mechanism. Conclusions and future research directions are in the last section.Global food security is affected by natural and man-made disasters. Climate change predictions suggest to increase the number and severity of natural disasters with likelihood of food crises in the future, and trade restrictions further exacerbate the severity of each food crisis by limiting supply as described below.The major impact of climate change on food supply is likely to slow down the growth rate and increase the instability of grain production, while higher average temperatures will shorten the growing season and reduce crop yields. An accelerated pace of climate change would have a greater negative impact on crop yields because of the non-linear relationship between yields and biophysical stresses. Once the temperature surpasses a critical threshold, crops will suffer severe damage and lead to a rapid decline in output .With increasing scarcity of water resources, the shrinkage of agricultural land caused by industrialization, urbanization, environmental pollution and land degradation, coupled with the occurrence and severity of plant diseases and insect pests, as well as more severe natural disasters caused by weather extremes, such as forest fires, sand and dust storms, erratic rainfall in some areas, as well as hurricanes and floods, there is a possibility that sea level rise will accelerate . MeanwhiIn addition to weakening the food security system in the Horn of Africa and the Middle East that are recurring famine and malnutrition, the food supply in India and Southeast Asia will be the most vulnerable regions affected by climate change , 22. TheAlthough the cultivation areas in high-latitude countries may be benefited by climate change, local planting conditions will be a factor. For instance, the poor soil condition in northern Russia makes it impossible to simply migrate wheat production to the northern part of the country to offset crop yield reductions in lower latitudes. There is also a possibility of breeding new varieties through genetic modification, which would allow those crops to adapt to weather extremes, but they will still face biophysical limits . Unless If we would continually see more extreme climate events and disasters caused by accelerating climate change, such as droughts, floods, heat waves, and ENSO extremes, these would gradually increase the systemic risk of production shocks. In the second half of the twentieth century, a once-in-a-century production shock event occurred. It is estimated that such shocks may occur as a once-in-30-year event by 2050, a risk increase of more than threefold. The worst-case scenario is that two successive critical harvests may be lost in major grain production areas, which could lead to an unprecedented systemic crisis , 24, 25.In recent history, there have been several grain price spikes with some regularity, approximately every 30 years . A long-Policymakers in some grain exporting countries imposed export restrictionsWhen grain importing countries are confronted with rising food prices, this can cause strong public resentment and tremendous pressure from social unrest , 30. PolIf grain exporting countries impose export restrictive measures and grain importing countries lower tariffs to increase imports, this may further drive up international food prices, causing the final results in trade volumes to be less significant . FAO repTaking the 2007–2008 rice crisis as an example, the thinness in the international rice marketNotwithstanding that Indian policies may have started the 2007–2008 rice crisis, the crisis stemmed in part from poor wheat harvests in Australia in 2005–2006 , which lAfter the 2007–2008 food crisis, some experts and scholars in agricultural trade policies proposed to strengthen WTO disciplines on export restrictions and to reduce the asymmetry in WTO regulations, mainly aimed at Article XI “General Elimination of Quantitative Restrictions” of GATT 1994, and Article 12 “Disciplines on Export Prohibitions and Restrictions” of the Agreement on Agriculture (AoA) , 29.The regulatory deficiency or under-regulation of WTO provisions on export restrictions are as follows , 29. FirIn order to remedy regulatory deficiency, Sharma  proposedOn the other hand, the tax-rate quota imposed by grain exporting countries in the same way as the tariff-rate quota (TRQ) will face how to set an appropriate quota, as well as the in-quota rate and the bound rate. Furthermore, grain exporting countries only need to activate tax-rate quota during the period of insufficient grain supply. However, as the urgency of exporting surplus grains in bumper harvest seasons, it becomes difficult to impose tax-rate quota regularly.Asia is the most populous continent and Southeast Asia is one of the world’s most vulnerable regions to climate change. After the 2007–2008 food crisis, more developing Asian countries reinforced their national food security by boosting domestic production, adjusting national food self-sufficiency goals, and increasing the size of public grain reserves. They also sought to improve food self-reliance of some staple grains by promoting grain trade, as well as advocating and participating in regional cooperation for food security. But problems remain as follows.The grain importing countries attempted to diversify their supplier base after the 2007–2008 food crisis, but that increased the cost of imported grains . AdditioSome Asian developing countries including China, Indonesia, and the Philippines intended to enhance national food security through adjusting food self-sufficiency goalsWhen the world wheat stocks-to-use ratio was at a relatively low level since 1970, that became the root cause of pushing up global wheat prices . In 2001Managing public grain reserves (buffer stocks) is not an easy task, the difficulty lies in storage costs and how to construct transparent and effective rules to determine the best time to buy and sell stockpiles, regardless of whether a price band or a price floor is used for the operational strategy. For instance, the rules for properly determining upper and lower limits of the price band and trigger conditions have to be dynamically adjusted based on medium- to long-term trends and fluctuations in historical grain prices. Crucially, without sufficient funds, public grain reserves will eventually fail in theory and in practice , 29, 56.The aim of the regional food reserve mechanism is to enhance food security in the organization’s member countries. However, insufficient total commitments by the organization’s member countries may limit the capability of the regional grain reserve scheme to respond to the emergency needs of large-scale natural disasters, partly because some member countries of the “free rider” mentality are perceived to be unwilling to contribute their “fair share”. Further, other grain exporters can