Re-thinking and re-assessing residential mobility by exploiting new developments in longitudinal analysis will allow geographers to understand, critique and address pressing societal challenges.While researchers are increasingly re-conceptualizing international migration, far less attention has been devoted to re-thinking short-distance residential mobility and immobility. In this paper we harness the life course approach to propose a new conceptual framework for residential mobility research. We contend that residential mobility and immobility should be re-conceptualized as  In recent decades studies have re-assessed and re-conceptualized how contemporary life is configured by the movements of people, objects, capital and information . This gr2 Population and attitudinal changes associated with the Second Demographic Transition challenge scholars to conceptualize how trends such as rising rates of solo living, the growth of ‘patchwork’ families and the popularity of ‘living apart together’ are linked to new forms of residential movement  moving is bound up with linked lives and structural connections. In the next section we examine how contextual changes – most notably those associated with the Second Demographic Transition and GEC – are creating new challenges for researchers which require re-thinking residential mobility at the levels of linked lives and structural connections. For each of these levels we discuss several ways in which re-conceptualizing residential mobility as a relational practice can advance knowledge and enable scholars to understand, critique and address current social challenges .While researchers are well aware of the difficulty of defining what constitutes residential mobility and how this differs from migration , the mosChanges in family structures and patterns of domestic living mean that continuing to define residential mobility as a discrete one-way transition overlooks an increasing proportion of residential mobility experiences. Instead of substituting one dwelling for another, these typically involve making frequent and often repeated or rhythmic moves between multiple residences . This diTwo overlooked forms of residential mobility have become particularly relevant in recent decades. The first is residential itinerancy. Rather like seasonal migration, we can conceptualize residential itinerancy as frequent shifts between multiple maintained residences which each function as temporary ‘centres of gravity’ around which people order their daily lives. Residential itinerancy is becoming increasingly relevant because historically high separation and divorce rates mean that contemporary western societies contain many divorcees, lone parents and children living in reconstituted or patchwork families . Joint cDemographic research also suggests the increasing prevalence of residential transience; particularly amongst young people leaving home, navigating higher education and entering the labour market . ResidenUnderstanding residential itinerancy and transience requires considering residential moves as practices rather than transitions. This can help us to better understand why people make particular types of move at different points in the life course. While existing theories explain residential mobility as an adjustment response to housing disequilibrium or dissatisfaction , this moRe-considering what constitutes residential mobility highlights the necessity of re-thinking how people make moving decisions. The dominant models of mobility decision-making are rooted in behaviouralism, casting moving decisions as an individualized cognitive process that is shared by all household members . While tRe-thinking residential mobility as a relational practice helps to address these deficiencies. An important first step is to contest the notion that households are unified entities within which everyone shares the same preferences, aspirations and goals . For exaThese studies indicate how re-thinking residential mobility as a practice rather than an event can deepen our understanding of the roles that intra-household bargaining, negotiation and trade-offs play in configuring patterns of short-distance residential mobility and immobility. This is important for incorporating the sensitivity to gendered power relations present within the family migration literature into models of residential mobility decision-making . This wiIncorporating a deeper sensitivity to power relations requires re-considering the temporal dimension of moving decisions. While many analyses concentrate on moving events , a growiImportantly, this work reveals that people frequently do not behave in accordance with their previously expressed desires and intentions . While tConcerns about pension provision, welfare restructuring and the prevalence of casual and low-paid employment are all prompting debate about how informal support can and should be used to complement or replace state assistance . Yet by Demographic trends such as population ageing, increased rates of solo living in midlife and the high prevalence of union dissolutions and lone parenthood make it crucial to understand how people use residential (im)mobility to facilitate the exchange of physical care, childcare and other forms of assistance within their social and kin networks . AlthougBy focusing on residential moves rather than life-course trajectories, existing perspectives downplay how the qualitative nature of interpersonal bonds ebbs and flows over time in response to changes in the linked life courses of family members or friends . Social Paying greater attention to the qualitative nature of linked lives can also bring a heightened sensitivity to power relations into analyses of residential mobility. While social capital theories construct linked lives as beneficial resources , demograThe importance of situating linked lives within the context of power and material inequalities has increased with recent structural changes in housing systems. These trends mean that residential mobility is becoming an increasingly relevant mechanism for the transmission of resources and inequalities over time and between birth cohorts . As housResidential mobility and immobility are also crucial for the (re)production of intergenerational inequalities in housing wealth. While changes in tenure patterns, housing policies (such as Right to Buy in the UK) and boom-bust cycles mean that some cohorts have accumulated more housing wealth than others , these iRe-thinking residential mobility can yield new insights about the connections between life courses and structural conditions. One way this can be achieved is by re-conceptualising residential immobility. According to Contemporary trends suggest several reasons to re-conceptualize how residential immobility is embedded within structural connections. Contrary to postmodern narratives of hyper-mobility, emerging evidence suggests that rates of long-distance migration are declining in some western societies, most notably the US . A varieEven if we cannot generalize from these findings, evidence that some societies have falling migration and residential mobility rates does suggest a need to revisit Considering residential immobility to be a practice further draws our attention towards how long-term changes are reshaping the meaning and implications of immobility . CheaperIn keeping with population geography, much writing about residential mobility is self-consciously scientific and based around sophisticated quantitative analyses of large datasets . While tThe political response to the GEC indicates that it is essential to examine how the social construction of residential mobility and immobility is bound up with the projection of power, with consequences for life courses and social norms . This re3 Yet at the same time, caps in housing benefit and the introduction of the ‘bedroom tax’ restrict welfare payments to tenants judged to be living in excessively expensive accommodation or over-consuming space. The aim of these policies is to compel poor households and social tenants to make residential moves to dwellings that are deemed more appropriate for their life-course position. Moving and staying are thus increasingly bound up with the support and enforcement of particular spatial visions and performances of good citizenship . In addition, continuously updated population registers in countries such as Denmark, the Netherlands and Sweden provide long periods of rich longitudinal data about entire populations. When combined with developments in sequence analysis and multilevel modelling (Although these limitations are being partially addressed by event history modelling of anticipatory and lagged effects , until rodelling , these rodelling .5 Even setting aside thorny issues of recall bias and contextual conditioning (By gathering data prospectively, these resources enable researchers to overcome the difficulties associated with using retrospective data.itioning , questioitioning . This crPerhaps the most daunting constraint facing researchers is the lack of longitudinal data about the links between individuals. Administrative and census resources rarely capture data on networks extending beyond the household unit. Furthermore, these datasets, as well as many surveys, often only allow people to report living in one place at once. This means that they are poorly suited to exploring practices of residential itinerancy and transience.de facto living arrangements as well as de jure residential status could also help capture frequent, cyclical and short-term residential movements (Overcoming these issues is becoming easier as new data emerge. Surveys such as the Gender and Generations Survey , United ovements .These empirical advances enable researchers to answer several sets of questions that emerge as a result of re-thinking residential mobility. The first concerns how the de-standardization of life trajectories combines with cohort and period effects to restructure how people practise and experience residential mobility and immobility in different times and places. For instance, contextual changes mean that events such as leaving home, parenthood and entering owner-occupation are experienced at increasingly diverse times which are strongly dependent on material resources . UnpackiAnother series of questions centre on the long-term relationships between residential mobility and life-course careers. The challenge here is to use prospective rather than retrospective data to analyse how mobility practices are linked together into long-term trajectories . DevelopA final set of questions concern how residential mobility can produce ripple and shadow effects stretching across linked lives. Ripple effects refer to the ways in which changes in one person’s life course may have effects upon the lives of those they are linked to. Examining ripple effects requires shifting analyses from the individual level to focus on dyadic relations. This could, for example, involve examining how returns to the parental home have consequences for the well-being of both children and parents. Given concerns about pensions provision and the difficulty of accessing homeownership , researcIn contrast, shadow effects refer to the ways in which events and experiences can have long-lasting effects on a person’s life course . Shadow This paper has argued that geographers need to re-think residential mobility. Although the life course perspective has long provided a rich overarching framework, little attention has been directed toward conceptualizing how mobility is bound up with linked lives and structural connections. This makes it difficult to understand contemporary trends. Viewing moves as discrete transitions between dwellings overlooks the relational residential itinerancy and transience being generated by demographic shifts, while neglecting how the diverse meanings of residential immobility are being shaped by economic and technological change. Similarly, conceptualizing residential mobility as an adjustment response to disequilibrium can tell us little about how moving and staying are influenced by the increasingly uneven distribution of resources and power within families, localities and countries . FurtherThese issues can be overcome by re-thinking residential mobility and immobility as relational practices that link lives together and connect people to structural conditions through time and space. This suggests a range of new research questions that can be answered by harnessing the ‘new opportunities for creative research’ produced by novel longitudinal datasets and emerging longitudinal methods : 117. TaDeveloping a new residential mobility research agenda will also benefit scholarship. By enriching the way in which we conceptualize how demographic processes are bound up with linked lives and structural connections, re-thinking residential mobility provides a way to comprehensively integrate time and space into life-course theory and analysis . This ap


