Several studies have demonstrated an association between psychological risk factors and HIV disease progression. However, there is limited information on the use of psychological interventions to improve HIV treatment outcomes in young people living with HIV.This pilot trial aims to evaluate the feasibility, acceptability and preliminary effectiveness of group support psychotherapy in improving adherence to anti-retroviral therapy and viral suppression in young people living with HIV in Uganda.N = 60) or IAC alone (N = 60). Primary outcomes will be indicators of feasibility and acceptability as well as preliminary effectiveness of GSP in improving ART adherence and viral suppression analysed by intention to treat using cluster-adjusted t tests and permutation tests. Secondary outcomes will be measures of depression, anxiety and cost-effectiveness.We recruited 120 young people with HIV, aged 10–18 years, who had non-viral suppression 6 months after initiating first-line anti-retroviral therapy (ART) from community based HIV clinics in Kitgum district, northern Uganda. Participants were randomly assigned to receive GSP plus IAC : 202006601935462 The availability of anti-retroviral therapy (ART) has improved the life expectancy of persons living with HIV worldwide . HoweverBarriers to successful care of youth with HIV include mental health disorders, poor medication adherence, socioeconomic instability, and HIV-related stigma . Also trIn Uganda, the national HIV treatment guidelines include psychosocial support services in the HIV care package . HoweverA retrospective cohort study on all children aged 9 months to 19 years that had been enrolled into 15 HIV care programs in 15 districts supported by the Infectious Diseases Institute (IDI) assessed the outcome of Intensive adherence counseling among 449 children with viral non-suppression . A repeaResearchers call for an urgent need for innovative strategies to respond effectively to the social, emotional and economic challenges faced by young people living with HIV . In partTo mitigate mental health challenges and improve HIV treatment outcomes, we developed group support psychotherapy—a culturally sensitive evidence based intervention that has been shown to effectively treat mild to moderate depression, improve posttraumatic stress symptoms, and hazardous alcohol use among adults living with HIV in Uganda . FurtherThe cognitive behavioral theory is one of the potential existing theoretical models that could guide the development of mental health interventions for young people living with HIV. Cognitive-behavioral therapy (CBT) is recommended for treatment of children and adolescents . We chosGiven the evidence we have gathered for group support psychotherapy, it can address the complex and dynamic interactions between young people, their families, and their environmental context .The goal of this paper is to describe the protocol for the evaluation of the feasibility, acceptability and preliminary effectiveness of group support psychotherapy in improving ART adherence and viral suppression among HIV positive young people in Uganda. In the preparatory phase of this trial, we aim to conduct community-based participatory qualitative research to obtain information on the potential usefulness of group support psychotherapy in addressing the psychosocial challenges that impact adherence to anti-retroviral therapy and viral suppression among young people with HIV in northern Uganda.In the trial phase of this study, the primary objective will be to assess the feasibility, acceptability and preliminary effectiveness of GSP in promoting ART adherence and viral suppression among HIV positive young people with non-viral suppression 6 months after initiating first-line ART at community-based HIV clinics in Kitgum district. Secondary objectives will include exploration of indicators of causal mediating processes and contextual influences, exploration of whether or not improvement in psychosocial challenges including depression, posttraumatic stress symptoms, suicide risk, social support, and stigma mediate or modify the effect of GSP on ART adherence and viral suppression, exploration of whether or not promotion of adherence through group support psychotherapy translates into better viral load suppression compared to standard care with intensive adherence counseling (IAC) and exploration of the cost-effectiveness of GSP to improve viral load suppression among HIV positive young people taking anti-retroviral therapy.We hypothesize that in comparison to the control intervention, GSP will demonstrate better feasibility, acceptability and better preliminary HIV treatment outcomes and better cost-effectiveness. The primary end point will be 6 months after the end of the intervention. Data will be used to design a definitive cluster randomized trial which will test the hypothesis that group support psychotherapy promotes better ART adherence and viral suppression than standard care with intensive adherence counseling among HIV positive young people with non-viral suppression 6 months after initiation of first-line ART in Uganda.Study participants will be recruited from community based HIV clinics in Kitgum district. The clinics take care of approximately 500 young people aged 18 years and below living with HIV. At the time we conceptualized this study, HIV clinic registers in Kitgum district showed that 60% of young people living with HIV (PLWH) initiated on ART were not suppressing the HIV virus. Therefore, we drew our study sample from a pool of approximately 300 young PLWH who had viral non-suppression. Kitgum district has a population of 232,000 individuals with over 90% engaged in small scale agriculture and animal husbandry as their major income generating activity. Kitgum district endured a brutal civil war for two decades (1987–2007) which led to a breakdown of health care delivery systems, loss of property and infrastructure.N = 2); their caregivers (N = 2) and their HIV care providers (N = 2). Key informant interviews will be held with various stakeholders including psychologists, pediatricians, child and adolescent psychiatrists, district health officials, community leaders and religious leaders to determine their perceptions towards using GSP as an intervention to promote adherence to ART alongside Intensive Adherence Counseling (IAC) among young people with HIV and their caregivers. The main objective of the workshops will be to discuss the potential of the current GSP intervention content, in addressing possible challenges/barriers associated with adherence to ART among young people with HIV. A community advisory board will be created to maintain the community's trust in the research process and members will also participate in key informant interviews.In the preparatory phase, we shall conduct a qualitative study. Thirty dyads of young people with non-viral suppression and their caregivers will be exposed to 8 sessions of the current group support psychotherapy intervention (GSP). At the end of the intervention, 6 focus group discussions will be conducted with the young people  verbatim. Informed consent will be obtained from participants before conducting KIs/FGDs. Thereafter, consultative meetings will be held with child and adolescent HIV and mental health experts to review our theoretical framework and assemble treatment strategies to be used in the GSP model for young people with HIV.In the trial phase, we shall conduct a pilot single-blinded randomized controlled trial to test the feasibility and acceptability of using GSP in combination with standard care IAC vs. standard care IAC only to promote ART adherence and improve viral suppression among HIV positive young people with non-virological suppression 6 months after initiation of first-line ART  guidelines  for inteTo be eligible for the study, participant dyads must consist of an HIV sero-positive young person (10–18 years) with ≥1,000 viral copies/ml 6 months after initiating first-line ART and a caregiver aged 19 years and older. Participant dyads will be excluded if they have visual or hearing impairments, active untreated major mental illness (untreated psychosis or mania or high suicide risk) or severe medical conditions (active tuberculosis or pneumonia) that would interfere with participation in interventions.All participants will be recruited from community-based HIV clinics in Kitgum district. Potential participants will be identified by their HIV care providers as not responding to their current antiretroviral (ARV) treatment regimen . Research assistants (RAs) and other study staff situated at the HIV clinic will work with staff in the HIV clinics to identify potential participants as they wait for their medication refills. RAs will be Luo-speaking staff with GSP research and HIV clinical experience. They will be extensively trained in the study protocol and supervised weekly by the project coordinator who is a social worker. They will be screened for psychosis and mania using quick screening questions for psychotic and manic symptoms. They will also be screened for high suicide risk using the SAD PERSONS scale. Individuals with psychotic and/or manic symptoms and /or high suicide risk will be excluded from the study.All young people (10–18 years)/caregiver dyads eligible to participate in the study will be approached by research assistants who will explain study procedures, determine eligibility, and then obtain informed assent/consent. Each dyad which assents/consents will be assigned to receive baseline interviewer administered demographic and psychosocial assessment battery and thereafter randomly assigned to receive either both GSP and IAC or IAC only.Randomisation will be done by urn randomisation picked by each participant. The young males and females will be separated into two groups. Each group will be presented with pieces of paper in opaque envelopes whereby half the number of papers will be marked X and the other half Y. Each member of the group will be asked to each pick one envelope. Individuals who pick papers with X will be assigned to both GSP and IAC while those who picked papers with Y will be assigned to IAC only. The same process was repeated for the caregivers.By design, both experimental and control interventions will be identifiable to participants but will be masked to independent outcome assessors, and data analysts.The content of the GSP has been described in previous publications , 30. GSPThe first session addresses issues related to introductions, the group process, expectations, and ground rules and making a pledge to commit to all sessions. Simple games will be used to explain concepts and help the young people get to know each other's name.The second session will use pictures and practical demonstrations with balloons, to explain the presentation and consequences of abnormal emotions such as persistent sadness, fear, anxiety and anger and how they relate to living with HIV. Thereafter, participants will be asked to communicate with peers and share newly learned knowledge.In sessions three and four, group participants share their most painful experiences. Here, various techniques will be used to help the young people open up. For example, expressive art exercises of body pain and heart wound. Here the young people are asked to draw a figure of the human body and place a mark where they feel pain. The counselor then encourages them to talk about the feelings associated with the pain they feel in the body part that is hurting. Another