be expected to resist such schemes due to conflicts of interest.Taking ASEAN Plus Three Emergency Rice Reserve (APTERR) as an example, authorized representatives of the Association of Southeast Asian Nations (ASEAN) member countries, China, Japan, and South Korea have signed the APTERR agreement in October 2011. Although APTERR’s three programmesIn addition, the earmarked rice reserves of ASEAN member countries were much lower than those of the Plus Three countries . Some ASEAN member countries made commitments merely for diplomatic purposes and only provided the bare minimum required. This caused total earmarked rice reserves of APTERR to be insufficient for large-scale nature disasters. Thus expanding the amount of earmarked rice reserves will be a necessary measure to enhance the capability of APTERR, especially for major rice exporters, while those with limited rice production capacity will need to increase cash donations to APTERR , 59.It is worth noting that climate change has gradually aggravated the severity of natural disasters, which may cause regional food shortages even more synchronized, and reduce the risk-sharing capability of countries in the region. Those countries may eventually require seeking assistance from outside the region. In addition, because APTERR is a regional rice reserve scheme, Southeast Asian countries are the major rice-exporting region in the world and they have encountered relatively mild resistance from rice-exporting countries other than APTERR member countries. However, if APTERR member countries agree to expand staple grain reserves beyond rice in the future, this could result in stronger opposition from other grain exporting countries.In the past few decades, transnational agribusinesses rarely involve in multilateral and regional food security mechanisms. Instead, dominant transnational food processors and commodity traders such as Archer Daniels Midland (ADM), Bunge, Cargill, and Louis Dreyfus (abbreviated as ABCD) control a fair amount of market share with extensive distribution network in the global grain trade and grain and oil seed processing industry. ABCD’s financial services divisions engage in financial transactions via derivative financial instruments in commodities futures markets, and have provided investment products to third-party investors in the last decade .A food supply chain is roughly composed of producers (growers), manufacturers (processors), distributors , food service providers, retailers and consumers . Maloni Transnational processors and/or retailers comply with these certification mechanisms provided by third-party organizations, such as UTZ Certified, SCS-001 and GLOBALGAP  and requIn summary, food safety and quality are the priority of food supply chain members for consumers under normal circumstances. However, the most important thing for consumers in emergencies is the quantities of adequate food available to support their basic needs. That is to say, there is no food safety without food security. From the perspective of CSR under climate change, it is worthwhile to require that transnational agribusinesses, especially food processors and commodity traders take more responsibility in food security within their business scope to keep this issue from arising in a crisis.This study proposes a framework of bilateral emergency export reserve mechanism based on multilateral and regional food security mechanisms which may incompletely adapt to the challenges of future climate change. The mechanism requires that part of a surplus of harvested grains in the grain exporting country be purchased at market prices with eligible post-harvest treatment by a transnational agribusiness, which is jointly appointed through grain exporting and importing countries, and be stored directly in local granaries of the producing country as emergency export reserves.8The principle is that a surplus of harvested grains will be purchased utilizing the cereals stocks-to-use ratio of the grain exporting country as an indicator to determine the level of crops exceeding the normal level within a certain period of time. For instance, it may be based on something as simple as determining if the cereals stocks-to-use ratio in the current year is greater than two standard deviations beyond that ratio’s moving average in the the past 5 years in the grain exporting country. However, the appropriate criteria-setting should be determined through bilateral negotiations of grain importing and exporting countries, with a goal of reducing the impact on consumers’ economic interests in the grain exporting country.In addition, while some grain importing countries separately signed bilateral emergency export reserve agreements with the grain exporting country, the distribution of newly purchased grains for emergency export reserves for grain importing countries can be subscribed in accordance with the share of each grain importing country, that is, participating in this mechanism in the export of grain exporting country for a certain period of time. If a certain importing country renounces its right to preferentially subscribe for quotas of emergency export reserves, then the remaining grain importing countries participating in this mechanism will take over the subscription proportionally.The timing and conditions of releasing stockpiles in emergency export reserves would be divided into two parts. First, if a grain importing country participating in this mechanism has to release its own strategic grain reserves (assuming 1 month), this signals its national grain stocks are almost exhausted. In that event, after deducting the storage loss rateAfter the edible stockpiles are sold to the grain importing country, the transnational agribusiness will repay procurement costs to the “emergency export reserve fund”. Additionally, if the transnational agribusiness makes profits from releasing those stockpiles,We must also address the shelf life of stockpiles. Those which are about to expire can be made into processed foods or livestock and poultry feed and sold by the transnational agribusiness to the grain importing country, which serves as a possible source to make profits regularly for the transnational agribusiness. Both procurement costs of stockpiles and taxation on those processed foods or feed for exports could serve as supplementary sources for an “emergency export reserve fund” for the grain exporting country. If the processed foods made via this mechanism continually increase, that may place pressure on grain importing countries who must purchase those processed foods. One way to help would be for the grain exporting country to eliminate or reduce the differential export tax (DET).To summarize, this mechanism has the features of reciprocity, food security enhancement and trade promotion. The expected benefits are as follows. First, transnational agribusiness purchases part of