Patients with peripheral artery disease are at high risk of coronary artery disease. An increasing number of studies show that a large proportion of patients with peripheral artery disease have significant coronary atherosclerosis, even in the absence of symptoms. Although the reported prevalence of subclinical coronary artery disease varies widely in patients with peripheral artery disease, it could include more than half of patients. No consensus exists to date on either the rationale for screening patients with peripheral artery disease for coronary atherosclerosis or the optimal algorithm and method for screening. An increasing number of imaging modalities are emerging that allow improved in vivo non-invasive characterization of atherosclerotic plaques. These novel imaging methods may lead to early detection of high-risk vulnerable plaques, enabling clinicians to improve risk stratification of patients with peripheral artery disease, and thus paving the way for individualized therapy. Atherosclerosis is a systemic degenerative inflammatory vascular disease and the primary underlying cause of coronary heart disease. Atherosclerosis develops over decades, with a long subclinical period. About half of all patients who die from coronary heart disease have no prior diagnosis or symptoms of cardiac disease . DespiteClinical risk stratification of asymptomatic patients is typically performed using global risk scores such as the Framingham risk score or HeartScore, rendering a 10-year risk of cardiovascular death on the basis of “classic” cardiovascular risk factors. In addition to the clinical risk scores, a number of medical conditions indicate a cardiovascular risk similar to that of patients with established coronary heart disease ••, 4. ThThis article will address the use of imaging methods for identification of subclinical coronary artery disease in patients with known PAD and will discuss the indications for imaging for subclinical coronary artery disease, both with regard to general screening and in the subgroup of patients with PAD who are referred for major surgery.More than 30 years ago, Hertzer et al. established that patients undergoing surgical management of PAD had a high prevalence of significant coronary artery disease and that a large proportion of the patients were asymptomatic . It is nA positive association between carotid and coronary atherosclerosis has been recognized for decades . In the The prevalence of subclinical coronary artery disease reported in the AMISTAD study is supported by both the PRECORIS study  and autoA recent review of the literature including 1,277 patients reported that 50% of patients with abdominal aortic aneurisms had significant coronary artery disease . This nuPatients with lower limb arterial disease are at increased risk of mortality from cardiovascular and coronary heart disease, even if PAD is asymptomatic . Only a In summary, the reported prevalence of subclinical coronary artery disease in patients with PAD varies widely Tables . This maScreening for coronary artery disease (CAD) in patients with PAD remains a controversial subject, both in the general PAD population and for selected subgroups, and particularly in PAD patients referred for major surgery.In patients with PAD who are referred for major surgery, whether for the PAD itself or for other diseases, the risk of postoperative cardiac morbidity and mortality is significantly higher, and preoperative screening for significant CAD is often recommended . HoweverOne recent study included 208 patients with PAD scheduled for major elective vascular surgery with a revised cardiac risk index ≥2 . PatientIn the CARP trial, McFalls et al. had determined that revascularization before vascular surgery did not alter long-term outcome when compared to patients randomized to no revascularization . This stn = 426) were without any clinical sign or history of ischemic heart disease. Patients were randomized to 1) angiography and percutaneous coronary intervention if a significant stenosis was detected or 2) no angiography prior to carotid endarterectomy. Systematic angiography was shown to significantly reduce the incidence of postoperative myocardial events. The 30-day survival and stroke rates were equal in the two groups [Patients with stroke are known to have high cardiovascular risk, even with optimal secondary therapy •. One tro groups . LimitatIf a significant CAD is demonstrated in the general population of PAD patients without coronary symptoms, should it then lead to medical prophylactic intervention or to coronary revascularization? In fact, very few studies have addressed the prognostic impact of image-guided therapy in this setting. Many will advocate that all patients with severe PAD should already be treated to maximal secondary prevention, and that imaging of the coronary arteries should not alter this treatment, and it is therefore not relevant. Others will advocate that significant coronary artery disease should lead to invasive treatment with percutaneous coronary intervention or bypass surgery in these asymptomatic but high-risk patients. A randomized controlled investigation is sorely needed to address these questions.In summary, numerous studies have identified severe subclinical CAD in a substantial proportion of patients with PAD, but a beneficial effect of general screening for CAD by either noninvasive or invasive imaging on occurrence of coronary events has yet to be determined. Large prospective randomized trials are needed in order to provide clarity. As a preoperative investigation before intermediate or high-risk cardiac surgery, limited data suggest a beneficial effect of preoperative imaging of the coronary vessels or myocardial perfusion distribution.From a theoretical risk reduction perspective, a potential benefit in both the general PAD patient population and as a preoperative coronary imaging study of subclinical CAD may be the identification of vulnerable plaques that are prone to rupture or to cause thrombus that may subsequently lead to myocardial infarction. Conceptually, this can be accomplished by imaging the plaque, the anatomy of the coronary vessel, or ischemia.In addition to invasive coronary angiography, a considerable number of noninvasive imaging modalities are available that can suggest or demonstrate the presence of coronary artery lesions, either by anatomical or functional or by combined anatomical-functional information showing increased risk of coronary events Table .Table 2NFlow-mediated dilatation is a test to measure endothelial dysfunction and thus a surrogate measure of coronary atherosclerosis. The endothelial dysfunction is measured in the brachial artery using ultrasound. Patients with PAD are known to manifest atherosclerosis, and as endothelial dysfunction is an early hallmark of atherosclerosis, it should be expected that flow-mediated dilation would be attenuated in all patients with PAD. This was demonstrated in a study of 44 patients with PAD but without symptoms of coronary artery disease . In addiCoronary artery calcium score (CACS) is calculated from a non-contrast CT of the heart. CACS reflects the total plaque burden and provides incremental prognostic information beyond traditional clinical risk scores  . HoweverAn intriguing perspective of CACS is the fact that it can reclassify risk in subsets of patients. For example, patients with diabetes and 0 CACS have a cardiovascular event rate similar to patients without diabetes, thereby challenging the notion of diabetes as a coronary heart disease risk equivalent per se . Future 18F-labeled sodium fluoride (NaF). This tracer is deposited by chemisorptions onto hydroxyapatite and is used in oncology to identify sclerotic bone metastasis. Recent evidence suggests that it is not equivalent to CACS imaging [Another method for imaging calcium is positron emission tomography (PET) using  imaging  but that imaging •.Compared to both NaF and particularly CACS, it may be more attractive to image more specific characteristics of the vulnerable plaque.Coronary angiography by CT (CCTA) is a non-invasive method using intravenous contrast, typically to assess luminal stenoses. However, it has been shown that CCTA can also provide images of the vessel wall, and thus plaque characteristics, including positive remodeling, densitometry, and calcification . With im99mtechnetium-labeled tetrofosmin or sestamibi during stress and rest. The use of PET for perfusion imaging is growing and has several advantages compared to SPECT: higher spatial resolution, faster acquisition, fewer motion artifacts, and absolute flow quantification. The perfusion tracers used for PET imaging are 82Rb, 15O-labeled water, or 13N-labeled ammonia [There are several methods for examining myocardial perfusion, and thus ischemia. Traditionally, this is accomplished by myocardial perfusion single-photon emission tomography (SPECT) using an intravenous injection of  ammonia . The prin = 111) on the association between PAD and subclinical CAD combined anatomical (CCTA) and ischemia (stress MRI) imaging [An important advantage of myocardial perfusion imaging is that it is a functional method of imaging perfusion at the myocyte level and thus can determine whether a borderline epicardial stenosis causes a significant change in perfusion. One study . Howeve18F-FDG). The molecule is a glucose analogue that accumulates in metabolically active cells such as macrophages. The first report on 18F-FDG accumulation in the large arteries emerged in 2001 [PET imaging of atherosclerosis has thus far focused primarily on fluorine-18-fluorodeoxyglucose  as a more specific tracer than 18F-FDG [As an alternative, some researchers have suggested  18F-FDG , but thi68Ga-DOTATATE has high affinity for somatostatin receptors, and a few studies have suggested a future role in plaque imaging [New and potentially more specific PET tracers for imaging coronary atherosclerosis are emerging . The tra imaging –48. PET  imaging •, 50, 51 imaging .Hybrid imaging combining anatomical information from a CCTA with metabolic or molecular information from PET imaging may represent a valuable non-invasive modality for the identification of significant microvascular disease and flow-limiting epicardial coronary artery lesions, as well as for demonstration of the characteristics of the vulnerable plaque in selected patients with PAD.Clinical integrated PET/MRI systems have recently been introduced. MRI can effectively characterize plaque morphology , and the combination with PET-derived molecular imaging holds great potential for in vivo identification of vulnerable plaques. The limited availability of the PET/MRI imaging systems and expensive production of specific PET tracers, however, will likely restrict such a technique to experimental use for some time. Thus far, few reports have been published on hybrid imaging for the study of atherosclerosis •, and noAn already significant and ever-increasing body of evidence indicates a high prevalence of subclinical coronary atherosclerosis in patients with manifest PAD. The value of general screening of coronary arteries with non-invasive imaging in patients with PAD is not documented. Limited data suggest that imaging patients with PAD before major surgery may be valuable. A palette of potentially specific tracers targeted against plaque vulnerability exists via various imaging modalities including PET, CT, MRI, ultrasound, and imaging combinations. Future studies will determine whether identification of patients with PAD at high risk for CAD complications will eventually improve prognosis.