technique is to present a timeline from childhood to present and ask the young people to place both positive and negative events on their time-line. Thereafter, participants are encouraged to share other problems with a trusted elder in their household or community. In sessions five and six, practical demonstrations of culturally positive coping skills such as the stress bucket, gardening, seed pounding and crocheting are used to teach participants positive coping skills. The last two sessions are dedicated to income-generating skills that young people can use to support their caregivers income generating projects. Our previous research revealed a need for an intervention that focused on treatment of depression symptoms and livelihood skills development to improve household basic income . PovertyBoth the World Health Organization (WHO) and the Ugandan ART guidelines recommend that asymptomatic persons living with HIV who have been identified with viral load (VL) ≥1,000 copies per ml should be offered Intensive Adherence Counseling (IAC) for 3–6 months see  and repeDuring baseline assessments, participants will be carefully screened and individuals for whom the interventions are deemed medically inappropriate or unsafe will be excluded as described in the exclusion criteria. Independent outcome assessors will screen all participants for adverse events at the end of treatment and at 6 months after the end of the intervention using a standard interview and reporting form.Any unfavorable and unintended sign or symptom associated with the participation in group support psychotherapy, regardless of whether it is considered related to the therapy will be regarded as an adverse event (AE).Any AE that results in any of the following outcomes: Death, Life-threatening, Event requiring inpatient hospitalization, Persistent or significant disability/incapacity will be regarded as a serious adverse event (SAE). Expected AEs associated with this study would be suicide attempts due to lack of treatment response to the group support psychotherapy.During participant recruitment, individuals will receive a suicide risk assessment . IndividIn order to maximize adherence to intervention sessions and retention, lay health workers (LHWs) who facilitate the group sessions and the HIV care providers who provide the adherence counselling will be provided with a financial incentive as an appreciation of their commitment to the project. For participants who miss group sessions, the LHWs will be facilitated to make home visits to re-engage them.Assessments of study measures will be conducted at baseline, at the end of the interventions (2 months), 6 and 12 months after the interventions. The goal of this pilot trial is to test trial procedures and processes and to get estimates of parameters for the main trial sample size calculation . TherefoWe will determine the cost-effectiveness of the GSP intervention compared to the standard of care IAC. To facilitate this, our proposed costing perspective is the “societal perspective”, which will include intervention costs, costs related to the use of other healthcare resources, as well as lost time to attend the intervention.” We will develop a questionnaire to collect information on the use of other healthcare resources that can be impacted by the intervention such as got insurance medical visits, ambulatory care, mental health-related medication, etc.Data on costs involved in delivering the two models will be determined and these will then be compared to the targeted outcomes of the two delivery models. The main primary outcomes of the study—ART adherence and Viral Load, will be utilized. Important to note, however, is that costs of research and research related activities shall not be included in determining cost-effectiveness. Additional data on economic costs—costs of lost time, for categories of participants, including voluntary unpaid participants, costs of additional workload, etc., in the study shall be explored, using shadow pricing methods. Costs will be identified from project documents and accountabilities. Additional costs will be generated from literature in case they may not be available in the available project documents. Major costs for services and other procurements shall be based on reimbursement contracts, and in some circumstances market rates when they were procured. Other databases including Uganda Bureau of Statistics (UBOS) shall be used to generate relevant data for use in cost-effectiveness analysis.Interview transcripts from the FGDs will be reviewed for accuracy, translated into English and transcribed. Atlas.ti qualitative data analysis software will be used for coding and thematic analysis . The intχ2 tests and independent two-sample ttests to compare categorical and continuous baseline demographic and psychosocial variables between study groups respectively. Similarly, we will also do bivariate analyses to compare these variables between those who had completed all sessions (completers) and those who had not (non-completers). Although randomisation to GSP and GHE will be done at the individual level, study participants will receive their respective interventions in groups (clusters). Since individuals within a cluster are likely to be correlated, we will use cluster-level analyses to make allowance for intra-cluster correlation.For the quantitative data, we will do bivariate analyses with clttest command to compare cluster means across treatment groups.We will apply ttests to cluster-level summaries, which is a robust method of analysis for cluster data . SpecifiTo do an intention-to-treat analysis, we will impute missing values with several imputations. We will construct five imputed datasets with the multivariate normal model assuming that data were missing at random. The participants complete baseline data will be used to create the multiple imputation datasets.To determine the outcome measure for use in cost-effectiveness analysis, the main assumption will be that there is a link between ART adherence and viral load. If this assumption be true, then cost-effectiveness analysis will utilize viral load (VL) as the primary outcome.This primary outcome will be mapped on to long-term outcome measures—QALY/DALY as the data may permit, using models such as WHO-CHOICE and or WHO DALY/QALY estimators, to generate cost-effectiveness . ApproprThe WHO-CHOICE (Choosing Interventions that are Cost-Effective) and DALY/QALY  estimators are two tools developed by the World Health Organization (WHO) to help evaluate the cost-effectiveness of healthcare interventions. The WHO-CHOICE estimator is a tool that calculates the cost-effectiveness of healthcare interventions based on their impact on disease burden and their cost. It uses a standardized approach to estimate the costs and health outcomes of different healthcare interventions, taking into account the local context of each country. The estimator is designed to be flexible and can be adapted to different healthcare settings and disease profiles.The WHO DALY/QALY estimator is a tool that measures the burden of disease and the impact of healthcare interventions on health outcomes. It uses a measure called Disability-Adjusted Life Years (DALYs) or Quality-Adjusted Life Years (QALYs) to quantify the impact of disease on individuals and populations. DALYs and QALYs take into account both the years of life lost due to premature death and the years lived with disability or illness. The WHO DALY/QALY estimator can be used to evaluate the cost-effectiveness of healthcare interventions by comparing the cost per DALY or QALY gained. Both WHO-CHOICE and DALY/QALY estimators are widely used by policymakers, healthcare providers, and researchers to help make informed decisions about allocating healthcare resources and designing cost-effective healthcare interventions.To determine cost-effectiveness of the service delivery models, we will compare the measures determined with conventional benchmarks such as Gross Domestic Product (GDP) per capita, or will compare with literature from other but similar contexts. Throughout the study we will apply the guidelines for economic evaluation from the second panel on cost-effectiveness  and the The study protocol will be presented to the relevant institutional review boards. Every participant will be reimbursed transport costs based on the rate for the furthest participant and refreshments will be served after focus group discussions and group support sessions. LHWs facilitating the group sessions will receive a financial incentive equivalent to 2.72USD per session.Group support psychotherapy is offered as a continuous service at the Kitgum general hospital. All study participants will have access to GSP if found to be highly beneficial in improving ART adherence and viral suppression. This trial is registered with The Pan African Clinical Trials Registry Number PACTR202006601935462.N = 61) and IAC alone (N = 60). An analysis of baseline, 6 and 12-month data is in progress. The results of this trial will be presented at national and international conferences. Manuscripts will be prepared for publication in peer-reviewed journals and reports will be prepared for submission to the funding agency.The trial has been approved by the Makerere School of Health Sciences Research Ethics Committee, and the Uganda National Council of Science and Technology. Recruitment began in June 2021 and closed October 2021. A total of 120 young people (10–18 years) living with HIV with their adult caregivers were recruited into the trial. They were randomized to receive the adolescent group support psychotherapy (A-GSP) and intensive adherence counseling (IAC)  years and will be delivered using play materials. Play therapy allows children to utilize toys and other play materials to express their own story and emotions without necessarily using words to participate in the counseling process . Play thGiven our prior research findings which indicated that GSP improved viral suppression through sequential reduction in depression symptoms and improvement in ART adherence , in thisMental health problems such as depression largely affect ART adherence which is critical to the success of viral suppression among young people living with HIV , 58. TheThis study has several limitations. First, the study will include only 120 participants from five community based HV clinics in one northern Uganda district. Our results may not be generalizable to other areas in Uganda. Second, study participants will reside in similar villages attending similar HIV clinics, thus the chances of contamination are high which may result in non-detection of significant differences when they truly existed. However the major goal of this trial is to determine feasibility and acceptability of study procedures in preparation of a definitive trial in the near future. Further, in view of the small number of mental health workers trained in delivering GSP using play materials, supervision of treatment sessions was not possible. Also, the limited numbers of diploma and degree-level health workers restrict the long term accessibility and sustainability of GSP among young people. Future research will assess whether or not the intervention can be administered by lay health workers.Successful completion of this trial will pave way for a definitive cluster randomized trial that can critically inform the national dissemination and implementation of GSP to improve HIV treatment outcomes in young people living with HIV in low resource settings.