surplus grains as a source of emergency export reserves based on market prices instead of guaranteed purchase prices to reduce trade-distorting domestic support for grain production and ease the fiscal burden. Meanwhile, it also reduces the impact of lower grain prices on farmers, and mitigates the pressure of selling surplus grains abroad by imposing export subsidies by the grain exporting country in bumper harvest seasons. In addition, the grain exporting country should undertake the obligation to stabilize grain supply, benefiting from the gradual opening of the markets of grain importing countries. Transnational agribusiness can also maintain a closer relationship by serving oversees customers in their emergency needs and manifest its CSR efforts.Secondly, the grain exporting country would establish a certain scale of emergency export reserves, with the timing of releasing those stockpiles in emergency export reserves to be determined by either the grain exporting country imposing export restrictions due to crop failures in its own country (which tightens the demand–supply gaps in world grain markets) or because of emergency needs in grain importing countries, perhaps due to natural disasters or other causes.The advantages of emergency export reserves are illustrated below: (1) emergency export reserves can be regarded as the second line of defense for food security for the grain importing country, thus reducing the impact of any export restrictions imposed by the grain exporting country participating in the mechanism; (2) the grain exporting country would allow a one-time release of stockpiles in emergency export reserves based emergency needs on grain importing countries. This would surpass the announcement effect of improving the food security of grain importing countries , 43, andIn addition, locating storage facilities nearer to potential recipient countries will allow them to receive rapid food aid. Perhaps the location of emergency export reserves can also be nearer to rail or shipping transport facilities for faster delivery of those stockpiles, which may also shorten the response time of emergency needs from the grain importing country.Third, the impact of climate change on the food security system of grain importing countries seems to be increasing, so the bilateral emergency export reserve mechanism would be a means of reducing the impact on food security of the grain importing country during times of turmoil in global grain trade. This may also allow international humanitarian organizations such as WFP to focus more on assisting the most vulnerable countries in emergency needs.At the same time, the grain importing country should be willing to pay for deposits of surplus grains of grain exporting countries, even in years where they have good crops and have filled its own storage facilities. Because doing so has the merit of enhancing national food security and increasing the transparency of its grain reserves information.Fourth, the grain importing country may purchase those stockpiles in emergency export reserves at market prices of normal years, with some added costs due to the inevitable depreciation. This will probably be at a better cost than those which must be purchased in emergencies and this has the benefit of reducing the distortion effect of G2G emergency procurement on international trade. It is worth noting that both importing and exporting countries may wish to consider signing penalty clauses for breach of contract, as well as provisions to terminate the agreement in extreme situations, rather than facing the default risks to all parties.Finally, the bilateral emergency export reserve mechanism can be signed in the form of Bilateral Trade Agreement (BTA). This mechanism could generate a positive spillover effect for regional food security by providing increased visibility and the ability to plan on a larger scale. Due to oligopolistic structures in international grain markets and things such as transportation costs and timeliness, the number of grain exporting countries that eventually sign these clauses with a certain grain importing country may be limited. Furthermore, regional food security could be reinforced in advance through market mechanisms that allow grain exporting countries to provide their own reliable services of emergency export reserves for grain importing countries, which would give the exporters in the mechanism a competitive advantage over those who are not in the mechanism.In recent years, the world cereals stocks-to-use ratio has so far been higher than the 2007–2008 level, and regional conflicts have been limited to some areas that have not yet affected major grain production regions. These have reduced the occurrence of short-term global food crises. However, a rapid rise in trade protectionism and the latest COVID-19 pandemic have hindered the process of global trade liberalization. Continued global population growth and long-term growth in per-capita GDP coupled with limited resources, and climate change could be a substantial influence on the long-term global food supply in the future, leading to the gradual reduction of food supply as well as demand gaps. These things may well serve to increase the frequency of contemporary food crises in the future. Further, almost every country around the globe engages in economic growth and full employment as the priority for governance, so that it may be doubtful that actual carbon reduction will progress as hoped for.It is observed that major food-exporting countries tend to inevitably impose export restrictions to protect national food security in the event of production shocks caused by climate change in the future. In addition, the impact of export restrictions will increase the risk of trade frictions between grain importers and exporters, and also the time required for grain importing countries to restore their confidence in food self-reliance. Further, faced with a food crisis, because of stagnation in the amount of in-kind assistance results in the increase in cash assistance provided by international humanitarian organizations. These couple with limited capability of regional food security systems motivate the proposal of a bilateral emergency export reserve mechanism in this paper. This would be an adaptation measure to prepare for the possibility of climate change. Transnational agribusiness would be appointed to manage a certain amount of stockpiles for emergency export reserves in the grain exporting country to strengthen grain importing country’s food security while providing more consistent markets for grain exporters. The timing of replenishing and releasing those stockpiles in emergency export reserves would be largely determined by the transnational agribusiness based on the principle of establishing a food security mechanism to meet emergency needs that may arise. This should also serve to