Recognizing the close relationship between poverty and health, national program managers, policy-makers and donors are increasingly including economic interventions as part of their core strategies to improve population health. However, there is often confusion among stakeholders about the definitions and operational differences between distinct types of economic interventions and financial instruments, which can lead to important differences in interpretation and expectations.We conducted a scoping study to define and clarify concepts underlying key economic interventions - price interventions (taxes and subsidies), income transfer programs, incentive programs, livelihood support programs and health-related financial services – and map the evidence currently available from systematic reviews.We identified 195 systematic reviews on economic interventions published between 2005 and July 2015. Overall, there was an increase in the number of reviews published after 2010. The majority of reviews focused on price interventions, income transfer programs and incentive programs, with much less evidence available from systematic reviews on livelihood support programs and health-related financial services. We also identified a lack of evidence on: health outcomes in low income countries; unintended or perverse outcomes; implementation challenges; scalability and cost-effectiveness of economic interventions.We conclude that while more research is clearly needed to assess suitability and effectiveness of economic interventions in different contexts, before interventions are tested and further systematic reviews conducted, a consistent and accurate understanding of the fundamental differences in terminology and approaches is essential among researchers, public health policy makers and program planners. It is widely acknowledged that conditions of poverty and ill-health exacerbate each other . Poor heRecognizing the close relationship between poverty and ill-health, national program managers, policy-makers and donors are increasingly including economic interventions as part of their core strategies to improve population health. For example, 19 73 %) out of 26 tuberculosis (TB) control proposals approved by the Global Fund in 2010 included either direct or indirect economic support . Health 3 % out oSuch ambiguity can lead to important differences in interpretation and expectations. With the breadth and complexity of these applications in mind, we therefore conducted a scoping review to identify different types of economic interventions that public health policy makers and program planners are most likely to encounter or consider implementing, to articulate differences in concepts underlying these different interventions and their applications, and to map the relevant evidence currently available. The purpose of this review is to clarify these terms for policymakers and practitioners and help to assess the value and feasibility of more targeted future research, including future systematic reviews.Based on our study objectives, we adopted best-practice principles of rapid (scoping) review designs based on the methodology outlined by various authors –11. To iFollowing a series of exploratory searches in PubMed and Google Scholar, we determined that the specific terms “economic” and “intervention” would yield results too broad and diverse to be useful, including a large number of irrelevant results related to economic evaluation but not economic interventions, defined as interventions that fundamentally target the economic status or decision making of households with respect to health and healthcare. Based on the abstracts and study descriptions from this initial exploration, we extracted an initial set of the most common terms used to describe economic interventions. These included: tax, subsidy, cash transfer, income transfer, bonus, pay-for-performance, micro-credit and micro-finance.Based on the underlying mechanisms of these economic interventions, these terms were then grouped into five main categories: price-based interventions (taxes and subsidies), income transfer programs, incentive programs, livelihood support programs and health-related financial services. We then further expanded the list of search terms under each category, paying particular attention to including alternative phrases that refer to the same economic intervention, such as income support/income supplement/financial supplement.We conducted five searches of systematic reviews published between 1st January 2015 and 10th July 2015 using PubMed (Medline) and The Cochrane Library (2015 July). We searched for papers containing ‘health’ in any field plus any of the final search terms detailed in Table Three researchers  conducted the literature review Fig. . ResultsFor each category of intervention, given the heterogeneity of interventions, outcome measurements, and settings, it was not appropriate to analyze the quality of reviews or evidence on impact. Instead, we used the reviews to address our first research objective by refining a definition of economic interventions and clarifying the underlying concepts, and highlighting relevant examples. We then addressed our second research objective by undertaking a mapping exercise where we focused on the size and chronology of the literature. We analyzed changes in the number of systematic reviews for each economic intervention over our ten year search period, and highlighted the main health outcomes that systematic reviews had focused on, thereby indicating areas where evidence of impact available for policy makers and programme planners is available.Based on our review, we further refined the following working definition of “economic intervention for health”: an intervention primarily designed to improve health outcomes by addressing the underlying determinants of demand or supply for health and health care – tastes/preferences (such as advertising), prices (such as taxes or subsidies), income (such as welfare programs or programs that enhance the ability to earn income), credit  and uncertainty (such as insurance). Interventions that correct imperfections or asymmetries in relevant information (such as provider report cards) may also fall under this (wide) technical definition.We found that economic interventions may be the central part of a health program , or undertaken as ancillary to a treatment program . Macro-level economic interventions take place at the level of markets for specific goods and services such as tobacco taxation policies, national insurance programs or fiscal policies affecting public health spending. Meso-level economic interventions operate at the level of institutions, such as grants or financing facilities provided to national disease programs for certain drugs or vaccines, while micro-level economic interventions target individual households, patients and providers. We first provide a refined definition of economic interventions in a health-related context, and then summarize findings from our mapping of evidence from systematic reviews.Governments and donors can intervene directly in markets for healthcare goods and services to exercise control over prices. For instance, in many critical services such as childhood immunization and national disease programs such as HIV or TB are typically provided by the public sector at reduced or no charge. Subsidy programs may be universal or further targeted to specific groups  via ration cards, stamps or vouchers for goods and services –14. For Taxes and subsidies may also be deployed with the objective of health promotion outside the healthcare sector. Taxes on tobacco are widely regarded as a leading instrument for tobacco control worldwide . On the Transfers refer to the redistribution of resources from one party to another. Income transfer programs aim to improve health by providing resources directly to targeted individuals or households. Income transfer programs may also be referred to as grants or economic support.Cash transfer programs include income support schemes that enable poor or otherwise vulnerable households to spend more on nutrition, healthcare, living conditions and education, all of which lead to better health in the short and long term. For example, South Africa has two well-studied programs, the Old Age Pension and the Child Support Grant (CSG), that provide monthly cash transfers to older adults and low-income primary caregivers of children respectively. Evaluation studies have found that receiving both types of support are associated with significant nutritional improvements in children , 19. ApaIncome transfer programs may also provide in-kind benefits rather than cash. The key distinction is that in-kind transfers restrict consumption to specific health-related goods and services , 22. ExaSubsidies and income transfers focus on relative prices and resource constraints respectively, but in some cases the distinction may not always be clear to practitioners. In-kind transfers may be thought of as effectively fully subsidizing the goods and services provided and vice versa – for example, food stamp programs are often referred to as both subsidies as well as in-kind transfer programs. In practice, programs that emphasize the direct delivery of benefits to needy recipients tend to be referred to as transfer programs, while programs that focus on transactions for specific goods and services tend to be referred to as subsidy programs.Provider and patient incentive programs are designed to reward or penalize specific and measurable actions or outcomes, independent of recipient needs . On the conditional cash transfer (CCT). Use of CCTs - in which targeted recipients are given transfers only if they undertake specified behaviors or meet specific goals related to health [Progresa, currently known as Oportunidades [An important type of intervention that combines financial incentives with an income transfer program is the o health , includiunidades , 35, whiunidades .commitment devices where individuals voluntarily commit to incurring penalties for failing to meet self-imposed goals [The design of incentive programs can take several forms, including lotteries, prizes and tournaments –39. Inceed goals , 41. Comed goals . These ied goals . A compred goals . For insed goals .Livelihood support programs aim to also improve health by increasing household income, albeit by enhancing their ability to earn it for themselves. Such interventions may include skill-building, employment matching or general entrepreneurship training, or transfers of income-generating assets or investment goods. This is in contrast to income transfer programs, which provide their beneficiaries with unearned resources for consumption spending.Livelihood support can also be provided in the form of microcredit, or credit services that are made available to individuals who may not qualify for traditional retail or commercial bank loans. Microcredit loans can be designed with various features that enable financial institutions to expand access to underserved groups, including use of group-based