Until recently, the evaluation of bone health and fracture risk through imaging has been limited to dual-energy X-ray absorptiometry (DXA) and plain radiographs, with a limited application in the athletic population. Several novel imaging technologies are now available for the clinical assessment of bone health, including bone injury risk and healing progression, with a potential for use in sports medicine. Among these imaging modalities is high-resolution peripheral quantitative computed tomography (HR-pQCT) which is a promising technology that has been developed to examine the bone microarchitecture in both cortical and trabecular bone at peripheral anatomical sites. Technologies that do not expose patients to ionizing radiation are optimal, particularly for athletes who may require frequent imaging. One such alternative is diagnostic ultrasound, which is preferable due to its low cost and lack of radiation exposure. Furthermore, ultrasound, which has not been a common imaging modality for monitoring fracture healing, has been shown to potentially demonstrate earlier signs of union compared to conventional radiographs, including callus mineralization and density at the healing site. Through the use of conventional magnetic resonance imaging (MRI), finite element analysis (FEA) can be used to simulate the structural and mechanical properties of bone. On the other hand, the ultrashort echo time (UTE) MRI can evaluate cortical bone quality by detecting water bound to the organic bone matrix and free water, providing important information about bone porosity. Several novel bone imaging techniques originally developed for osteoporosis assessment have great potential to be utilized to improve the standard of care in bone fracture risk assessment and healing in sports medicine with much greater precision and less adverse radiation exposure. A broad spectrum of diseases can affect bone, encompassing infectious, rheumatologic, oncologic, congenital, degenerative, and traumatic etiologies , 2. ImagDespite these advances in technology and the clinical utility they may provide, limitations and challenges still exist. The aim of this review is to present an overview of novel bone imaging modalities and their clinical utility in the context of sports medicine. These techniques can potentially improve the standard of care in bone fracture assessment and fracture healing in both elite and recreational athletes with greater precision and fewer adverse effects.This review was conducted using a search of the PubMed libraries, with keywords being “sports medicine imaging,” “HR-pQCT,” “bone high-resolution MRI,” “ultrasound sports medicine,” “ultrashort echo time MRI,” “MDCT sports medicine,” and “DEXA sports medicine.” Articles were chosen based on their applicability to the stated goal of this review, namely, a clinical application in sports medicine. Other studies were included that demonstrated the utility of the imaging techniques and were deemed by the authors to be critical “technological advancement” or “proof of concept” papers. The excluded studies were those without a clear clinical correlation or focused strictly on technical aspects of the imaging modalities. This review is not meant to be completely extensive. Rather, it is structured to introduce readers who may not routinely stay up-to-date with radiology or sports medicine literature to the emerging technical developments that are taking place in the field.The prevalence of bone injury in athletes is elevated compared to the general population. For example, it is estimated that up to 40% of athletes will experience a stress fracture at some point in their career . The mos2. A summation of the pixels within a specified area facilitates the calculation of BMD. These values can be represented in units of g/cm2 or transformed into normalized T- and Z-scores . Th. Th95]. UTE MRI is being utilized in the sports medicine clinic currently to monitor postoperative healing and evaluate tendinopathy. Chu and colleagues used UTE mapping to demonstrate changes in deep cartilage tissue health two years after anatomic ACL reconstruction, finding that about 3 of 4 ACL-reconstructed patients had intact central medial femoral condyle cartilage, and that the UTE values of the cartilage varied significantly with injury status and arthroscopic grade. The authors were optimistic that these techniques could be used to identify joints at risk for rapid regeneration and subsequent osteoarthritis . A folloIn addition to postoperative evaluation, UTE has proven useful in evaluating various tendinopathies. One group of investigators asked if UTE MRI could be used to distinguish between healthy and diseased Achilles tendons. They recruited ten patients with symptomatic Achilles tendons as well as ten healthy controls and scanned their Achilles tendons in four different locations with UTE MRI. The patients were also assessed with clinical metrics such as the Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Society (AOFAS) score. They found that the UTE-T2 scores significantly differed between the pathologic Achilles tendon and the healthy Achilles tendon. They also found a rough correlation between the UTE-T2 scores and the traditional clinical metrics, suggesting to the authors that UTE-T2 scores might be a promising marker to detect and diagnose Achilles tendinopathy . PatellaSeveral novel imaging modalities have been presented, providing further insight into managing bone injuries with new methods of monitoring healing and fracture risk. Awareness of these technologies and their utility has enabled an innovative transition from the research and clinical settings to early adoption across team sports at elite levels. In the professional sports medicine environment, imaging is often readily available and can serve as the basis for many critical decisions pertaining to an athlete's current health, risk, return to play, and even career longevity. Conventional radiographs, CT, MRI, and US all serve a role in the effective management of stress injuries to bone and their individual roles will undoubtedly increase in the coming decades, especially at the highest level of competition.Point-of-care US is a cheap and effective technology that can be immediately performed on-site at a sporting event or training facility following an injury. This allows for early, accurate diagnosis of numerous pathologies along with monitoring of healing through serial imaging , 102, anThe application of CT- or MRI-based bone quantification and FEA in sports medicine is also projected to increase over the coming years. High-profile athletes represent crucial assets to professional organizations wherein medical information gets immediately relayed to all stakeholders, including the physician, sports medicine and performance staff, coaches, front office members, and agents, in addition to a consulting physician if a second opinion is required. For instance, the “dreaded black line,” the hallmark sign on X-rays for anterior tibial cortex stress fractures, was classically seen as fractures in the bone. More recently, these fracture lines were examined microscopically in athletes indicating the fissures were in fact low-density bone undergoing intense remodeling, meaning healing was already underway, but the region was mechanically insufficient to handle normal stress . FollowiThe primary application of MDCT and HR-pQCT in sports medicine is the imaging and quantifying bone microstructure at distal sites and the extremities. This includes the tibia, and distal radius, as well as all the bones of the foot including the metatarsals. As mentioned previously, bone microarchitectural images enable representative quantifications which are related to disease state, fracture history, and risk, as well as nutritional health. Since MDCT scanners are widely available and HR-pQCT scanners are becoming increasingly more prevalent, these methods can be readily adopted to all competition levels to track healing progress longitudinally, as well as evaluate the impact of different training regimens and dietary changes on fracture risk. High-resolution MRI scans enable imaging of trabecular bone that is analogous to the quality of CT images without subjecting the patient to ionizing radiation. MRI can also image trabecular microstructure in deeper tissues like the proximal femur which are unattainable via CT due to the radiosensitivity of the pelvis. Cortical bone composition and mechanical parameters can be quantified with UTE MRI. However, MRI scans are more expensive and take longer than CT scans, and specialized high-resolution or UTE bone sequences are somewhat limited, so it is likely that MRI methods will be more applicable in research and in clinical practice at the professional level. As the state-of-the-art method for assessing bone strength, image-derived FEA can provide impactful quantitative and qualitative information to practitioners by generating bone mechanical parameter estimations, as well as 3D strain maps which indicate areas of structural vulnerability under loading. The data can provide an evaluation of the percent change in bone strength after each serial scan and is particularly useful in tracking bone healing if a healthy baseline scan is available for comparison. These metrics provide objective evidence of bone healing as a means to aid practitioners in making more informed decisions on whether to continue to advance rehabilitation or delay intense activity. Although CT- or MRI-derived FEA provides the most accurate methods available for quantifying bone health, these methods are expensive and require specialized software, extensive user expertise, and computation time. Moreover, further research is necessary to identify the optimal bone healing threshold sufficient to return to rigorous activity. As such, initial adoption of these methods will ostensibly come from professional teams with elite athletes whose health is inextricably linked with their team's financial future. Nevertheless, it is anticipated that these methods will see rapid expansion in the field of sports medicine as a whole in the coming decades.The current standard practice for the evaluation of bone injuries in sports medicine relies primarily on qualitative assessments. The imaging methods outlined above have the ability to provide quantitative information to improve decisions and, ultimately, outcomes in the sports medicine field. As always, it is important to note that routine imaging can have its challenges around providing objective markers for healing, especially with slower-healing bone stress injuries. It is conceivable in these situations that quantitative imaging data could be supplemented with other blood-based biomarkers and patient feedback to further improve outcomes. In addition, further research is needed to delineate normative quantitative bone data for each modality in the sports populations. While normative data exist for DXA in osteoporotic subjects, there is no anthropometric baseline data for athletic cohorts, and further research is needed to fill this void before informed decisions can be made. Furthermore, radiology technicians consistently attempt to provide reliable images, but human error can lead to issues emulating the exact image registration, motion artifacts, parameters, and exposure. Moreover, imaging parameters such as resolution, scanner model, and sequence can impact quantitative measures, so uniform and reproducible protocols must be enhanced to enable comparison between different imaging sites.