simplify operating procedures and to increase its transparency, and more importantly to reduce the impact of trade shocks on grain importing countries participating in the mechanism.The mutual trust and cooperation of grain importing and exporting countries participating is crucial in developing a sustainable mechanism. This mechanism can be incorporated into the bilateral trade agreement (BTA) signed by the signatories, and the activation of this mechanism requires fiscal support and congressional approval of the signatories. The maintenance of its operation depends on the management capabilities of the appointed transnational agribusiness. Therefore, responsible agencies of the signatories need to conduct regular reviews with the appointed transnational agribusiness, especially after each food crisis. Accumulating operational experience and improving deficiencies in management will help narrowing the gap between performance and goals, and make the mechanism more sustainable in responding to emergencies. Further, if this mechanism operates normally in major grain importing and exporting countries, it may serve to demonstrate that there may be an incentive for other grain importing and exporting countries to sign their respective bilateral emergency export reserve agreements under the same framework, thereby realizing bilateral cooperation for food security in practice and indirectly promoting regional food security in advance. Meanwhile, it is also a possible source of supplementary reserves to reduce the operational burden of multilateral food aid or regional food security systems.The completeness of laws and the support of theoretical models and empirical evidence enhance the resilience of the mechanism as a prerequisite for its economic operation, therefore, future research directions are suggested as follows: (1) the clear determination of “property rights” to the emergency export reserves needs to be made to ensure that the grain exporting country will fulfill its obligations to release those stockpiles in emergency export reserves; (2) a quantitative model must be established to institutionalize and regularly adjust the optimal level of emergency export reserves to improve management efficiency; (3) a determination of the proper insurance coverage for both grain importing and exporting countries must be made to allow for emergency export reserve reinsurance; (4) to reduce storage costs and improve the emergency response capacity, the corresponding economic batch quantity in emergency export reserves can be further explored; and (5) allowing farmers to voluntarily store part of their harvested grains in emergency export reserves as well as the “grain bank”


Metabolomics investigates a broad range of small molecules, allowing researchers to understand disease-related changes downstream of the genome and proteome in response to external environmental stimuli. It is an emerging technology that holds promise in identifying biomarkers and informing the practice of precision medicine. In this review, we summarize the studies that have examined endogenous metabolites in patients with psoriasis and/or psoriatic arthritis using nuclear magnetic resonance (NMR) or mass spectrometry (MS) and were published through 26 January 2021. A standardized protocol was used for extracting data from full-text articles identified by searching OVID Medline ALL, OVID Embase, OVID Cochrane Central Register of Controlled Trials and BIOSIS Citation Index in Web of Science. Thirty-two studies were identified, investigating various sample matrices and employing a wide variety of methods for each step of the metabolomics workflow. The vast majority of studies identified metabolites, mostly amino acids and lipids that may be associated with psoriasis diagnosis and activity. Further exploration is needed to identify and validate metabolomic biomarkers that can accurately and reliably predict which psoriasis patients will develop psoriatic arthritis, differentiate psoriatic arthritis patients from patients with other inflammatory arthritides and measure psoriatic arthritis activity. Psoriasis (Ps) is an inflammatory skin disease that affects over 7.25 million Americans and 1.25 million Canadians , which iMetabolomics is an emerging “omics” science that studies a broad range of small molecules (<1500 Da) present in a biological system. This includes diverse chemical and physical structures such as sugars, nucleotides, amino acids and lipids. The metabolome is a rapid indicator of biological status . MetabolThe purpose of this review is to summarize the most recent metabolomics studies in psoriatic disease and determine the gaps in the literature to provide direction for further research exploration. To achieve this goal, we will first introduce the typical metabolomics workflow, summarize and discuss the methods used in each step of the workflow, and finally discuss the results of the studies to identify any gaps in the literature that can provide a direction for future research exploration.Metabolomics studies often follow a standard workflow consisting generally of 5–6 steps . Initialsample preparation techniques are then considered and are dependent on the sample size, type, costs, throughput and resources available. This step is the most critical aspect in the workflow since the type of sample preparation method employed, can have an enormous effect on the observed metabolite profile and in turn, the accuracy of biological interpretation ..7].NMR is a beneficial analytical technique used in metabolomics due to its good quantitative capability in determining absolute concentrations of metabolites with high reproducibility, its minimal sample preparation requirements and ultimately sample conservation since samples are not destroyed ,50. NMR Data is acquired relatively quickly and can be interpreted using established libraries for metabolite comparison . A few lm/z] ratio). MS is commonly paired with either GC or LC separation techniques in metabolomics due to its high sensitivity and good coverage of metabolites . Hi. Hi31]. The skin metabolome of Ps and PsA patients and its association with disease diagnosis and disease activity has been investigated in several recent studies . SeveralVarious lipids have been described at different levels in the skin of Ps patients compared to healthy controls. Mathers et al. described increased concentrations of electrophilic fatty acids in lesional skin compared to non-lesional skin, extracted from Ps patients, suggesting that electrophilic fatty acids may be involved in skin inflammation . Luczaj A few studies seeking to identify biomarkers for disease diagnosis and disease activity in patients with psoriatic disease, have explored metabolites in urine samples . Two stuSetkowicz et al. compared the urinary metabolites of 12(S)-hydroxyeicosatetraenoic (HETE) acid in Ps patients and found higher concentrations of tetranor-12(S)-HETE in Ps patients compared to controls . 