liability to offset collateral requirements, small loan sizes, frequent repayment schedules and borrower training/counseling.Like income transfers, microcredit programs for livelihood support may be rolled out with an anti-poverty mandate that implicitly includes health improvements, or specifically be provided to patient populations that have difficulty accessing credit due to stigma, or have increased need for enterprise support . ExampleFinally, we note that these interventions apply to providers as well: livelihood support for healthcare entrepreneurs may also be seen as a contribution to population health . For insThe final category of interest relates to programs that provide financial services related to healthcare, including savings, loans and insurance. While income or livelihood support programs provide households with resources or the means to produce them, financial services allow households to manage resource allocations and risks.Medical savings accounts or health savings accounts are savings accounts dedicated to health expenditure. Examples of this include Singapore’s national Medisave program, as well as new experiments with medical savings account provision in China. Savings products may be combined with incentives or penalties connected to health as well. For instance, the CARES program for smoking cessation in the Philippines combined a savings account with a commitment device to incentivize ex-smokers to abstain .Loan products aim to alleviate credit or liquidity constraints rather than budget constraints. These may range from hire-purchase schemes for expensive equipment, to emergency community or hospital-based revolving credit lines that can be used to support unexpected medical expenditures to microcredit schemes set up for the purchase of specific health-related items. As microcredit providers increasingly leverage their platforms to provide healthcare and social services, and vice versa, such schemes may become more prevalent. For instance, Tarozzi et al. describe the offer of microcredit by BISWA, a provider in India, to support the purchase and maintenance of bed-nets in malaria-endemic Orissa . Loans aInsurance products provide benefits in the event of illness, in exchange for regular premium payments, allowing households to better manage the uncertainty associated with health, by effectively pooling their unpredictable individual risks with that of other households in the scheme. Health insurance helps remove financial barriers to care in unforeseen emergencies and mitigating the impact of catastrophic health expenditures. With the expansion of universal coverage, health insurance programs are increasingly being rolled out among populations in low and middle-income countries.microinsurance generally refers to low-premium, low-benefit schemes for the poor, involving community-based risk-pooling and management [However, additional financial protection may still be required to support groups that tend to be underserved by mainstream commercial or social insurance schemes . These mnagement . One exanagement .Our literature review is summarized in Fig. Under price interventions (taxes and subsidies), we identified 55 relevant reviews out of 145 retrieved from the search; the majority of which have been published after 2009. The predominant health areas that have been covered by systematic reviews on this topic include: addressing substance abuse and alcohol and tobacco control; changes in nutritional behavior and maternal and child health. We identified 48 reviews on income transfer programs; keys areas of focus include: rehabilitation to allow return to work; maternal and child health; healthcare provider behavior and TB/HIV.The largest number of systematic reviews has been conducted on incentive programs, reflecting the increase in results-based financing programs worldwide. We found 75 relevant papers from a review of 181 retrieved from the search. The majority of reviews in this area, 52, have been published between 2011 and 2014. Key health areas that have been focused on include improvements in quality and equity of healthcare provision; tobacco control/smoking cessation; healthcare provider retention and diabetes/chronic illness management.There was much less evidence from systematic reviews on livelihood support programs and health-related financial services, for which we identified seven and ten systematic reviews respectively. Unlike the other economic intervention categories, the majority of reviews on livelihood support have a fairly narrow disease focus were focused on HIV patients. However, the analysis of changes in the number of systematic reviews over the past ten years Fig.  indicateIn order for appropriate and effective economic interventions to be selected by policy makers and program planners, it is important for terminology and intended impact of distinct interventions to be clear, and for existing evidence of impact to be examined. Recognizing the increased interest in economic interventions to improve public health, this paper focuses on proposing a general definition, approach and terminology relating to key economic interventions, and comparing the amount of evidence available from systematic reviews for different categories of economic interventions.We note that in spite of our proposed overall definition, in some cases, there is no consensus definition of a specific type of intervention, with some definitions focused only on the target population, or some aspect of the intervention design – for instance, microinsurance is used by some to mean any kind of low-cost insurance for the poor, while others use the term microinsurance and community-based insurance interchangeably. This confusion is compounded by the fact that reality is, in fact, complex: the categories above are not always clear-cut. Programs may have numerous (different) interventions at multiple levels. It should also be noted that programs themselves may evolve from one to another for various reasons: for instance conditional cash transfer programs may find that the administrative burden of monitoring conditionality is too high and transform into unconditional programs; or conversely, unconditional cash transfer programs that may not meet their objectives may decide to impose conditions.The results of our literature review demonstrate that there is a considerable difference between economic interventions in the availability of evidence from systematic reviews. There are far fewer reviews on livelihood support programs and health-related financial services; in order to inform policy makers of the impact of these interventions, this gap in evidence should be addressed by interventional and observational studies as well as by systematic reviews. While the number of reviews on taxes and subsidies, incentive programs and income transfer programs is much higher, there is a notable dearth of reviews focused on health outcomes in low income countries. We also identified an overall lack of information about unintended or perverse outcomes from economic interventions on factors such as equity of service quality and availability, healthcare worker satisfaction, patient satisfaction and healthcare worker time allocation. For example, there is evidence to suggest that one of the world’s largest demand-side incentive programs promoting hospital births through the provision of cash incentives, India’s Janani Suraksha Yojana, not only improved women’s access to services but also increased fertility rates . It is iWe conclude that while more research and analysis is clearly needed to assess suitability and effectiveness of economic interventions in different contexts, before interventions are tested and further systematic reviews conducted a clear and accurate understanding of the fundamental differences in terminology and approaches is essential among researchers, public health policy makers and program planners. When conducting future assessments of economic interventions, we stress the importance of considering sustainability, scalability, cost-effectiveness and intended consequences.


While there is a large consensus that plant–plant interactions are a crucial component of the response of plant communities to the effects of climate change, available data remain scarce, particularly in alpine systems. This represents an important obstacle to making consistent predictions about the future of plant communities. Here, we review current knowledge on the effects of climate change on facilitation among alpine plant communities and propose directions for future research. In established alpine communities, while warming seemingly generates a net facilitation release, earlier snowmelt may increase facilitation. Some nurse plants are able to buffer microenvironmental changes in the long term and may ensure the persistence of other alpine plants through local migration events. For communities migrating to higher elevations, facilitation should play an important role in their reorganization because of the harsher environmental conditions. In particular, the absence of efficient nurse plants might slow down upward migration, possibly generating chains of extinction. Facilitation–climate change relationships are expected to shift along latitudinal gradients because (1) the magnitude of warming is predicted to vary along these gradients, and (2) alpine environments are significantly different at low vs. high latitudes. Data on these expected patterns are preliminary and thus need to be tested with further studies on facilitation among plants in alpine environments that have thus far not been considered. From a methodological standpoint, future studies will benefit from the spatial representation of the microclimatic environment of plants to predict their response to climate change. Moreover, the acquisition of long-term data on the dynamics of plant–plant interactions, either through permanent plots or chronosequences of glacial recession, may represent powerful approaches to clarify the relationship between plant interactions and climate change. Empirical studies and reviews in the last decade leave no doubt that the multiple effects of current and predicted climate change will affect plant communities not only directly, e.g., via “thermophilization,” but also indirectly, through changes in interactions among species  is one of the most important conceptual advances made over the past two decades with respect to plant–plant interactions along environmental gradients. In its current definition, the SGH predicts that positive interactions among plants .Facilitation along latitudinal gradients. We hypothesize that the outcomes of plant–plant interactions will change along large latitudinal gradients, together with the magnitude of climate change and characteristics of the alpine environment.Facilitation and the long-term buffering effect of alpine nurse plants. Our hypothesis here is that the persistent buffering effects on microenvironmental conditions by some alpine nurse plants may offer long-term biotic refuges for other alpine plants.In this paper, we