Plant respiration is a foundational biological process with the potential to be optimized to improve crop yield. To understand and manipulate the outputs of respiration, the inputs of respiration—respiratory substrates—need to be probed in detail. Mitochondria house substrate catabolic pathways and respiratory machinery, so transport into and out of these organelles plays an important role in committing substrates to respiration. The large number of mitochondrial carriers and catabolic pathways that remain unidentified hinder this process and lead to confusion about the identity of direct and indirect respiratory substrates in plants. The sources and usage of respiratory substrates vary and are increasing found to be highly regulated based on cellular processes and environmental factors. This review covers the use of direct respiratory substrates following transport through mitochondrial carriers and catabolism under normal and stressed conditions. We suggest the introduction of enzymes not currently found in plant mitochondria to enable serine and acetate to be direct respiratory substrates in plants. We also compare respiratory substrates by assessing energetic yields, availability in cells, and their full or partial oxidation during cell catabolism. This information can assist in decisions to use synthetic biology approaches to alter the range of respiratory substrates in plants. As a result, respiration could be optimized by introducing, improving, or controlling specific mitochondrial transporters and mitochondrial catabolic pathways. Plant oxidation of respiratory substrates is regulated by mitochondrial transport and metabolic processes; modifications may enable oxidation of alternative substrates and improve efficiency. These can be used to drive the electron transport chain (ETC) and oxidative phosphorylation in mitochondria with or without CO2 release. There are also other compounds external to mitochondria that can be metabolized to provide tricarboxylic acid (TCA) cycle intermediates or NAD(P)H to mitochondria; however, they will not be the focus of this review.COifecycle . Beyond ) plants , there i) plants . RespiraTo further complicate the landscape of respiratory substrates, partial oxidation of respiratory substrates and the operation of non-phosphorylating bypasses in the ETC limit the efficiency of respiration in generating ATP . ExternaOur knowledge of which respiratory substrates are the major contributors throughout the diurnal cycle, under stress conditions, and across plant development is improving but remains incomplete. Our insight into how plant cells prioritize carbon sources to break down for energy, or to use for biosynthesis and storage, and when to switch, is still elementary. This Update Review aims to provide an update on recent discoveries in the use of respiratory substrates under normal and stressed conditions and delineate the gaps in our current understanding as we seek respiratory optimization in plants.2. Knocking out either MPCs  cause retardation in organ size and root length  residing in the inner mitochondrial membrane and the first step of pyruvate oxidation is carried out in the matrix by the mitochondrial pyruvate dehydrogenase complex (mtPDC) yielding acetyl-CoA, NADH, and COher MPCs  or the mher MPCs  has a det length , abolitit length . Detailet length , at least length . These it length  that aret length . This met length .Respiration at night relies largely on catabolism of daily replenished starch reserves in leaves and on sugars transported from photosynthesizing tissues to produce respiratory pyruvate in non-photosynthesizing plant tissues . CytosolAlanine is converted into pyruvate via a transamination reaction catalyzed by AlaAT coupled with the amination of 2-oxoglutarate (2-OG) into glutamate . The catIn vivo13C labeling patterns show that pyruvate is readily converted to alanine via alanine aminotransferase H and COt growth . We havet growth  due to tt growth  between t growth . Pyruvatt growth .Zea mays), while total NAD-ME activity was decreased by light, it was found that NAD-ME1 expression was decreased while NAD-ME2 expression was increased by light. This could indicate divergent diurnal roles between NAD-ME isoforms  leaves . The glyoxylate cycle is important for lipid mobilization during germination of oil-storing seeds but also operates at a lower flux in leaves in the light . The gly) leaves  and in A) leaves , suggest) leaves , hence t2 under current CO2 concentrations  under stress conditions via glutamate decarboxylase in the cytosol . GABA isled GABA . This prled GABA . The actled GABA . The GABled GABA . It provled GABA .The degradation pathways of the BCAAs valine, leucine, and isoleucine have been identified as essential factors for plant survival of sugar starvation . The firThe first step of lysine catabolism is located in the cytosol where lysine is converted into 2-aminoadipate-6-semialdehyde (AASA). The next enzyme, α-aminoadipate semialdehyde dehydrogenase, can be targeted to cytosol or mitochondria  and its 2 release  showed how acetate can be incorporated into biomass and support energy production , which substrates are best for complete catabolism to COHow important are metabolons, microenvironments, and mitochondrial heterogeneity in regulating substrate choice and usage in plant respiration?How can we best engineer the usage of alternative respiratory substrates in plants and test the benefits for whole plant carbon use efficiency and growth?The following materials are available in the online version of this article.. Energetic characteristics, stoichiometry of catabolic products, and concentrations of respiratory substrates.kiac599_Supplementary_DataClick here for additional data file.


The study of mate choice and sex roles has come a long way from the assumption that only males are promiscuous and females are coy. However, fragments of this mindset might still influence our research today. In their review, We find Richardson and Zuk’s review both informative and eye-opening. This is so, despite the fact that their meta-analysis did not reveal large biases in mating preferences between virgin and non-virgin females in previously published literature. Their review still shows how using virgin females is the standard of most mate choice studies, and that only a few papers explicitly state that mated females were used. We strongly agree that more studies should be aware of the potential shortcomings that arise from this discrepancy between experimental animals and wild animal populations.This problem has gone largely unnoticed until now, as even in the otherwise comprehensive book on mate choice by There are several reasons why using virgin females might be justified in mate choice studies. Virgin females are often seen as a “clean slate” unbiased by previous mating experience. A study on reproductive isolation might therefore be more interested in investigating innate female preferences, and using virgin females may yield more reliable results through this approach. However, when estimating the overall reproductive isolation between populations or species, the role of behavioral isolation in restricting gene flow might be seriously underestimated if learned mate recognition is not taken into account . We therRichardson and Zuk choose to limit their focus to studies of three categories: reproductive isolation, inbreeding avoidance and sexually transmitted disease. We are impressed with the thoroughness of the meta-analysis in this framework, but also recognize that it leaves out some large categories of mate choice research. For example, we still lack corresponding knowledge of studies that measure sexual selection acting on male phenotypic traits. If the use of virgins is widespread in this field as well, we could expect potential underestimation of female choosiness. The authors also do not consider the effects of different mating systems in their analysis, but it might warrant further study. In systems where females are significantly mate-limited, virgin females may have a stronger reason to be less choosy than mated females. The differences in choosiness between virgin and mated females might therefore be the largest in species where females also compete for access to males .The authors caution future researchers to be aware of the unknown mating status of wild-caught females. However, we would argue that a sufficiently large sample of wild-caught females should be the best representation of the types of potential mates the males would encounter in the wild. Using only wild-caught females would therefore avoid most of the concerns presented by this review, at least when it comes to estimating realistic female preferences in wild populations.In summary, Richardson and Zuk raise an important concern for mate choice studies. Future research needs to take this issue into careful consideration. In addition, we think that the extent to which mating status might affect choosiness deserves to be delved into in its own right, and in both sexes, to estimate behavioral differences between virgin and non-virgin individuals.


Aging is accompanied by a dysregulation of adaptive processes. On the one hand, physiological adaptation mechanisms such as learning and memory, immune system plasticity and exercise-dependent muscle remodeling are blunted. On the other hand, several maladaptive processes increase with age including cancer, pathological cardiovascular remodeling and metabolic dysregulation. With increasing age the quotient of beneficial adaptation (Ab) to harmful adaptation (Ah), Ab/Ah, decreases. The adaptation-maladaptation framework of aging entails that there are age-related pathological phenotypes that are the result of activation of physiological adaptation mechanisms  and their occurrence over time might, to some degree, be inevitable. Aging might hence result from the organism’s inability to solve the adaptation-maladaptation dilemma. The present work explores the concept of counteracting aging through adaptation and proposes that interventions such as exercise, environmental enrichment and dietary restriction work in counteracting aging because they increase the ratio Ab/Ah by both raising Ab  and decreasing Ah . Molecules whose aging-related expression changes can explain aspects of dysfunctional adaptation such as CREB and certain immediate early genes are examined and it is delineated how a better understanding of the dynamical organization of adaptation cascades could elucidate the seemingly complex role of adaptation in driving aging as well as protecting against it. One of the major symptoms of aging in animals is a decreased body-wide ability for adaptation, which expresses itself as impaired neural plasticity , decreasThe present work explores how dysregulated adaptation is a central feature in animal aging and provides a framework to integrate various findings on the biology of aging at different levels of biological organization from the molecular to the behavioral. The adaptation-maladaptation framework of aging focuses on underlying functional patterns in living systems instead of concrete molecular or cellular entities and can integrate different biological scales of organization.One of the central points of the present framework is that a fundamental phenomenon in aging is the decrease in the ratio of beneficial adaptation (Ab) to harmful adaptation (Ah) - Ab/Ah. As the organism ages, this ratio decreases consistently at various levels, from cells to tissues to the whole organism. Living systems and their subsystems become progressively less able to adapt to challenges from the environment  but instead display increasingly dysfunctional adaptation .At the cellular level, a core aspect of mammalian aging is a decrease in plasticity which leads to a decrease in Ab. In humans, memory performance is impaired with increasing age  and in aConversely, many adaptive processes are misdirected in age-related disorders leading to an increase in Ah, with for instance adaptive transcription being involved in maladaptations such as cancer, metabolic dysregulation and autoimmunity . A centrIt was previously outlined how adaptive transcription involving molecules such as cAMP-response element binding protein (CREB) is central to mediating the anti-aging effects brought on by physiological stimulation and several interventions such as blood transfer from young to old animals .An interesting observation is that these molecular adaptation mediators are oftentimes reduced with age, potentially explaining the reduction in Ab. Previous research has shown that CREB levels decrease in the rodent brain with age  and incrOn the side of Ah, several adaptive transcription mediators have been shown to be involved in maladaptive processes. Oncogenesis is promoted by CREB  and CREBAnother factor is that adaptation processes generally seem to work via potentially harmful mechanisms. Adaptive transcription induction in neurons for instance, which is required for memory formation, causes DNA double strand breaks (DSBs)  and DSBsOne way to increase Ab is to engage adaptive programs via subjecting the body to physiological challenges including exercise, environmental enrichment and dietary restriction. Previous work has explored how these interventions counteract aging through the activation of adaptive gene programs . EnvironA related way to raise Ab is to directly overexpress adaptive transcription components. In many cases, the