12(S)-HA few metabolomics studies in psoriatic disease have examined metabolite profiles in multiple sample matrices . CompariThe majority of metabolomics studies in psoriatic disease herein reviewed focused on discovering metabolites associated with Ps. Differing levels of several amino acids between Ps patients and healthy controls was described. There were some inconsistencies in the literature regarding the levels of asparagine and tryptophan in peripheral blood of Ps patients compared to healthy controls. One study described Ps patients having higher levels of asparagine in serum , whereasNumerous studies have suggested the essential nutrient choline and its derivatives may be potential biomarkers for psoriasis and two studies found a higher relative abundance of choline in skin lesions of Ps patients compared to uninvolved skin ,26. PhosArachidonic acid (AA) is an omega-6 polyunsaturated fatty acid (PUFA), that gives rise to eicosanoid production and abnormalities in AA metabolism were associated with Ps in several studies. AA was found at lower levels in the plasma metabolome of Ps patients compared to controls , and thrOther metabolites that have been found across studies to be potential biomarkers for psoriasis diagnosis are urea and lactic acid. Two studies found higher levels of both metabolites in the serum of Ps patients ,17, but l-arginine/ADMA ratio, threonine, ornithine, glutamic acid, asparagine, urocanic acid and palmitoylcarnitine (C16) [Our literature search revealed inconsistent results regarding the correlation of glutamine with Ps activity. One study described a negative correlation between serum glutamine and PASI scores , while ane (C16) ,19,22,32The diagnosis of PsA may be improved with metabolic biomarkers that are able to differentiate PsA from healthy controls, patients with Ps and patients with another type of arthritis such as RA. Compared to healthy subjects, PsA patients have elevated levels of glucuronic acid in their serum . PsA patOnly a few studies have correlated metabolites with measures of PsA disease activity. In serum, trimethylamine-N-oxide (TMAO) a known risk factor for cardiovascular disease and obesity, positively correlated with PsA skin and peripheral joint activity . AdditioThe purpose of this review was to summarize the most recent metabolomics studies in psoriatic disease and use the determined gaps in the literature to propose a direction for future research. The vast majority of studies presented in this review, identified metabolites that may be associated with psoriasis diagnosis and activity. These studies revealed mostly the involvement of amino acids and pathways associated with lipid metabolism to be potentially useful as biomarkers. Many of these findings were similar across different studies using various sample matrices and metabolomics methods. Some findings, however, were not consistent across different studies, which is likely a result of different samples being used and at least partially attributed to the wide variety of methods available for each step of the metabolomics workflow. Experts in the field are currently building a general consensus concerning the minimum reporting standards for metabolomics experiments in order to facilitate experimental replication and enable comparison of data by others . It is aThere were very few studies that examined the metabolome of PsA patients and correlated metabolites with PsA diagnosis and PsA activity. Further exploration is needed to identify and validate biomarkers that can accurately and reliably predict which Ps patients will develop PsA, differentiate PsA patients from patients with other inflammatory arthritides and measure PsA activity. The synovial fluid, which is in direct contact with articular cartilage, bone and synoviocytes may provide the best reflection of the biochemical state of the joint under pathophysiological conditions. Although invasive to obtain, synovial fluid may be a promising source of biomarkers for PsA. Additionally, the availability of a wide variety of treatments for psoriatic disease, poses a need for biomarkers that can predict a patient’s response to a particular therapeutic agent. Metabolomic biomarker profiles may lead to personalized treatment plans that can maximize efficacy while minimizing toxicity. Furthermore, the relationship between the metabolome of patients with psoriatic disease and the microbiome and diet can be more closely examined. In a heterogenous disease like PsA, an accurate biomarker-based test will need to include demographic factors such as sex, gender and ethnicity. Integrating metabolomics with other high-throughput-omics technologies such as genomics, transcriptomics, and proteomics will highlight aberrant signaling pathways likely driving psoriatic disease. In combination with emerging technologies, metabolomics has the potential to advance our understanding of psoriatic disease and lead to the development of clinically useful biomarkers specific for this patient population.Metabolomics is an emerging technology that holds promise in identifying biomarkers and informing the practice of precision medicine. In this review, we have summarized studies that have examined endogenous metabolites in patients with Ps and/or PsA using NMR or MS. The majority of studies identified amino acids and lipids that may be associated with Ps diagnosis and activity. Further investigation is needed to identify and validate metabolomic biomarkers that can accurately and reliably predict which Ps patients will develop PsA, differentiate PsA patients from patients with other forms of arthritis and measure PsA activity.Our protocol was registered on Open Science Framework on 3 December 2020 . Strateg


Next-generation sequencing (NGS) has revealed large numbers of genetic variants in LGMD-related genes, with most of them classified as variants of uncertain significance (VUSs). VUSs are genetic changes with unknown pathological impact and present a major challenge in genetic test interpretation and disease diagnosis. Understanding the phenotypic consequences of VUSs can provide clinical guidance regarding LGMD risk and therapy. In this review, we provide a brief overview of the subtypes of LGMD, disease diagnosis, current classification systems for investigating VUSs, and a potential deep mutational scanning approach to classify VUSs in LGMD-related genes. Limb-girdle muscular dystrophies (LGMDs) are the fourth most common form of genetic muscle disease. They are defined by progressive weakness that predominantly affects the pelvic and shoulder girdle muscles, with age of onset ranging from early childhood to late adulthood. Based on their inheritance patterns, LGMDs are further subdivided into two main groups: autosomal dominant forms or LGMD1/LGMD-D, and autosomal recessive forms