provide an overview of the extent to which facilitation among plants will interact with the effects of climate change in the organization of alpine plant communities in future decades. We provide a review of current knowledge, and suggest directions for future research. In particular, we focus our contribution on the following four issues and associated hypotheses:On 3 April 2014 we conducted a search of the peer-reviewed literature via Web of Science using the following terms: “plants” AND  AND “climate change” AND (“facilitation” OR “positive interaction”). We obtained a total of 80 references. We then extended this selection by reviewing the relevant literature cited in each of these 80 papers and obtained a second list of 96 references. Later, we reduced this list by retaining only those references that (1) provided explicit data on both climate change and facilitation among plants, and (2) considered facilitation above the treeline . Studies along elevational gradients were only considered if they focussed explicitly on climate change effects. Studies that explicitly documented plant–lichen interactions in the face of climate change were also included. This search resulted in a shortlist of only 17 papers, published between 1997 and 2014  the majority of these facilitated species were not present in a recently deglaciated area (0–13 yrs) directly above this site, where A. aretioides itself was absent  and it would be particularly relevant to take advantage of these designs to focus on the future of plant–plant interactions. Alternatively, using proglacial chronosequences as a space-for-time substitution approach to the study of climate change effects  facilitation among plants, thus evidencing the important role that plant–plant interactions may play in the future of alpine communities under the effects of climate change.There are two reasons for taking a closer look at plant–plant interactions along latitudinal gradients when addressing the future of alpine plant communities in the face of climate change: (1) patterns and mechanisms of interactions are expected to vary with latitude; and (2) the intensity of warming may also vary with latitude. A recent review of tropical alpine environments proposed that plant–plant interactions are under the control of a number of drivers, which are distinct from those found in extratropical alpine regions, including aseasonality, the absence of persisting snow cover, different plant life-forms, and the possible inversion of precipitation gradients. They are expected to generate both temperature and water stresses for plants at high elevation sites  and did not provide any clear latitudinal pattern , whereas low-latitude alpine regions are largely overlooked. A recent review of nurse plant mechanisms on the global scale lends support to this view by evidencing a strong research gap on plant interactions in tropical  regions . Similarly, in the high-Andean wetlands of Bolivia, the dominant species Distichia muscoides provides a terrestrial, but water-saturated substrate for a very specific plant community, which is believed to be threatened by reduced water availability as a result of accelerated glacial recession, a direct consequence of warming  comprise 1309 species, the majority of which are alpine species (Aubert et al., n Figure , whereasn Figure . Howevers Figure . This sug Figure . Howevera Figure . These tFestuca orthophylla (Figures Along with alpine cushions, tussocks are also long-living life forms (at least several decades; Catorci et al.,  Figures  may prov Figures . As a coIn summary, these data seem to corroborate our fourth hypothesis that some alpine plants may provide biotic refuges for other alpine species through their long-term, non-transient buffering effects on abiotic parameters in the face of climate change. Cushion plants, whose growth is particularly slow and regular, are examples of such species. Tussock grasses, whose growth is cyclic and irregular, are not.Evidencing the possible long-term facilitative effects of some alpine plants on their neighbors revealed a third migration option for established alpine plants under the effects of climate change, which is directly connected with facilitation among plants. Interestingly, each of these migration options is partially sustained by facilitation among plants Figure . Upward A. aretioides provide strong agreement with the hypothesis that cushions reduce the maximum temperature during the day, especially in comparison with rocks, bare soil, and dead cushion parts (Figure Temperature buffering has been cited as an important facilitating mechanism by alpine cushion plants. Consequently, the effects of alpine nurse plants on temperature under climate change are predicted to be a crucial driver of the distribution of alpine species. Recent methodological advances in alpine regions have permitted the spatial representation of plant and soil surface temperatures using thermal cameras. Results have demonstrated that variations in surface temperature and root temperature under global warming are not necessarily correlated with atmospheric temperature (Scherrer and Körner, s Figure , and incs Figure .Combining these data with the spatial representation of other abiotic data such as humidity, nutrient availability and topography may provide powerful interpretations of the mechanisms underlying plant–plant interactions at the landscape scale in the face of rapid climate change in alpine regions.Fabien Anthelme, Lohengrin A. Cavieres, and Olivier Dangles contributed to the conception, the structure and the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Detection of retinal lesions like micro-aneurysms and exudates are important for the clinical diagnosis of diabetes retinopathy. The traditional subjective judgments by clinicians are dependent on their experience and can be subject to lack of consistency and therefore a quantification method is worthwhile.In this study, 10 moderate non-proliferative diabetes retinopathy (NPDR) patients and 10 severe NPDR ones were retrospectively selected as a cohort. Mathematical morphological methods were used for automatic segmentation of lesions. For exudates detection, images were pre-processed with adaptive histogram equalization to enhance contrast, then binary images for area calculation were obtained by threshold classification. For micro-aneurysms detection, the images were pre-processed by top-hat and bottom-hat transformation, then Otsu method and Hough transform were used to classify micro-aneurysms. Post-processing morphological methods were used to preclude the false positive noise.After segmentation, the area of exuduates divided by optic disk area (exudates/disk ratio) and counts of microaneurysms were quantified and compared between the moderate and severe non-proliferative diabetic retinopathy groups, which had significant difference(P < 0.05).In conclusion, morphological features of lesion might be an image marker for NPDR grading and computer aided quantification of retinal lesion could be a practical way for clinicians to better investigates diabetic retinopathy. Early detection of eye disease due to diabetes, glaucoma, and age-related macular degeneration has a significant impact on the prevention of blindness. It’s estimated that nearly one million patients would be screened every day worldwide for diabetic retinopathy(DR) by 2025. Detecting and counting lesions in the human retina like microaneurysms and exudates is important for clinical diagnosis of DR , 2, but During November 2012 to October 2013, 20 patients diagnosed with DR by fundus image but without cataract degeneration, optic disk edema, macular degeneration, retinal vessel obstruction which could affect retinal images were included in our study. For these patients, 10 patients  were graded as moderate non-proliferative diabetes retinopathy (NPDR), and another 10 ones  were graded as severe NPDR according to the international classification for NPDR [The original retinal images were pre-processed, and the green channel of RGB image was obtained to enhance the contrast between background and foreground tissues. In this study, adaptive histogram equalization algorithm was firstly used to improve the image intensity contrast.Jn is the gray values after treatment; Imax, Imin is the largest and lowest gray values in original image respectively; In is the gray value before treatment; a is luminance compensation coefficient. After processing, the exudates had higher contrast which was easier for further segmentation .In clinical practices, fundus image observation could help clinicians to detect the microcirculation changes in vivo. However, such observation was usually dependant on the observers’ experience. Although some guidelines for qualification of lesions in four quadrants of retinal image, the description of different amounts of aneurysms and exudates increases clinicians’ work loads. Nowadays, different standards for DR have been published , morpholThe computer framework used in our study was mainly based on mathematical morphological analysis, from segmentation and measurement, which is different from machine learning methods that train the classifier based on textual or intensity features and output the classified result as grades –14. The There are also some weaknesses for our computer framework in clinical practice. Taking microaneurysms’ detection for example, if no apriori knowledge is known about the size of microaneurysms then this process could be quite challenging. And the center of a circle can also be represented by a peak with a height less than the number of edge pixels, the incomplete or ellipse shaped circle will increase the segmented errors. Another limitation in our study is that the variation of FOV from different digital fundus cameras could affect the exudates/disk ratio because of different observation areas are investigated.In conclusion, a computer framework based on mathematical morphological analysis could be utilized as a reference for clinicians to quantify exudates and microaneurysms in NPDR, and larger exudate area and more aneurysm counts might help grading the NPDR, larger samples and prospective clinical trials are needed for further validation.


The initiation of erythropoietin therapy for the purpose of renoprotection may need to be sooner than that for erythropoiesis, because erythropoietin may attenuate renal fibrosis through macrophage adjustment and endothelial cell protection by other uncertain mechanisms. Although, agents re-establishing the initial function of renal erythropoietin-producing cells could defer kidney fibrosis, however more studies should be carried out to determine the cellular target of erythropoietin in kidney and developinga new erythropoietin derivative for renal care.Erythropoietin improves anemia in almost all patients with chronickidney disease (CKD) ,2. Anemi, in vivo macrophage regulation could be one of the mechanisms that explain the antifibrotic properties of erythropoietin in CKD  have been completely observed by the authors.None declared.