overexpression of adaptive transcription molecules leads to enhancement of physiological function in processes such as learning and memory and exercise. Aging-related memory deficits can be reduced by overexpression of adaptation regulators such as CREB  and DnmtThe decrease in Ah might be difficult to achieve without blunting Ab. One way could be by desensitizing adaptive processes through engaging them acutely. Many adaptation processes are desensitized after initial activation  which cetc.) and understand how to direct, restrict and boost adaptation processes which has been previously discussed  and processes  can be implicated in protection against aging, as well as in driving aging-related pathologies  as wellPerhaps negative effects from the passage of time in biological organisms, and hence aging, might be inevitable. On the one hand, if the organism does not engage its adaptation mechanisms, certain types of molecular damage are reduced  but maladaptation takes over and leads to a reduction in health. On the other hand, if the organism engages its adaptation mechanisms, it increases its health and decreases aspects of Ah but also incurs negative effects such as molecular damage. Thus, aging is perhaps the consequence of the fact that the organism cannot solve the adaptation-maladaptation dilemma permanently, leading to the adaptation-maladaptation theory of aging. An interesting challenge in longevity therapeutics is to solve this conundrum and uncouple beneficial adaptation from harmful adaptation. Another explanation for a reduction in Ab and also for the increase in Ah could be a loss of adaptive precision, meaning that, when challenged, the organism, perhaps as a result of molecular damage, fails to adapt adequately. The organism fails to reach its adaptation goal state with regard to Ab  but instead “lateralizes” its plasticity mechanisms to drive dysfunctional cellular remodeling . An aging-dependent dysregulation of stimulation-induced transcription has been reported .Another important open question is whether the expression of certain adaptive mechanisms and biomarkers is causative or homeostatic and compensatory. Some adaptive responses could be activated to ensure homeostasis after damage or prevent damage rather than to drive dysfunction themselves. This highlights the importance of direct experimental manipulation of certain markers in addition to association studies.The adaptation-maladaptation framework of aging posits that a cornerstone of aging is a decrease in the ratio of beneficial adaptation to harmful adaptation (Ab/Ah) at several organizational levels of the organism, from cells to cell networks to the whole body. Decreases in Ab lead to lowered capacities in physiological adaptation functions such as learning and memory, immune system plasticity and muscle anabolism, whereas increases in Ah promote dysfunctional metabolic remodeling, cancer, autoimmunity and pathological cardiovascular remodeling among others. Certain adaptation mechanisms such as adaptive transcription can be involved in protection against aging as well as driving aging-related pathologies. Thus, aging-related decline might be inevitable but not necessarily due to random accumulation of damage over time but because adaptive mechanisms will, one way or the other, lead to progressive dysfunction . Because aging is at least partly an active process, it might be possible to counteract it if we understand how biological goal states can be influenced and how adaptation mechanisms can be directed. To do so, we need to study the underlying molecular signaling dynamics in greater detail beyond mere up- or downregulation and beyond simple association studies. Studying aging from the perspective of the adaptation-maladaptation dilemma with the central phenotype of a reduction in Ab/Ah opens up new experimental and theoretical approaches to study longevity mechanisms.


There is increasing recognition of the need to study genotype by environment (G×E) interactions in farm animals. This interest is currently driven mainly by the desire to breed robust animals with high resilience and reduced environmental sensitivity , or by tBhatia et al. the authors performed a comprehensive investigation of the genetic basis of pelvic organ prolapse, a serious welfare and economic issue plaguing sow production. They found a moderate heritability of pelvic organ prolapse and six genomic regions, which together explain up to 9% of genetic variance of the trait in the studied population. Different incidence and heritability of pelvic organ prolapse reported in other cohorts provide a possible indication of G×E interaction influencing its manifestation, which warrants further investigation. As further discussed by the authors, more precise description of the prolapse condition is required for better understanding of the background of the trait.In the study of Freitas et al. examined the best environmental descriptors based on seven climatic variables obtained from public weather station information as well as critical periods to evaluate heat tolerance and its genetic relationship to a range of reproduction, growth, and body composition traits in Large White pigs. They found evidence for G×E interactions for most of the studied performance traits. The authors further demonstrated that heat tolerance is heritable and genetically correlated with different performance traits, indicating that genetic improvement of heat tolerance in Large White pigs is feasible. Notwithstanding the observation that public weather station data show reasonable correlation with on-farm weather records, the authors recommend validation of their findings using in-barn recorded environmental data.It is not only important to thoroughly characterize the phenotypic trait, but also to accurately record and define the environmental conditions that will be investigated in terms of their interaction with the genotype. There is a steadily growing number of routinely measured parameters, e.g., from smart technologies, that can be harnessed for these purposes. Hu et al. investigated copy number variation (CNV) in three ecotypes of Tibetan sheep kept in three different environments differing primarily in altitude, feed availability and temperature. Because single nucleotide polymorphisms (SNPs) are ideal genetic markers for genome-wide association studies, other types of genetic variation are currently largely neglected. However, due to their higher functional potential and mechanisms linking their emergence with cellular responses to  environment, CNVs  using mRNA-Seq data. This approach , originally developed in humans for high-throughput screening of G×E interactions  and methodological advances  will bring new possibilities for accurate and fine-grained characterization of the environment, phenotypic response and genome, and will provide a tremendous boost to research in this important area.


COVID-19 has caused significant public health problems globally, with catastrophic impacts on health systems. This study explored the adaptations to health services in Liberia and Merseyside UK at the beginning of the COVID-19 pandemic (January–May 2020) and their perceived impact on routine service delivery. During this period, transmission routes and treatment pathways were as yet unknown, public fear and health care worker fear was high and death rates among vulnerable hospitalised patients were high. We aimed to identify cross-context lessons for building more resilient health systems during a pandemic response.The study employed a cross-sectional qualitative design with a collective case study approach involving simultaneous comparison of COVID-19 response experiences in Liberia and Merseyside. Between June and September 2020, we conducted semi-structured interviews with 66 health system actors purposively selected across different levels of the health system. Participants included national and county decision-makers in Liberia, frontline health workers and regional and hospital decision-makers in Merseyside UK. Data were analysed thematically in NVivo 12 software.There were mixed impacts on routine services in both settings. Major adverse impacts included diminished availability and utilisation of critical health services for socially vulnerable populations, linked with reallocation of health service resources for COVID-19 care, and use of virtual medical consultation in Merseyside. Routine service delivery during the pandemic was hampered by a lack of clear communication, centralised planning, and limited local autonomy. Across both settings, cross-sectoral collaboration, community-based service delivery, virtual consultations, community engagement, culturally sensitive messaging, and local autonomy in response planning facilitated delivery of essential services.Our findings can inform response planning to assure optimal delivery of essential routine health services during the early phases of public health emergencies. Pandemic responses should prioritise early preparedness, with investment in the health systems building blocks including staff training and PPE stocks, address both pre-existing and pandemic-related structural barriers to care, inclusive and participatory decision-making, strong community engagement, and effective and sensitive communication. Multisectoral collaboration and inclusive leadership are essential.The online version contains supplementary material available at 10.1186/s12913-023-09162-8. COVID-19 has caused a global public health emergency with a catastrophic impact on many aspects of society, economies and health  and threEarly health system responses to the COVID-19 pandemic focused on containing the spread of the virus and reducing related morbidity and mortality . With thHealth system measures adopted as part of COVID-19 response may have affected health service delivery both positively and negatively . The panAlthough there has been extensive analyses of the public health impact of COVID-19 response measures, including effects on disease containment , 20, litWe employed a cross-sectional qualitative design to better understand COVID-19 adaptations and their impact on health services. This approach provides potential for exploring participant perspectives within their embedded context . A colleData were collected from participants in Liberia and Merseyside, UK. These settings were selected due to demand from stakeholders for research to help inform their COVID-19 responses. The research team had strong pre-existing links and networks within both settings which facilitated timely access to data and sharing of study findings. The two contexts are different in terms of their level of economic development and health system organisation, but provide an opportunity to compare COVID-19 responses from low- and high-income settings and for the countries to learn from each other. A purposive sampling technique was employed to select participants in both contexts. Based on this approach, individuals were selected based on their role in the health system along with their ability and willingness to provide useful information relevant data . This enData in both study settings were collected by experienced researchers between June and September 2020. This occurred during the early stages of the pandemic when response measures in both contexts were being newly implemented, providing participants with the opportunity to reflect on their impact. A relative lull after the first wave of the pandemic afforded healthcare workers and policy actors the time and space to reflect and be interviewed about their experiences. Data were collected through individual interviews. Interviews were predominantly carried out remotely by experienced researchers in English language, via online platforms such as Microsoft Teams and Zoom due to physical distancing measures adopted to promote infection control. A minority were carried out in person with physical distancing measures, according to local guidance. Each interview lasted approximately 45 minutes and was audio-recorded. Topic guides were developed with broad open-ended questions based on the conceptual framework and explored key areas such as governance and decision-making; use of ethical guidelines; human resource management; infrastructure (information technology and communications) and health care worker support; introduction of innovations; and perceptions of the equity and quality of service delivery. Adaptations were made according to the health systems context in each country. While discussion in Merseyside focused at the regional and health facility levels, in Liberia, it focused on the national and county levels. Participants were interviewed once within the study timeframe. They were informed about the broad interview topics during the consent process and only heard about the specific questions during the interview.Audio-recordings were transcribed verbatim using Otter.ai software, with quality assurance conducted by a second researcher against the recording. Data were analysed with the support of NVivo12 software based on a framework analysis approach . A codinKey findings are described in themes below. These are presented alongside illustrative quotes from the data and relevant case studies.