or LGMD2/LGMD-R .Like other inherited disorders, diagnosis of LGMD begins with a detailed medical and family history followed by a physical examination. Ancillary testing is helpful and includes laboratory tests such as creatine kinase level determination, muscle magnetic resonance imaging, or electrodiagnostics. Final diagnosis often requires muscle biopsy processed via histochemistry and immunohistochemistry. However, due to large phenotypic heterogeneity and overlap across the LGMD subtypes, genetic testing is required for accurate determination of the LGMD genetic subtype. In some LGMD cases, Sanger sequencing is still considered standard and is the first diagnostic test performed, especially for known familial variant testing. For some patients, if protein-based assays and targeted Sanger sequencing are unable to identify the genetic causes, next-generation sequencing (NGS) is particularly useful. Recently, panel-based NGS has become widespread in the field of disease diagnosis, prediction, and risk assessment, showing high efficiency. Therefore, NGS can greatly help improve the diagnostic success rate of skeletal muscle disorders including LGMDs (reviewed by ). For exThe large number of genetic variants identified by widespread NGS of LGMD genes has created a strong demand for accurate classification of these variants that provides necessary information to make an informed clinical decision for early diagnosis or personalized treatment. Variant classification, the process of determining if a DNA variant causes disease, is currently based on the ACMG guidelines . The latVUSs represent an ongoing challenge to the interpretation process, as these variants are more often novel with little to no published data to support classification. Current methods to refine the pathogenicity of VUSs fall into two categories.Classical approaches for interpreting variants require genotype–phenotype association studies in which large patient cohorts are needed to include enough patients with each variant to achieve statistical significance. This strategy has clear limits in interpreting variants associated with rare diseases such as LGMDs because the variants are present in only a few individuals. Another strategy is to broadly share genetic variants with little to no clinical information with clinical geneticists and research communities with the hope of aggregating genetic data across cohorts. Because VUSs are regularly identified from genome-wide testing, they can more easily be resolved through access to phenotype data from other individuals harboring the same variants observed elsewhere . The maiIn order to rapidly predict variant effects and serve as a basis for clinical decision making, many computational or in silico approaches have been developed that rapidly analyze all possible variants of a gene of interest by predicting their effects at both the nucleotide and amino acid level. In silico refers to computational tools in chemistry, biology, and pharmacology that determine the effect of variants on primary and alternative gene transcripts and other genomic elements as well as the potential impact of variants on protein structure, activity, post-translational modification, and protein–protein interaction. Several methods have successfully been applied to human disease modeling, drug discovery, and variant interpretation. Certain types of variants detected by genetic testing using methods such as short insertions, deletions, and truncating mutations are more easily classified as pathogenic by in silico prediction tools, because their effect on protein structure and function is more evident.Missense variants in protein-coding regions, which comprise 45% of variants implicated in disease , are morCurrently, for variant prediction of LGMD genes, computational prediction is the only approach that can provide evidence at a large scale. Unfortunately, this high-throughput approach poses certain limitations. It can identify only a small fraction of pathogenic variants with high confidence because none of these tools reach an accuracy above 90% . A recenTo overcome the limitations of biochemical assays and computational predictions, an experimental approach to assess thousands of variants simultaneously is needed. Deep mutation scanning (DMS), a technology collectively pioneered by Fowler et al. , Ernst eAll instances of DMS share a similar process, but the type of functional assay is often specific to a protein and its function being tested, which can include the impact of variants on protein structure, catalytic or enzymatic activity, stability, ligand binding, protein interaction, or the expression of a fluorescent protein. The most frequently used functional assay is growth-based. This assay is usually performed in yeast or cell lines where the pathogenesis of a variant is coupled with the organism’s survival with or without a drug selection . Phage dDeep mutational scanning approaches have been widely applied to cancer-risk genes. For example, with the use of DMS, more than 2000 missense variants in BRCA1 were measured , improviSarcoglycans are a family of transmembrane proteins found within the dystrophin–glycoprotein complex (DGC). DGC is a large molecular complex that plays both a mechanical and signaling role between the intracellular cytoskeleton and the extracellular matrix around muscle cells ,57. FourSarcoglycans were first associated with LGMD in a report of a severe form of muscular dystrophy (SCARMD) affecting 93 children in Tunisia . AffecteSGCA gene. This step was performed by cloning mutant oligonucleotide pools into a lentiviral vector. The libraries with thousands of different variants were then packaged into lentivirus, followed by expression in our cell-based model where the genotype is linked to phenotype. The multiplicity of infection (MOI) was controlled to be 0.1–0.3 so that each transduced cell would express only one SGCA variant. The design of the functional assay for mutant selection was based on the fact that α-sarcoglycan is a surface protein, and disease-causing variants often lead to premature degradation and deficient trafficking, resulting in the absence of sarcoglycan on the cell surface. In this case when non-permeabilized cells were labeled with fluorescent-conjugated sarcoglycan antibodies, cells harboring pathogenic variants were more likely to exhibit little to no surface sarcoglycan expression and show low to no fluorescent signal. In contrast, cells carrying benign variants were more likely to show high fluorescent signal. Fluorescently labeled cells were then sorted into different bins according to fluorescence intensity and further subjected to high-throughput sequencing to measure the frequency of variants across bins.As the first step of designing a DMS protocol, mutational libraries were constructed to cover all possible single amino acid changes throughout the entire