The use of antibiotics in animal husbandry has long been associated with the appearance of antibiotic resistance and virulence factor determinants. Nonetheless, the number of cases of human infection involving resistant or virulent microorganisms that originate in farms is increasing. While many antibiotics have been banned as dietary supplements in some countries, other additives thought to be innocuous in terms of the development and spread of antibiotic resistance are used as growth promoters. In fact, several clay materials are routinely added to animal feed with the aim of improving growth and animal product quality. However, recent findings suggest that sepiolite, a clay additive, mediates the direct transfer of plasmids between different bacterial species. We therefore hypothesize that clays present in animal feed facilitate the horizontal transfer of resistance determinants in the digestive tract of farm animals. The exposure of bacteria to inhibitory concentrations of antibiotics results in the selection of resistant sub-populations. In addition, sub-inhibitory levels of many antibiotics raise mutation and recombination rates in bacteria, increasing the probability of resistance acquisition, even to unrelated antibiotics ,2. Antim2+ or Cu2+) [Animal feed also contains other supplements such as certain clays. Sepiolite, for example, was authorized for use by the European Union in 1990 and registered as technological additive E-562. The purpose of these minerals is to make digestion more efficient. These additives are believed to improve growth and animal product quality, and are widely used in feed for broiler chickens . Such pror Cu2+)  either oor Cu2+) , or adsoor Cu2+) . Scientior Cu2+) .A relationship between the presence of sand or clay minerals and bacterial genetic exchange has been reported, and the possibility that mineral-mediated DNA transfer between different bacterial species plays a role in the evolution of antibiotic resistance has received some attention . TransfoEscherichia coli, Salmonella enterica (serovar Typhimurium), Pseudomonas aeruginosa and Mycobacterium smegmatis [Here we propose that “recipient” bacteria can be transformed by DNA fragments or plasmids from “donor” bacteria adsorbed onto mechanically-penetrating mineral nanofibers. Laboratory work has already provided proof of concept of this idea; the exclusive combination of friction forces and sepiolite allows plasmids to be easily transferred between bacterial species, including strains of megmatis . These eThe combination of clays present in animal feed, the presence of both pathogenic and commensal bacteria in the animal gut, the mechanical friction provided by peristalsis in the rumen and intestines (or the strong abrasive action of the gizzard in poultry), and the routine administration of antibiotics to livestock (providing the selective force required for the fixation of antibiotic resistance), led us to hypothesize that clay-mediated DNA transfer among bacteria may occur in farm animals. This phenomenon could provide an additional HGT mechanism able to disseminate antibiotic resistance and virulence genes across species .i.e., the frequency of integration of foreign DNA into the bacterial chromosome) [The presence of antibiotics would not only provide the selective pressure to fix transformed cells in their populations, but is also an additional source of DNA via cell lysis. Plasmid DNA, which does not need to integrate into a recipient bacterium’s chromosome, might be efficiently introduced by clay-mediated transfer. Mobile elements such as transposons or integrons also become active in the presence of antibiotics  and coulomosome) ,26 mightin vitro and the parameters necessary for its occurrence are relatively well characterized [In vitro, an optimum transformation pressure of 3.9 kPa has been recorded [Clay-mediated transfer of DNA have been experimentally demonstrated cterized ,22,27. Din vitro [in vitro [in vitro. Taken together, the confluence of in vitro and in vivo data suggests that gastrointestinal tract is a plausible scenario for clay-mediated DNA transfer.The gut environment is generally characterized by a low pH and an elevated osmolarity. These circumstances could, in principle, hamper DNA transfer, but clay-mediated transformation has been shown to be robust to such conditions as clay materials can adsorb DNA over a wide range of pH. Since DNA stability is compromised at highly acidic conditions, clay-adsorbed DNA is unable to transform bacterial cells at pH lower than 3 . Howeverin vitro . Regardiin vitro . The osmin vitro , which iOne might argue that if free DNA fragments were present in the digestive tract of animals, they would be rapidly degraded. On the other hand, it has been shown that clay-adsorbed DNA is very resistant to degradation in the gut and soil . Additioin vivo. Thus, we propose that the role of sepiolite and other clays as promoters of antibiotic resistance and virulence trait transfer in farm animals should be investigated. To what extent the proposed mechanism of clay-mediated HGT could operate in vivo is difficult to answer. Conjugation consists of transferring DNA fragments ranging from a few base pairs to large chromosomes or plasmids. The process of conjugation requires cell-to-cell contact, mating pair formation and transfer of plasmid DNA through a conjugative pilus. The genes for conjugative machinery are encoded by autonomously replicating plasmids or by integrative conjugative elements in the chromosome [−3 transconjugants per recipient per hour in bacterial biofilms in vitro. According to the authors, these values are from one to three orders of magnitude greater than those reported by other studies [in vivo is slightly different. Conjugation rates have been examined using mice, yielding highly dissimilar results that vary from very low frequencies [−1 transconjugants per donor cell, a value that was much higher than the rate found in vitro (~6 × 10−8) using the same strains [in vitro measured rates of genetic exchange are poor estimators of the in vivo frequencies.Previously discussed arguments and laboratory results obtained to date, provide sufficient evidence to recommend examining clay-mediated DNA transfer romosome . Conjuga studies , while tquencies  to as hi strains . These r−6 to 10−8, which are comparable to most of conjugation experiments [in vitro results may underestimate the frequencies of this atypical HGT if it indeed occurs in vivo. Nevertheless, even very low frequencies of DNA transfer should be taken into consideration, as the possible consequences for human and animal biosafety could be of great importance. Furthermore, risk assessment should not be based solely on the observed frequencies, as they are not good predictors of long-term effects on bacterial communities [In our previous experiments we found frequencies ranging from 10eriments . Howevermunities .An ideal testing framework for our hypothesis may consist in a double blind, stratified experiment in which four groups of gnotobiotic animals are given feed containing or lacking sepiolite, an appropriate bacterial donor strain and antibiotics acting as selective force .in vivo transfection efficiency and wide margins of error, this hypothesis might be accurately tested in a cost-effective way. However, a testing scenario would be strongly limited by the fact that experiments would require an S1 security level, and this is difficult to achieve with livestock animals. We should also admit that it is enormously difficult to detect rare HGT events and the resulting bacterial transformants within large heterogeneous microbial communities [Faecal samples would then be collected to isolate bacteria in a medium designed to counterselect donor strains. Differences in the transfer of resistance genes would reflect the effect of the clay. Available reports on the efficiency of sepiolite in promoting bacterial transformation , the higmunities , which cmunities ; althougEpidemiological observations correlating the use of clay supplements with higher incidence of antibiotic resistance can be useful to initiate additional studies. In near future, the possibility of doing large comparative metagenomic studies in the microbiome of livestock may help to correlate the use of clay with altered frequencies of HGT. If our hypothesis is correct, “remodeled” bacteria are being transmitted from farms to communities. Clay materials in animal feed perchance significantly contribute to the spread of antibiotic resistance and virulence genes, increasing the problems of antibiotic ineffectiveness in the treatment of human and animal infections. This new mechanism of HGT may promote the acquisition of virulence factors and antibiotic resistance by gut pathogens with broad implications for humans and animals.Here, we present a hypothesis raising the concern that under a livestock feeding regime, the confluence of factors such as antibiotic pressure, diversity and size of bacterial populations, the presence of potential pathogens, the particular physiology of digestive tract of cattle and clay present as a feed additive might favor clay-mediated horizontal gene transfer. The kind of transferred materials may consist of plasmids, and more importantly fragments of genomic DNA that may spread both antibiotic resistance and virulence factors between potential animal and human bacterial pathogens and transmit them to the community. We encourage the scientists from related disciplines to be aware about this possible mechanism and perform additional studies to see to what extent this HGT is operating.


The presence of multiple subclones within tumors mandates understanding of longitudinal and spatial subclonal dynamics. Resolving the spatial and temporal heterogeneity of subclones with cancer driver events may offer insight into therapy response, tumor evolutionary histories and clinical trial design. The identification of somatic events and mutational processes that drive a cancer is increasingly important for precision cancer diagnosis and therapy. To date, sequencing efforts have identified several hundred cancer-driver mutations and genomic aberrations across multiple cancer types –4. SequeThere is a need, therefore, not only to determine which driver events occur in a tumor but also to understand their relative timing during tumor evolution. Moreover, our understanding of how changes in the prevalence of different subclones over time impact upon therapeutic response and clinical outcome remains limited. There is an increased realization of the need to understand a tumor’s evolutionary history using both spatial and longitudinal genomic information and to identify driver events and mutational processes that contribute to tumor initiation, maintenance, progression and subclonal diversification. Here, we summarize recent findings on the relevance of subclonal driver events. We also describe how subclonal diversity might contribute to the limitations of targeted therapies and how it can be leveraged to study the evolutionary history of a tumor and to optimize clinical trial design.Subclonal populations of tumor cells arise from either random genetic drift or from the selection of cells that have a phenotypic advantage within a particular environment . In bThe subclonal diversity within a tumor if viewed as a snapshot, rather than longitudinally, provides little information about the future evolutionary routes that subclonal populations might take. Has the dominant subclone within a tumor outcompeted less fit minor subclones or is a new fitter subclonal population emerging Figure ? A greatDeciphering genetic intratumor heterogeneity can reveal the temporal composition of genetic events that take place during the disease course. Bioinformatics tools such as ABSOLUTE  and PyClWith regards to evolutionary timing, clonal somatic mutations that are present in all tumor cells will have been acquired relatively ‘early’ in tumorigenesis, before or during the appearance of the most-recent common ancestor. These early mutations are a mix of both driver events that contributed to tumor initiation and passenger mutations that may have preceded transformation. Conversely, subclonal mutations, which are present in only a