“… lots of patients, especially the youth, are happier having that [video and telephone consultation] and may be accessing care more because if they’ve got a long way to travel, then they don’t need to travel, they don’t need to worry about their parking. They don’t need to worry about having to sit in a waiting room for an hour” . Many clinicians perceived virtual delivery to be as effective as in-person delivery, with the added benefit of greater convenience to patients, for example:: “virtual consultation has highlighted different ways of working, and probably more efficient ways of working sometimes as well … In a lot of cases, you can gain as much as 90% of your diagnosis from [patient] history, it’s less about the examination.” . Some health workers in the community reported telephone triage systems enabled them to efficiently allocate scarce resources to patients who needed care most.As exemplified in Fig. we’ve been told to use e-consultations as much as possible. But we’ve got a lot of patients who haven’t got a computer…they are of a different generation and struggled to access care during the pandemic….” . Several clinicians complained virtual consultation and reviews did not permit optimal patient assessment and led to misdiagnosis and mistreatment, especially among persons with learning disabilities and persons with impaired vision and cognitive function. They noted effective assessment required considering physical attributes and interactions with carers and the environment. Another widely identified challenge was the ability to build rapport. Even senior primary care staff acknowledged a fear of missing important aspects of patient diagnosis and care.“… I think you lose an element of connection - ability with people to ask questions, to challenge you, to ask for more information. And there is a level of nuance that you don’t get.” Despite the perceived benefits, respondents in Merseyside noted elderly patients; people with mental health conditions or learning disabilities; people who were homeless or had history of alcohol or substance misuse were disproportionately affected by the transition to telemedicine due to limited capacity to use a smart phone, as illustrated by this clinician: “In Liberia, rather than patient engagement, virtual communication tools  were employed to supervise and engage with community health workers to ensure continued provision of essential services in rural communities amid lockdown and travel restrictions. Such communication tools  were widely deployed within hospitals in Merseyside to facilitate multi-disciplinary collaborative working among healthcare professionals to enhance patient care and staff wellbeing.Initial COVID-19 response measures in both study settings involved diverting resources meant for routine service delivery, notably personnel, equipment, and medical supplies. Respondents were of the view that reallocation was necessary to prevent hospitals becoming overwhelmed by COVID-19 cases, and it was sometimes more efficient. However, many elective services in primary and secondary care were reported to have been discontinued due to capacity constraints caused by the reallocation, resulting in long waiting times, delays in critical investigations and treatment, and compromising quality of care Fig. . Health “Some of the community health workers have been positioned to immigration check points to provide temperature checking and all of that. Those are volunteers that are supposed to be in the communities providing NTDs services…. That has a direct negative impact on the NTDs services at the community.” Meanwhile, Liberia placed strong emphasis on the need for continuation of essential health services Fig. . CommuniService cancellations in Merseyside were noted to have disproportionately affected socially disadvantaged groups with pre-existing difficulties with healthcare access, such as ethnic minorities, refugees, and low-income households, in comparison to other groups who could afford private care as an alternative. In Liberia, respondents identified rural residents, people living with severe physical disabilities, children under 5-years of age, pregnant women, and people with chronic disease as those who were most affected by the disruptions in service delivery.Several measures were identified for improving equitable delivery of routine services in the context of the capacity constraints. In both contexts, cross sectoral collaboration was felt to have contributed to lessening pressures on routine service capacity. Partnerships formed between NHS trusts and private sector organisations facilitated the provision of cancer operations including for patients who could not afford private care following the service closures. In Liberia, engagement with the media helped to counteract misinformation about COVID-19 and promote service utilisation. Social prescribing and community-based service delivery were implemented to ensure the continuation of essential routine services while reducing pressure in hospitals for COVID-19 care in Merseyside. This was noted to be particularly useful for older people and clinically vulnerable patients who could not visit facilities to access care as well as low socio-economic patients whose access were curtailed by disruptions in transport and shift to telemedicine.widespread misperception that the vaccines were contaminated with COVID” . Respondents reported patients presenting with advanced illness and feared that the delay would lead to excess deaths.Participants in both contexts reported huge reductions in the uptake of emergency and elective services. Uptake was particularly low among people with high healthcare needs: the elderly, pregnant people, and people with ongoing chronic illness. They were concerned about contracting COVID-19 at face-to-face appointments. In Merseyside, interviewees felt patients were not coming for needed consultations as the media and government were perpetuating the message that services were unavailable. Government ‘stay at home’ messages in the UK may have been perceived literally, while disruptions in local transport services further constrained physical access. In Liberia, respondents reported a decline in treatment adherence and an increase in self-medication with many pregnant women staying at home and using non-professional care  leading to increased adverse pregnancy outcomes Fig. . Many pa“During the peak, nobody was coming to hospital with anything. Nobody turned up with strokes to the emergency department. … I think there’s going to be a lot of missed cancer diagnoses…. these are really going to negatively affect people if they couldn’t have their chemotherapy and their cancer has now progressed.” “…for the last two weeks or so some of the deaths we have had, they are not COVID-19 related death, but people thought that they had COVID-19 so they stay away and by the time they present them to the hospital some of them end up having renal failure and they end up dying of heart attack.” In Liberia, as highlighted in Fig. Respondents across both contexts highlighted the positive effects of the infection control measures, such as PPE, physical distancing, and hand and face hygiene, in minimising the spread of COVID-19 and other nosocomial infections. In Merseyside, hospital-based routine services were divided into designated areas according to a traffic light system originally developed for the EVD response, with patients cohorted to minimise interaction between those with COVID-19 and those without COVID-19. Many respondents identified such a system to have streamlined internal patient flow and prevented COVID-19 infections.In Merseyside, professionals felt restrictions on physical contact due to PPE, which improved patient safety but inhibited patient interaction and quality of care. Many reported that the wearing of gowns, visors and masks hindered their ability to examine patients, build rapport and be heard and seen. This particularly affected the elderly and those with visual and hearing impairment. Patient education, conducted virtually or whilst wearing PPE, limited the kind of conversations that health workers were able to have with patients and were even more difficult among patients with hearing and speech impairment. Further, respondents noted that the lack of face-to-face interaction coupled with the ban on family visitation to hospitals denied patients psychosocial support, stunting their recoveries, especially among elderly who had less access to smart phones and face time See Fig. . In LibeThe effects of the COVID-19 response on the morale and wellbeing of health workers were widely discussed by respondents across both settings and noted to have affected staff performance in the delivery of quality routine health services. The redeployment of routine health staff was linked with increased workload in both settings, with evidence of staff burnout, fatigue and poor mental health reported. Staff satisfaction and morale in Merseyside was diminished by the lack of face-to-face contact with patients and colleagues which negatively affected performance. Some providers tried to alleviate these through virtual therapy with a psychologist as well as online quizzes and simultaneous team tea-breaks see Fig. . Increas“There were some health clinicians that were out of fear either turning patients away or refusing to see patients. Some will just give prescriptions and might not do proper examination because of the fear factors and the unavailability of the requisite PPE.” In Merseyside, redeployment and remote working was noted to have disrupted staff supervision and support, with many junior health workers having to work in isolation without adequate support and oversight. Similarly, in Liberia, in-person supervision of community health workers was pared back due to social distancing and shortage of PPE. Although social media was later employed to provide virtual supervision, respondents noted this may have had a negative impact on the quality of routine services, especially in rural areas, where connectivity was challenging.Respondents across both contexts felt the limited influence of local actors in health decision-making hampered the development of timely solutions to routine health service delivery and exacerbated waiting lists and health equity issues. At the start of the pandemic, several health decisions about routine services, such as the cancelation of elective care in Merseyside and the deployment of health staff to COVID-19 services in both settings, were centralised top-down directives passed down to the local level for implementation. Participation of community actors in priority setting and response decisions were reported to be limited in both contexts. In Merseyside, respondents perceived centralised directives were oriented towards achieving political objectives and did not reflect local realities. These often led to friction between local leadership and frontline staff who wanted scope to influence the decisions. Many reported that they felt under-valued and unmotivated due to their limited participation in health decisions. However, on occasions where staff were given the opportunity to influence local health decisions, specialised committees harnessed staff expertise and appropriate solutions to effective local service delivery were developed; there was greater staff participation; and participants (staff) reported greater job satisfaction. In Liberia, working with community members and local governance structures enabled health system actors to address community misperceptions about childhood vaccination, improve confidence in the health systems and to promote uptake of routine health services during the pandemic Fig. .confusion over what and how healthcare services should be provide and prioritised at the early stages of the pandemic” . Respondents noted that the capacity shortfalls were compounded by historic underfunding of the health services. In Liberia, learning from experience of EVD epidemic, health system actors recognised the need for early preparedness prior to the COVID-19 pandemic and steps were taken to support the continuation of routine services. However, these efforts were undermined by funding constraints and existing capacity gaps in the health service.Participants in Merseyside noted that local response in routine service delivery was severely hampered by a lack of advance pandemic preparedness. Although some NHS hospitals had a pandemic plan, it was based on an influenza pandemic, and not regularly updated. A lack of relevant local information to inform modelling work and other response strategies in Merseyside was widely reported. As a result, there was shortage of medical supplies such as PPE, human resources and “Overall, we found early response measures implemented to tackle the COVID-19 pandemic in Liberia and Merseyside had mixed effects on the equitable delivery of routine essential health services, impacting both the demand- and supply-side of access and quality of care. The adoption of digital technology in health service delivery enabled continued access to vital health services in both contexts but was associated with sub-optimal diagnosis and care among elderly and people living with disabilities  in Merseyside. Reallocation of existing health resources to COVID-19 care diminished the capacity for routine health service delivery in both settings, with socially vulnerable populations  disproportionately affected by delayed diagnosis and treatment for critical health conditions. Redeployment of health workers responsible for routine service delivery increased staff workload and affected their mental health and performance in both contexts. While limited local autonomy