SGCA in which each amino acid was substituted with each of the other 19 common amino acids or a premature stop at every single position. Although some substitutions are unlikely to occur naturally, their inclusion could still provide us valuable insight. However, our libraries were limited to missense and nonsense SGCA variants. The functional impact of other variants such as frameshift, indels, splice variants, and variants in non-coding regions needs to be further evaluated. Pathogenic variants in SGCA resulted in the mislocalization of α-sarcoglycan to the cytoplasm but not the cell membrane, which allowed us to separate variants by fluorescence labeling assays. Variants associated with differing levels of α-sarcoglycan on the cell membrane could be separated by FACS, and they were all subsequently sequenced by NGS. Our functional assay is considered a well-established functional approach that can provide strong evidence in SGCA classification. The ACMG provides two sets of criteria for variant classification, including the strong evidence codes PS3  and BS3 . Our functional assay based on membrane localization of the α-sarcoglycan met criterion PS3 [SGCB variants, we started evaluating the variant effect on complex assembly. Finally, preliminary data on SGCA variant classification show a bimodal distribution of variant types within our mutational library, indicating the presence of potential pathogenic and benign variants. However, interpreting the variants that fall between these two populations, such as variants that lead to a mild or impenetrant phenotype, is challenging. Thus, our current approach is biased toward severe pathogenic variants and leads to some variants not being resolved by DMS. To accurately annotate these variants, a secondary in vivo validation is needed.In our DMS approach, we constructed saturation mutant libraries for rion PS3 , and theNext-generation sequencing is steadily becoming more common in accurate disease diagnosis. Large-scale sequencing results in the identification of enormous numbers of genetic variants with unknown clinical significance. Resolving the functional consequence of variants is an ongoing challenge. As we described in this review, there are several approaches that are currently being used for VUS classification. However, they are limited by throughput and accuracy. A high-throughput screening approach that can functionally test the effects of thousands of variants at once has not yet been reported on LGMD genes. We proposed a DMS approach to scan all possible missense and nonsense mutations throughout the SGCA coding region, regardless of whether they were previously reported in a patient. A similar approach is being tested on other sarcoglycan genes to improve the classification of VUSs. Furthermore, to make our screening data easily accessible for research and clinical use, we publicly shared our data using the NIH sequencing reads archives (SRA) for raw data and the Gene Expression Omnibus (GEO) database for estimated functional scores. Our goal is to share data and interpretations for all tested variants via online portals with online user interfaces to enable rapid searches for specific variants and evidence that supports their pathogenicity . We think that our functional classification of VUSs supports immediate diagnostic interpretations of newly identified genetic variants and the application of this high-throughput approach for additional LGMD genes improves the diagnostic rate of LGMDs.


Freezing of gait (FOG) is a common and challenging clinical symptom in Parkinson’s disease. In this review, we summarise the recent insights into freezing of gait and highlight the strategies that should be considered to improve future treatment. There is a need to develop individualised and on-demand therapies, through improved detection and wearable technologies. Whilst there already exist a number of pharmacological , non-pharmacological  and surgical approaches to freezing , an integrated collaborative approach to future research in this complex area will be necessary to systematically investigate new therapeutic avenues. A review of the literature suggests standardising how gait freezing is measured, enriching patient cohorts for preventative studies, and harnessing the power of existing data, could help lead to more effective treatments for freezing of gait and offer relief to many patients. Freezing of gait (FOG) is a disabling symptom that affects more than half of all advanced Parkinson’s disease (PD) patients . It profUnfortunately, FOG has a complex pathophysiology that is only somewhat understood. Critical anatomical areas involved in locomotion are the pontomedullary reticular formation (PMRF), mesencephalic locomotor region (MLR) including the pedunculopontine nucleus (PPN), basal ganglia and frontal cortical regions . These sOne of the first considerations when thinking about the development of an effective therapy for FOG, is just how to go about measuring the symptom itself. The current consensus statement defines FOG as the “brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk” . This deConfirming any effective treatment would also require an accurate and objective measurement of FOG ; Table 1In an effort to generate more objective measures, some researchers have developed standardised FOG assessments, such as the FOG Score , freezinInstruments such as accelerometers , 2017, fVisually scoring FOG from video by independent raters is still currently recognised as the gold-standard for assessing FOG severity in PD . This apNot surprisingly, most current research trials are focused on symptomatic therapies for patients with established FOG (see below), rather than exploring approaches to delay or prevent the onset of freezing. However, some data does exist about these “at risk” groups  and idenThere are only a limited number of longitudinal studies that have followed patients without freezing to explore those characteristics that are associated with the future emergence of FOG, and whilst highlighting some of the potential risk factors for developing FOG, more integrated studies looking across further potential variables are probably required to understand the pathophysiological mechanisms by which they might be operating . These sOther novel approaches for identifying those patients at risk of developing FOG are also being described. One recent study found that compared to a non-freezer group, patients who developed freezing within 5 years demonstrated increased baseline anti-saccade latencies (>300 ms), whilst having equivalent motor and cognitive deficits . Indeed,It is also possible that biomarkers might prove useful in identifying those non-freezers at greatest risk of transitioning to FOG. Severe reduction in DAT activity in the caudate and putamen is associated with significantly higher incidence of FOG . PreviouThus, mechanisms