subset of tumor cells, represent ‘later’ events occurring after the appearance of the most-recent common ancestor and so after tumor initiation. Clonal and subclonal mutations can be further temporally dissected by looking at chromosomal amplifications; mutations acquired before amplification will be present on at least two chromosome copies, whereas mutations acquired after amplification will be present on only one copy –28 Figu.Figure 3BAP1 (BRCA1 associated protein-1), PTEN (phosphatase and tensin homolog), PIK3CA , SETD2 (SET domain containing 2) and TP53 (encoding tumor protein p53), were always subclonal, and thus probably involved in ccRCC progression. Selection for mutations in these genes during later stages of ccRCC development is evidenced by the observation that different subclones acquire mutations in the same gene in parallel.In breast and pancreatic cancers, the majority of known mutational and copy number driver events are relatively early events ,16,27,29in situ hybridization analyses, as a subclonal event in prostate tumors but often as a clonal event in triple negative breast cancer [Driver events are not always clonally dominant across all cancer subtypes. For example, loss of the tumor suppressor PTEN has been identified, by sequencing and fluorescence t cancer ,29,30. St cancer ,29 but pt cancer ,22. Nevet cancer .Deciphering genetic intratumor heterogeneity sheds light not only on the temporal acquisition of somatic driver events, but also on the temporal dynamics of mutational processes. Analysis of breast cancers found that early mutations were dominated by C-to-T transitions, predominantly in a CpG context, probably reflecting spontaneous deamination of methylated cytosines . By contTaken together, these studies highlight the diversity in tumor evolutionary processes, with variation in both the temporal acquisition of driver mutations and the mutational signatures themselves observed both within and between tumor types. As more samples are analyzed, it will be important to validate which driver genes are always clonal  and which may occur later in tumor evolution, driving subclonal expansions. Early drivers may serve as optimal therapeutic targets in future drug-development strategies . ImportaHeterogeneity between primary and metastatic lesions has profound implications for approaches to genomic research and patient care, as does the heterogeneity of clones within a single sample that changes over time because of cell-intrinsic mechanisms such as genomic instability or selective pressures from tumor-directed therapy.TP53, few driver genes were ubiquitous in the multiple sampled regions from each patient. In ccRCC, multiple biopsies are required to better define the true extent of genomic heterogeneity and clinically relevant mutations. For example, mutations in the mammalian target of rapamycin kinase that confer resistance to everolimus can be found in some but not all tumor regions [Spatial heterogeneity in solid tumors can result in significant sampling bias. In high-grade serous ovarian cancer, multi-region sampling of six patients prior to treatment demonstrated the diversity of somatic mutation, copy number and gene expression within each patient . Other t regions ,23.Sequencing studies have demonstrated heterogeneity of driver events between primary tumor and metastatic sites. Similar heterogeneity has also been demonstrated for clinically relevant biomarkers ,16,23. AThe sequencing of two temporally separated CLL samples from treated and untreated patients showed that many of these tumors underwent clonal evolution and that the presence of a subclonal driver was an independent risk factor for disease progression . ConversMET amplification prior to treatment, which was selected for during therapy [MET amplification at such a low frequency would be difficult to identify in a heterogeneous biopsy sample. Conceivably, these patients may have benefited from combination EGFR TKI and MET inhibition to forestall selection of the drug-resistant subclone.A number of studies have demonstrated that treatment can act as a selection pressure in some malignancies, driving clonal evolution and selecting for certain subclones. This emphasizes the importance of longitudinal tumor sampling strategies to depict tumor genomic landscapes. In acute lymphoblastic leukemia, copy number abnormalities (CNA) were strikingly different between samples taken at diagnosis and after relapse following chemotherapy . On retr therapy . NotablySimilarly, the presence of the EGFR T790M mutation, which is associated with resistance to EGFR TKI therapy, has been demonstrated prior to treatment with EGFR inhibition in patients with NSCLC . In thisde novo on treatment, or that resistant subclones were present in the pre-treatment tumor at frequencies that were below the limits of detection [In a study of patients with colorectal cancer, multiple somatic mutations in KRAS , which are associated with resistance to anti-EGFR antibody therapy, could be detected non-invasively through cfDNA analysis during the acquisition of drug resistance, and were predicted to be present in a subclone prior to treatment . By contetection .RB1 (encoding retinoblastoma 1), PIK3CA and PTEN that bore the signature of temozolamide-induced mutagenesis [Cancer therapies not only can act as the selection pressure to drive tumor evolution along a certain lineage if pre-existing subclones possess genotypes that are associated with a drug-resistant phenotype ,19 but aagenesis ,45.Greater understanding of resistance mechanisms Table  suggestsIn some cases, it is becoming clear that resistance to therapy can be mediated by more than one resistant subclone. In colorectal cancer, different mutations in KRAS (exon 12 and 13), associated with resistance to EGFR monoclonal antibody therapy, were found in the same patient . In anapThe extent to which the presence of subclonal drivers and intratumor heterogeneity impacts upon the different responses witnessed with both systemic chemotherapy and precision medicines remains unclear ,54–57. MThe identification prior to therapy and subsequent management of low-frequency subclones harboring driver events that influence clinical outcome is clearly a major challenge. Such subclones may be present at a low frequency within one biopsy, could be spatially separated within a primary tumor or might be differently distributed in the primary tumor and its metastases. In recent years, clinical trial designs have moved from stratification that is based on histology to classification by molecular subtype ,60. The a priori knowledge of the clonal frequency of the driver event at the time of surgery and at relapse, the latter being provided by analysis of a repeat biopsy of the metastatic site and by cfDNA and CTC analysis. These analyses will help to determine whether targeting clonally dominant drivers improves progression-free survival and how subclonal driver events impact upon disease progression and drug resistance. In the future, knowledge of dominant and subclonal drivers and resistance mechanisms may allow more optimal treatment allocation. WES will also allow assessment of the protein-coding mutational burden and the potential neo-antigenic repertoire of each tumor. This information can then be correlated to the response to immunotherapy of those without an actionable mutation for which there is an approved precision medicine.Patients from the UK-based TRACERx multi-region sequencing longitudinal observational study of NSCLC who relapse with locally advanced or metastatic disease will be eligible for the Deciphering Anti-tumor Response and evolution With INtratumour heterogeneity (DARWIN) clinical trials program Figure . PatientWithout the use of single-cell approaches, addressing whether subclonal populations that have resistance to therapy are present prior to treatment or are selected during therapy is hindered by the limit of detection of low-frequency cancer cell populations. Conventional Sanger sequencing can detect variants down to the level of approximately 10% prevalence. Some studies have used mutation-specific PCR strategies followed by targeted sequencing or mass spectrometry to enrich low-frequency populations within archival material, allowing detection of subclonal events at 0.1% prevalence ,63. MassThe advent of NGS has permitted greater resolution in determining the extent of heterogeneity within individual tumors. Distinguishing early and late somatic events may allow a better understanding of the genes and mutational processes that are involved in tumor initiation in comparison with those involved in maintenance and metastasis, which in turn might inform new therapeutic avenues. Moreover, the distinction of clonally dominant events from subclonal driver events might allow the acceleration of drug development towards targeted early, truncal drivers of disease. Although targeting clonally dominant drivers may make intuitive sense, some trunk drivers may only be relevant for tumor initiation and targeting these drivers after clonal diversification might not be efficacious.Furthermore, the origins of the ‘lethal’ subclone or subclones might be determined by somatic events that occur later in tumor evolution and not in the dominant clone. Therefore, efforts to limit disease progression might require a greater understanding and optimal targeting of subclonal driver events.High-throughput functional assessment of validated mutations will be important to assess the significance of these mutations and to avoid wasting resources on the further investigation of sequencing artifact or passenger mutations. The wealth and depth of data may allow us to find unanticipated gene-gene interactions and might reveal new unappreciated cancer drivers that are involved in epistatic interactions . Clinica


Infantile colic is a common disturbance occurring in the first three months of life. It is a benign condition and one of the main causes of pediatric consultation in the early part of life because of its great impact on family life. Some pediatricians are prone to undervalue this issue mainly because of the lack of evidence based medicine guidelines. Up to now, there is no consensus concerning management and treatment. Literature reports growing evidence about the effectiveness of dietary, pharmacological, complementary and behavioral therapies as options for the management of infantile colic. Dietary approach, usually based on the avoidance of cow’s milk proteins in breast-feeding mothers and bottle-fed infants, more recently has seen the rise of new special formulas, such as partially hydrolyzed proteins and low lactose added with prebiotics or probiotics: their efficacy needs to be further documented. Investigated pharmacological agents are Simethicone and Cimetropium Bromide: the first is able to reduce bloating while the second could reduce fussing crying, but it has been tested only for severe infantile colic. No other pain relieving agents have been proposed until now, but some clinical trials are ongoing for new drugs.There is limited evidence supporting the use of complementary and alternative treatments  or behavioral interventions.Recent studies have focused the role of microbiota in the pathogenesis of this disturb and so new treatments, such as probiotics, have been proposed, but only few strains have been tested.Further investigations are needed in order to provide evidence-based guidelines. Infantile colic is a common condition worldwide: about one in five infants younger than three months develops colic. Although infantile colic is considered to be a self limiting and benign affection, it is often a stressful problem for parents and a frequent and wrongly undervalued cause for pediatric consultation ,2. InfanDespite the prevalence of the condition, the pathogenesis remains partly unknown. A theory hypnotizes that infant’s nervous or digestive system may be immature. Also behavioral issues such as family tension or inadequate interaction between parents and infant have been considered, but these issues are really controversial. Concomitant risk factors remain partially unknown; however, maternal smoking, increased maternal age and firstborn status may be associated to the development of