and participation in COVID-19 response hindered local innovations and entrepreneurship and alignment to local priorities in Merseyside, in Liberia, emphasis on greater community engagement in response planning improved the utilisation of non-COVID-19 essential health services during the pandemic.Our findings suggest that although health system measures introduced in the wake of the COVID-19 pandemic in UK and Liberia may have been useful in dealing with the increased demand for care from the pandemic, they led to unintended adverse impact on access and use of critical non-COVID-19 health services. This is consistent with growing evidence of COVID-19 measures disrupting essential health services –37. PujoThe inequities of the COVID-19 response measures in our study were in part linked to pre-existing disadvantages of vulnerable groups limiting their capability to adapt to the constraints to healthcare imposed by the pandemic . The higFindings from the current study highlight important lessons for optimal delivery of routine essential services in the ongoing COVID-19 response and future shocks. These are aligned with the people-centred approach and have been outlined in two separate policy briefs focusing on Liberia  and MersOur findings underscore the need to strengthen the building blocks of the health system in normal times to create surge capacity and enable ongoing health service delivery during a crisis . GovernmFurther, we identified that improving the capacity and wellbeing of health staff is critical to engendering health system resilience to assure delivery of essential health services. There is the need to ensure the availability of sufficient staff in normal times so that in crisis these are not overstretched. While staff redeployment may be necessary to deal with staff shortfalls in the immediate pandemic period, the process should be driven by judicious planning and workload management backed by data on staffing needs to minimise potential unintended consequences in other essential service areas. Improving job satisfaction among health workers through financial and non-financial incentives is essential to boosting morale and enhanced performance . With paConsistent with Cascini et al., advance pandemic preparedness based on participatory and inclusive planning process, along with frequently updated locally informed guidelines and intersectoral collaboration are essential for assuring effective health services during pandemic .The cross-sectional qualitative study design may limit the generalisability of our findings. However, the purposive sampling and data saturation techniques employed to select the participants enriched the study data and enhanced the validity of the findings. The comparative approach of the study involving participants being selected across different levels of the health system in the study countries improved the breadth of the data but made comparison difficult. The different level of participants used in the two study settings  may have resulted in some of the differences in findings related to differing perspectives. Further, not including a larger number and range of participants from sub-national health systems levels in Liberia may have limited the depth of understanding about the impact of COVID-19 response at the local level in the country. The study was carried out at a single point in time and at an early stage of the pandemic when response measures where only starting to be introduced. Since then, the pandemic and related response measures have continued to evolve and so would be their impacts. An impact analysis of the COVID-19 response on equity and quality of routine services from the perspective of service users would strategically complement this data and analysis.This analysis of the impact of the COVID-19 response measures on routine services shows that while they sometimes improved safety and ensured continued access to vital health services during the pandemic, they disrupted equitable access to many routine essential services, with socially vulnerable groups disproportionately affected. Pre-existing health system capacity and social inequalities shape the ability to maintain equitable access to quality routine services during COVID-19. Evidence from this research can be useful to inform pandemic response planning to ensure optimal delivery of essential health services during public health emergencies. Ongoing COVID-19 responses and future shocks should prioritise addressing both the immediate and structural barriers to care; evidence-based practice and decision-making; and robust engagement with communities and patients, leveraging culturally sensitive and inclusive approaches. It is essential to ensure adequate funding and investment in the building blocks of the health system in normal times. Further, there is the need for greater autonomy for local decision-making coupled with inclusive and participatory leadership that promote the involvement of staff and community leaders in local decisions on health services.Additional file 1.


Mathematical modeling of anatomically-constrained neural networks has provided significant insights regarding the response of networks to neurological disorders or injury. A logical extension of these models is to incorporate treatment regimens to investigate network responses to intervention. The addition of nascent neurons from stem cell precursors into damaged or diseased tissue has been used as a successful therapeutic tool in recent decades. Interestingly, models have been developed to examine the incorporation of new neurons into intact adult structures, particularly the dentate granule neurons of the hippocampus. These studies suggest that the unique properties of maturing neurons, can impact circuit behavior in unanticipated ways. In this perspective, we review the current status of models used to examine damaged CNS structures with particular focus on cortical damage due to stroke. Secondly, we suggest that computational modeling of cell replacement therapies can be made feasible by implementing approaches taken by current models of adult neurogenesis. The development of these models is critical for generating hypotheses regarding transplant therapies and improving outcomes by tailoring transplants to desired effects. In addition to describing normal neural function, new computational modeling paradigms have successfully recapitulated various aspects of neurodegeneration and injury. For instance, models of Parkinson’s Disease (PD) have demonstrated overt motor deficits as well as subtle cognitive symptoms due to loss of striatal dopamine and suggested new hypotheses regarding PD as a disorder of altered synaptic plasticity and not simply of motor function . Next, the model should provide a readout that maps to a behavioral metric to examine clinical efficacy of a treatment regimen (III). As for the therapy, it is essential that a mechanistic representation of the therapy itself be incorporated (IV), including temporal and spatial dynamics to the extent possible (V). To illustrate how this approach will apply to an existing paradigm we will discuss the computational modeling implications of using cells derived from human pluripotent stem cells (hPSCs) in the context of stroke, as this area has proven a significant target for both modeling and cell replacement.We have developed a set of criteria that we believe will be required for an accurate predictive modeling resource Table . We advoin vivo imaging studies in mice have revealed that peri-infarct sensory regions can “remap” their RFs after stroke, responding to peripheral stimulations that were previously restricted to now-damaged cortices , which supplies blood flow to the basal ganglia and nearly the entire dorsolateral surface of the temporal and parietal cortices (Mohr et al., Due to the hierarchical nature of the cerebral cortex, its development and reorganization following injury have been significant targets for modeling studies (Willshaw and von der Malsburg, More anatomically-relevant models have developed hypotheses as to the mechanisms underlying alterations in RFs. For instance, models of sensory cortex that incorporate laterally projecting excitatory and inhibitory units demonstrate immediate expansion of RFs near to the lesion site due to disinhibition; units near the lesion site no longer receive lateral inhibitory connections from ablated cells, unmasking weaker afferent synaptic connections (Sober et al., in vivo and in silico is an effective measure of behavioral output (Lytton et al., One of the key aspects for modeling stroke recovery While physical rehabilitation can assist stroke patients with regaining motor function, neither spontaneous recovery nor current intervention strategies provide complete symptom amelioration Kalra, , and no in vivo, including voltage-gated currents, spiking, synaptic activity (Muotri et al., in vitro and in vivo (Weick et al., While multiple mechanisms may underlie transplant-mediated recovery (Lee et al., With respect to stroke, transplanted cells improve behavioral outcomes, extend processes into brain parenchyma, and express synaptic proteins (Ishibashi et al., As mentioned, a major consideration for modeling therapeutics is the incorporation of an accurate mechanistic and temporal representation of the therapy itself Table . At leasUnfortunately, most publications measuring functional properties of hPSNs demonstrate report only RS phenotypes (Wernig et al., Interestingly, the development and incorporation of hPSNs into existing neural networks shares many features of adult neurogenesis. Most importantly is the progressive maturation of excitable properties including synaptogenesis (Zhao et al., In order to illustrate the complexity of incorporating new neurons into existing circuits, it is useful to consider systems in which there is ongoing integration of new neurons within the normal brain. Adult neurogenesis in the DG region of the hippocampus provides just such a system (Zhao et al., The maturation process is non-trivial. New neurons pass through several distinct functional stages prior to settling into long-term behaviors (Figure s Figure . In the s Figure . Over ths Figure  and axons Figure . From a s Figure .Maturation affects other neurons in circuit. One computationally intriguing observation regarding adult neurogenesis is the direct interaction between new neurons and mature neurons in the network. Electron microscopy studies suggest that young neurons preferentially target existing synapses, both dendritic and axonal, as a prelude to formation of new synapses (Toni et al., de novo, but at least in some cases involves subverting existing synaptic machinery. While synaptic competition presents intriguing computational possibilities for DG neurogenesis, namely a mechanism for young neurons to sharpen tuning curves of mature neurons, this interaction represents a potential concern with respect to adding neurogenesis to other regions.A direct interaction between young and old neurons may be suitable for the DG; its primary function is thought to be in facilitating memory encoding, not memory storage. As a result, sharpening RFs over time could be beneficial (O’Reilly and McClelland, The above summary highlights two major computational considerations that must be accounted for when approaching neuronal replacement therapy. First, new neurons do not mature in isolation, and the progression from a progenitor state to a fully functional neuron is complex. While neurogenesis has been evolutionarily preserved in the DG, networks normally lacking neurogenesis may be more sensitive to the addition of neurons. It would not be unreasonable to expect that the addition of neurons could shift the balance of a network out of normal operating bounds, causing either seizures or depressed overall activity (Schneider-Mizell et al., Second, the functional displacement of an impairment, either acute or through degeneration, is not static. Rather, compensatory mechanisms are initiated almost immediately. While such compensation can be clinically beneficial it represents an additional challenge for cell replacement. In the time that it takes for a replacement therapy to begin and the neurons to be incorporated, the network itself will have changed; as a result, “reversing” the effects of disease may no longer be sufficient Figure . Rather,What should a model capable of addressing these issues look like? Although not used to model stroke, the three-layer GENESIS model used by Mazza et al.  is amongWhile large-scale, biophysically realistic models are currently time-consuming to construct and computationally expensive to simulate, we envision that future simulation tools and high performance computing capabilities will facilitate such modeling endeavors. We hope that our outlined vision for how to approach these efforts will provide a roadmap for understanding the computational implications of cell replacement therapy. The extent to which insights from adult neurogenesis apply to stem cell therapies remains to be seen, and future models will have to consider not only the proposed therapy but also the unique aspects of the brain region affected, its function, and the disease. Nonetheless, improved modeling tools and approaches in recent years provide computational neuroscience with a unique opportunity to influence the development of an exciting area of therapeutic development.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.