already exist for enriching patients at risk of developing FOG who might be suitable for intervention studies. Such enriched cohorts would not only be a target group for early treatments, but may also reduce costs of recruitment and follow-up if accelerated FOG development is accounted for in a trial design.It is well known that FOG occurs more frequently in the Off-state  and thusThe phenomenon of On-freezing is less common and much more difficult to manage as its relationship to dopamine levels is not fully understood . A recenThough degeneration of dopaminergic neurons is the pathological hallmark of PD, non-dopaminergic neurons are also lost in the disease . CholineDrugs that enhance noradrenergic transmission have also been investigated for FOG, given its possible association with noradrenergic neuron loss in the locus coeruleus . HoweverDrugs already established in improving anxiety and depression  may alsoDeep brain stimulation (DBS) provides access to deep brain structures and the ability to directly modulate networks implicated in the pathogenesis of FOG . ConventAlternative stimulation strategies targeting non-STN structures, such as the pedunculopontine (PPN) area  and the It is well recognised that the traditional “open loop” DBS approach for PD requires external input to adjust stimulation parameters with the stimulation being delivered continuously without regard for fluctuating clinical or electrophysiological states. In contrast, “closed loop” DBS is now being explored with bidirectional devices that can both sense neural signals and deliver stimulation in response to specific electrophysiological changes, thus acting in real time. Such neural signals include prolonged beta (13–30 Hz) bursts , and lowThese findings suggest that whilst DBS for FOG does offer potential, more studies with homogenous patient populations undergoing standardised procedures and assessments will be required to progress the field. In addition, it is likely that patients will need close monitoring over extended periods of careful treatment titration to optimise their clinical benefits .Whilst a number of guidelines for physiotherapy in PD exist e.g., , there iA recent meta-analysis of 19 studies involving 913 patients showed that interventions tended to have similar duration of each session (45–60 min) and number of sessions per week. Prolonged home based interventions (median 4 months) showed more promise of efficacy, whilst in terms of intervention categories, action observation and treadmill training had the most significant effect sizes . Common Cognitive and affective deficits certainly modulate FOG  and it sLess standardised interventions are yet to be investigated for FOG. However, it has been reported that meditation may protect against grey matter atrophy  and is aLarger trials specifically investigating neuropsychiatric intervention strategies for FOG are now needed. These studies could potentially target both those with established FOG and an enriched population of at-risk patients. These studies will need to have much larger numbers than those already conducted, which will probably necessitate coordinated international multi-centre approaches where cross-over designs with multiple active arms may be the most efficient method to compare different techniques. These would ideally be conducted in combination with standardised objective measures of FOG and mechanisms for interpreting neurobiological changes such as functional neuroimaging  or neurMethods to modulate neuronal activity non-invasively also represent an attractive approach to access the distributed cortical and subcortical areas involved in FOG. Repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and more recently, non-invasive vagal nerve stimulation (nVNS), have all been explored as potential options.Non-invasive brain stimulation is thought to improve motor symptoms of PD by inducing focal release of endogenous striatal dopamine following stimulation of the ipsilateral cortex , 2003, alocus coeruleus, a region implicated in the pathogenesis of FOG, as well as exerting anti-inflammatory properties that may be important in halting disease progression. Recently, the first randomised, double-blind trial to investigate nVNS administered stimulation to the cervical vagus for 12 min each for 4 weeks in 33 PD patients with FOG (Vagus nerve stimulation (VNS) is an approved treatment for refractory epilepsy and depression that is also being investigated as a novel treatment for FOG in PD, especially following the availability of non-invasive transcutaneous stimulators (nVNS) . It has with FOG . The autwith FOG . ExcitinSpinal cord stimulation (SCS) for FOG is also under investigation targeting spinal afferents to modulate cortical motor circuits . DespiteTo date, methods in randomised controlled trials to improve FOG are heterogeneous in timing, duration, type of intervention (single target vs. multitarget), and outcome measures. Most studies aim to improve FOG symptoms once they have developed, which may be too late in the disease process. There are, as yet, no studies using population enrichment strategies  to examine interventions in participants at high risk of developing FOG. Designing future trials in FOG might also require matching the candidate intervention to the subpopulation most likely to benefit. For example, a trial testing cognitive behavioural therapy might require a cohort of anxious freezers .To inform such trials, exploratory studies to clarify the neurobiological components of freezing  and to identify the most accurate ways to gather this data will be important. Objective non-gait freezing paradigms that quantify freezing frequency and duration such as Virtual Reality (VR) gait , SteppinWearable technology or home-based “smart” systems to non-invasively measure FOG in the community should become a priority. This would allow for long-term recording, providing the large number of training events needed for algorithms to learn freezing signals in the individual patient in order to subsequently predict FOG in real time. Deep learning has already been deployed to automatically detect gait freezing in video recorded walks  and alsoThere are also opportunities to make better use of already collected data. In a cross-sectional study of 172 PD patients, longer duration of treatment with dopamine agonists trended toward increased FOG, whilst longer duration of amantadine use trended against FOG, though these results did not reach significance in multiple regression . CollaboThis review summarises the major difficulties in understanding and treating FOG. What is apparent is that a multimodal approach will be crucial to tackle this problem . CollaboCC performed the literature search and manuscript writing. SL was responsible for project conception, structuring, and editing. Both authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.