infantile colic . InfantiA correlation between colic and sleep disorders has been suggested, but recent findings show that the two disorders frequently occur in different infants . There iHigher levels of ghrelin and motilin were found in infants affected by colic, even though further studies are required to clarify their role in infantile colic .Calprotectin is a calcium-binding protein produced by immune system cells and so it could be used as an index of intestinal inflammation if measured in fecal samples. It is demonstrated to be useful in differentiate inflammatory bowel disease (higher level) from functional abdominal pain in school-age children , but itsConcerning infant colic, Olafsdottir didn’t observe difference between colicky and healthy infants  while RhAs a consequence of the lack of a complete comprehension of the causes of the condition, a wide spectrum of treatment modalities has been suggested ,15,16.The diagnosis is easy getting an exhaustive anamnesis and performing a correct physical examination in order to evaluating signs and symptoms  Table 22. Other • Dietary advices may be distinguished according the type of feeding as follow ,19:▪ breast-fed infants: a monitored low allergen maternal diet avoiding cow’s milk and dairy food with appropriate intake of vitamins and minerals may be suggested. A period of at least two weeks is necessary to check the effectiveness of the diet and dietary intervention in mother has to be continued only if effective ,20. Evid▪ bottle-fed infants: first-line approach is represented by formulas based on partially hydrolyzed whey proteins with prebiotic oligosaccharides that have been tested to be effective , while t• Pharmacological treatments: simethicone, which reduces gas production, may be helpful for some infants, although several randomized controlled trials noted no difference in reducing colic episodes compared with placebo ,15. A RCLactobacillus reuteri ATCC 55730 and its daughter strain Lactobacillus reuteri DSM 17938 to breastfed infants is well tolerated and improves symptoms of infantile colic compared with simenthicone or placebo [E. coli colonization has been observed. At present, growing data are available on the role of probiotics in colic [L. reuteri may be effective as treatment for crying in exclusively breastfed infants with colic, but there is still insufficient evidence to support probiotic use to manage colic, especially in formula-fed infants, or to prevent infant crying [• Probiotics: the use of probiotics in infantile colic is based upon the hypothesis that aberrant intestinal microflora could cause gut dysfunction and gas production, contributing to symptoms. Some studies have shown that administration of  placebo -30. The in colic , and thein colic . Recentlin colic . A recent crying .• Indrio et al. have performed a RCT that shows the efficacy of L. reuteri in preventing infantile colic and other functional gastrointestinal disorders .• Recently, Sung et al. have described another RCT that shows no effect of L. reuteri in treating infantile colic, but this study has been conducted in a really heterogeneous population of infants with many confounding factors . However, the meta-analysis reported by Sung in the same article confirms the positive effect of L. reuteri in reducing symptoms due to infantile colic .• Complementary and Alternative Therapies: in the absence of safe and effective pharmacological interventions, complementary therapies have assumed an increasingly important role in the management of infantile colic.Foeniculum vulgare), chamomile (Matricariae recutita) and lemon balm  may help calming the infant and reducing abdominal distension [. However, the administration of herbal products in infants with colic raises some concerns about the potential nutritional effects (these treatments provided for a long time could lead to a decreased intake of milk), the lack of standard dosages and the possible content of sugar and alcohol. In conclusion, parents have to use them with attention and under medical control.▪ Herbal supplements: herbs such as fennel , but long-term benefits are not demonstrated. The controversial nature of these interventions, their popularity among caregivers and the presence of weak supportive evidence underline how further rigorous researches are needed .▪ Acupuncture: standardized light stimulation of the acupuncture point LI4 twice a week for 3 weeks has shown reduction in the duration and intensity of crying, with no serious reported side effects . However▪ Behavioral interventions: parents’ responsiveness should be stimulated but with recommendations not to exhaust themselves and underlying that they can leave their infant with others when necessary. Many studies have proposed “infant massage”, although it does not significantly improve symptoms. A recent Cochrane Database Systematic Review acknowledges that “there is some evidence of benefits on mother–infant interaction, sleeping and crying, and on hormones influencing stress levels. Further research is needed”. A more recent study describes an approach based on regularity in infant’s daily care and feeding, accompanied by instructions to swaddle during sleep. The aim consists in helping the infant to establish a regular sleep–wake rhythm that can reduce parental distress and improve quality of interaction between parents and child ,42.The first step is to offer general advice and to provide parents of infant with infantile colic with reassurance, emphasizing the favourable and self-limiting nature of this condition. In the meantime a well-tolerated, multifactorial and personalized strategy should be adopted in order to provide a safe and effective therapeutic approach.The available data in literature are not fully synthesized in an exhaustive systematic review: recently a Cochrane review concerning manipulative treatment has been published , while fThe lack of consensus about infantile colic management in medical literature, the physical and psychological impact affecting colicky infants and their parents and the evidence of controversial advice in many media outlets, such as website and magazines, make the production of further good-quality studies necessary in order to develop new and more effective treatments and to elaborate specific clinical guidelines.Producing good-quality and comparable studies in order to obtain useful guidelines is not easy: first of all, we have to find specific, quantifiable and objective outcomes.Studying infantile colic, Authors have mainly used subjective data such as caregivers’ observations of crying time: the use of new objective methods may help overcome these limitations.Little is known about effective therapies for treatment of infantile colic, due to the lack of a complete understanding of the pathogenesis and the self limiting course of this disturb. So, continued efforts toward research and discovery in this field is mandatory for improving knowledge concerning oral probiotic supplementation, dietary approach and safe pain relieving agents.The authors declare that they have no competing interests.FS: wrote the paper. SC: wrote the paper. ADeM: wrote the paper. LCdiM: wrote the paper. All authors read and approved the final manuscript.


Such circuit level study in animal models may help us understand how diverse genetic and environmental risks can produce a common set of EEG, MEG and anatomical abnormalities found in ASD.Most recent estimates indicate that 1 in 68 children are affected by an autism spectrum disorder (ASD). Though decades of research have uncovered much about these disorders, the pathological mechanism remains unknown. Hampering efforts is the seeming inability to integrate findings over the micro to macro scales of study, from changes in molecular, synaptic and cellular function to large-scale brain dysfunction impacting sensory, communicative, motor and cognitive activity. In this review, we describe how studies focusing on neuronal circuit function provide unique context for identifying common neurobiological disease mechanisms of ASD. We discuss how recent EEG and MEG studies in subjects with ASD have repeatedly shown alterations in ensemble population recordings . Because these disease-associated electrophysiological abnormalities have been recapitulated in rodent models, studying circuit differences in these models may provide access to abnormal circuit function found in ASD. We then identify emerging  Autism spectrum disorders (ASD) have an estimated prevalence of 1 in 68 children, potentially reaching as high as 1 in 42 males . AlthougStudies over the last 40 years have revealed a multitude of alterations in ASD, ranging from genetic risk factors, to differences in whole brain connectivity  increased in cerebellar cortex of subjects with autism  balance contributes to the disorder  has also been focus of research with regards to pathology and treatment in ASD. Multiple studies show altered ACH related findings, such as decreased Positron emission tomography (PET) binding, altered post mortem immunoreactivity for receptors and mRNA, and decreased relative choline levels in Another major neuromodulator linked to ASD is dopamine. Several studies have shown that dopamine is increase in frontal cortex Chugani, , and mulThis non-exhaustive summary of alterations to the neurotransmitter and neuro-modulator systems suggests targets for treatment, yet also indicate that no single target will be broadly effective. Single perturbations are not consistently present throughout all cases of ASD, and furthermore such alterations are usually found in differing combinations; yet ultimately they synergize to produce the symptomatology known as ASD. Thus, hypothesis such as E/I balance suggests common neuronal circuit differences that could be targeted to repair circuit function in ASD.Maternal infections, fever and antibiotic treatment, as well as post-natal infections, are associated with an increased likelihood of the child being diagnosed with ASD Hsiao, . This reSub-cellular and synaptic alterations are not the only alterations found in ASD. At the level of local cytoarchitecture, post-mortem studies of individuals with ASD have shown increases in the density of minicolumns in multiple cortical regions, while each column itself is narrower, primarily due to decreases in peripheral neuropil compartments , and evoked power would be the amplitude of the resulting wave. Yet, because ITC is only a measure of trial-to-trial phase reliability and not the amplitude of power generated by the stimulus, ITC can be independently disrupted. Such a case could occur when a manipulation could increase the ability cells to more temporally accurately fire, but the total amount of cells firing is reduced.In contrast to the loss of phase reliability across repeated stimuli, other findings in the gamma band are an increase in baseline spectral activity in ASD and increased stimulus related non-phase locked activity  direct cellular modulation of local circuit properties; (2) assays of ensemble activity linking circuit dysfunction to E/MEG phenotypes; and (3) measures of functional connectivity. Below we discuss each of these approaches.in vitro work in the hippocampus that looked at the role of the peptide Oxytocin. Oxytocin, is a neuromodulatory peptide known to be important in social bonding, prosocial behavior and social recognition , that can measure voltage changes across all the excitable membrane Box , this enBox 2in vivo level  activity measured by E/MEG are produced by synchronous neuronal activity arising from these local cortical interactions  fast spiking cells in generating high-frequency oscillations was demonstrated by specifically expressing the photoactivated Clin vitro from cortical slices and in vivo from cortical surface can be used to assay the functional connectivity that is associated with local coherence in E/MEG. An immediate area of investigation could directly identify how connectivity is mediated , using in vitro pharmacological tools and differing ionic composition  in ASD have been well documented  have similar genetic underpinnings with ASD . There iAll authors contributed to the preparation and finalizing of this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.