In this mini-review, we first define the characteristics of “regulatory” DCs (rDCs) and then focus on the contribution of non-hematopoietic stromal cells to their generation within specific tissue microenvironments. We also highlight areas of research that warrant future attention, arguing for a focusing of efforts toward a better understanding of the features of stromal cell populations that enable the induction of rDCs. Finally, we discuss how an understanding of stromal cell-myeloid cell interactions may lead to new therapeutic strategies for cancer, autoimmunity, and infectious disease.Dendritic cells (DCs) are specialized antigen presenting cells of bone marrow origin that can exist in tissues in either an immature or mature state. DCs have a myriad of roles in immunity and tolerance induction, but are perhaps best known for their role in the activation and differentiation of naïve T cells at the onset of an acquired immune response. Over the past decade, a body of literature has developed that suggests that DCs, as well as many other myeloid cell populations, are also capable of exerting “regulatory” effects on T cell responses. However, relatively little is known regarding the mechanisms by which such regulatory myeloid cells arise  This has given rise to a literature that contains a significant level of confusion. That many of these myeloid cells also share phenotypic characteristics has only compounded the problem. For example, the assignment of cells as DCs based solely on CD11c expression has not always been helpful  lie at the interface of innate and adaptive immunity, playing a critical role in the initiation of effective T cell-mediated immune responses. Paradoxically, DCs also have the potential to exert powerful negative regulatory effects on the immune system  production  fibroblastic reticular cells (FRCs), whereby nitric oxide produced by LN FRCs regulates T cell proliferation via direct effects on T cells, in addition to modulating cDC function . Splenic stroma-induced rDCs directly induce IL-10-producing Tr1 Treg lo/int MHCIIlo/int CD11b+ myeloid cells, capable of IL-10 production, the direct suppression of CD4+ T cell proliferation and (in some cases) the induction of Treg. Although several other functional features can also contribute to the identification or characterization of rDCs, these are either tissue-context dependent, or have not yet been assessed in all stromal-induced rDC populations.Taking these multiple parameters into consideration, a “minimal” definition of stromal-induced rDCs can be reached as CD11cL. donovani , a chronic infection caused by the intracellular parasite As stromal cells from organs considered mucosal (Li et al., Unlike the relatively conserved phenotypic and functional characteristics of rDCs, there are multiple reported mechanisms by which stromal cells induce these cells. Physical contact between splenic stromal cells and mature cDCs has been shown to be required for their polarization toward a rDC phenotype, in a process also dependent on fibronectin (Zhang et al., 2 and IL-10, the release of these mediators by stromal cells has also been implicated in their generation, with splenic endothelial-produced IL-10 (Tang et al., 2 (Liu et al., Diverse stromal cell-derived products such as IL-6 (Huang et al., A potent immunoregulatory circuit endowing human DCs with IL-27-dependent regulatory potential was recently described (Ilarregui et al., in vivo and the lineage relationship of rDCs to conventional DC populations. Transcriptional and epigenetic profiling of rDCs from a multitude of tissue sites and disease states will allow for these questions to begin to be addressed. As many of the mediators previously reported to be important for rDC generation are produced widely within the immune system, it is important to determine how they contribute to the generation of rDCs within a defined tissue microenvironment. As it is likely that a multitude of synergistic signals underlie the induction of rDCs by stromal cells, revealing the extent of redundancy in this system will be key in finding pathways essential for rDC induction by stromal cells. In addition, extending our knowledge of the processes by which pathogens, vaccination, or chronic inflammation can modulate stromal cell function, and thus favor or suppress rDC induction in vivo will be crucial when considering therapeutic strategies aimed at manipulating rDC abundance or function.As evidenced by this short review, there is still much to be revealed regarding the precise mechanisms by which stromal cells induce the differentiation and/or expansion of rDCs Figure . Indeed in vitro will provide clues as to novel mechanisms responsible for their in vivo induction. This type of analysis has already been performed for splenic stromal cell populations capable of inducing immature DC populations in vitro (Despars et al., Furthermore, a more detailed analysis of the stromal microenvironment that supports rDC generation in vivo. Even within the same organ it would appear that diverse stromal populations such as fibroblasts (Svensson et al., in situ, allowing for the visualization of the distinct microenvironments that facilitate the induction of these cells. However these approaches will necessitate the development of specific tools for the identification of rDCs in vivo. Such experiments are also likely to challenge the conclusions drawn from conventional experimental approaches.More fundamentally, it is essential that we gain a much deeper understanding of the stromal cell populations capable of rDC induction To bring clarity to the field, the following approaches should therefore be taken to address the major outstanding research questions regarding stromal cell-induced rDCs:– Transcriptional and epigenetic analysis of stromal-induced rDCs from distinct tissues to determine whether subsets exist and their relationship to cDCs.in vivo, which will require the development of new tools for rDC identification.– Imaging approaches to visualize the stromal cell-rDC niche – Transcriptional and epigenetic analysis of stromal cells capable of rDC induction, specifically comparing these profiles to those of stromal cells from distinct tissues and/or disease states.Extending our knowledge of both rDCs and the stromal cells that induce them may allow for the potential therapeutic benefits of this immunoregulatory axis to be realized.With patient-specific pro-inflammatory DC infusions effective in phase III trials for prostate cancer (Kantoff et al., ex vivo expansion of myeloid cell populations for infusion has disadvantages. Instead, harnessing the capacity for stromal cells to regulate rDC induction by specifically targeting them for functional modulation in vivo could provide a method to enhance rDC induction for the amelioration of autoimmune or inflammatory disease, or conversely repress rDC induction during the immunosuppression associated with chronic infection and cancer. Stromal targeting approaches have already attracted much interest in the oncology field (Engels et al., Although clearly feasible, the By expanding our knowledge regarding the detailed mechanisms underlying stromal cell – regulatory dendritic cell interactions, we may advance one step closer to the ultimate goal of subtly manipulating immune function by targeting stromal cells within an inflammatory microenvironment.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.


Massively Parallel Sequencing (MPS) allows sequencing of entire exomes and genomes to now be done at reasonable cost, and its utility for identifying genes responsible for rare Mendelian disorders has been demonstrated. However, for a complex disease such as the common cancers, study designs need to accommodate substantial degrees of locus, allelic, and phenotypic heterogeneity, as well as complex relationships between genotype and phenotype. Such considerations include careful selection of samples for sequencing and a well-developed strategy for identifying the few “true” disease susceptibility genes from among the many irrelevant genes that will be found to harbor rare variants. To examine these issues we have performed simulation-based analyses in order to compare several strategies for MPS sequencing in complex disease. Factors examined include genetic architecture, sample size, number and relationship of individuals selected for sequencing, and a variety of filters based on variant type, multiple observations of genes and concordance of genetic variants within pedigrees. A two-stage design was assumed where genes from the MPS analysis of high-risk families are evaluated in a secondary screening phase of a larger set of probands with more modest family histories. Designs were evaluated using a cost function that assumed the cost of sequencing the whole exome was 400 times that of sequencing a single candidate gene. Results indicate that while requiring variants to be identified in multiple pedigrees and/or in multiple individuals in the same pedigree are effective strategies for reducing false positives, there is a danger of over-filtering so that most true susceptibility genes are missed. In most cases, sequencing more than two individuals per pedigree results in reduced power without any benefit in terms of reduced overall cost. Further, our results suggest that although no single strategy is optimal, simulations can provide important guidelines for study design. Examples in familial breast cancer and melanoma will be presented to illustrate these points.