Antiretroviral agents with long-acting properties have potential to improve treatment outcomes substantially for people living with HIV. In November 2017, the Long acting/Extended Release Antiretroviral Resource Program (LEAP) convened a workshop with the aim of shaping the research agenda and promoting early development of long-acting or extended release products for key populations: pregnant and lactating women, children aged up to 10 years, and adolescents aged 10–19 years. Goals included strategies and principles to ensure that the needs of children, adolescents, and pregnant and lactating women are considered when developing long-acting formulations. Research should focus not only on how best to transition long-acting products to these populations, but also on early engagement across sectors and among stakeholders. A parallel rather than sequential approach is needed when establishing adult, adolescent, and paediatric clinical trials and seeking regulatory approval. Pregnant and lactating women should be included in adult clinical trials. Adolescent-friendly trial design is needed to improve recruitment and retention of young people. In 2017, an estimated 10·1 million women and 1·8 million children younger than 15 years worldwide were living with HIV.5NCT02951052) or prevention (HTPN084) of HIV-1 infection, including cabotegravir and rilpivirine, and other treatments such as broadly neutralising anti-HIV-1 monoclonal antibodies.Long-acting or extended-release (herein referred to as long-acting) nanoproducts of antiretroviral therapies and other HIV related treatments  are given on a monthly or less frequent basis and have the potential to play a key part in HIV treatment and prevention, particularly in populations where poor adherence hinders successful treatment.Historically, new HIV drugs and products have taken time to become available for children and pregnant and breastfeeding women. Concerns about teratogenicity of dolutegravir highlight the importance of increasing participation of pregnant woman in clinical research.Panel 1Topic 1•Should long-acting, extended release formulations for children: should they be the same as for adults?•Discuss the advantages and disadvantages of trying to develop unique formulations for paediatric applications •Can and should implants and alternative drug delivery technologies be developed for children?Topic 2•What to do when a woman becomes pregnant?•How would recommendations differ for a woman who becomes pregnant while on long-acting, extended release drugs for treatment or prevention, versus managing a pregnant woman who asks to initiate a long-acting, extended release regimen?Topic 3•What are the main challenges in enrolling and retaining adolescents in clinical trials for HIV treatment and prevention?•What are the possible solutions to improve retention?Topic 4•What are the major regulatory and formulation approval challenges related to these three key populations?•Are there easy-to-implement, innovative approaches to speed approval?The Long Acting/Extended Release Antiretroviral Resource Program (LEAP) convened a workshop in Rockville, MD, USA, in November 2017, to generate discussion among key experts and stakeholders around long-acting products for pregnant and lactating women, infants, children, and adolescents.Long-acting products could provide substantial benefits over the standard of care for women in the ante-partum, pregnancy, and post-partum periods (including while breastfeeding or at risk for new pregnancies), including improved adherence and viral suppression during times when adherence might be reduced.Pregnant and lactating women are excluded from many clinical trials of novel antiretroviral agents and other therapies, leading to a paucity of data to support or discourage the use of these drugs throughout pregnancy and lactation.In the absence of specific studies to obtain pregnancy safety data before drug licensure, such data could be obtained from registries and observational studies after a drug is marketed. However, detection of safety issues associated with drug exposure during pregnancy or lactation are thereby delayed while these populations are exposed to potentially inadequate or harmful treatments.In addition to the possible risks of fetal exposure to new drugs, we must consider the risks of withholding potentially more convenient or efficacious drugs, or newer therapies with less toxicity from pregnant and lactating women with relevant conditions, because of paucity of data.Reproductive toxicity studies should be done early on, to provide the risk data required for the design of clinical studies. Ex vivo placental perfusion models can be helpful in providing a preliminary understanding of the kinetics of placental transfer of novel long-acting agents, but data from humans are necessary to accurately describe placental transfer kinetics.Two main scenarios exist in which long-acting products could be studied in pregnant and lactating women: when unintended or unplanned pregnancies occur in women participating in clinical trials, and active prospective enrolment in clinical trials. Eventually, high-quality postmarketing surveillance studies could also provide important data. Ongoing and future studies of investigational agents in non-pregnant women should allow those becoming pregnant during the trial to remain in the study and on their assigned study drug, with collection of key safety and efficacy data (for mothers and infants) in a systematic and structured manner, following additional informed consent. This approach should be the norm, unless there are specific reasons against inclusion of pregnant women, such as preclinical data indicating a safety concern for mothers or fetuses or pharmacokinetic modelling showing inadequate exposures in pregnant women. Therefore, pregnant women could feasibly be involved in clinical trials, providing specific criteria are met;Consideration should be given to dedicated pharmacokinetic and phase 2 studies during pregnancy, once phase 1 and 2 data from non-pregnant adults are available. Consideration should also be given to phase 3 studies in pregnant women if the likelihood of safety concerns is low on the basis of preclinical or pharmacokinetic modelling data. For initial pharmacokinetic studies of long-acting products in pregnancy, these drugs could be added to a suppressive regimen to provide added protection from transmission during delivery and breastfeeding. Conversely, if enough women in the phase 3 trial became pregnant and remained on study drug, and if the data collected could help establish pharmacokinetics and dosing in pregnancy, then an additional study might not be needed. However, to rule out less frequent safety issues in pregnancy (which would require larger sample sizes), an observational study after licensure would be needed.A standardised protocol for women who become pregnant during a trial should also be developed and made available, in an open forum, for use by all. This protocol could be adapted for different therapeutic agents and would outline the minimum pharmacokinetic, pregnancy outcome, and maternal and infant safety and toxicity monitoring required for all women who become pregnant during a study. In addition, infant follow-up data, up to at least 1 year of age, or through cessation of breastfeeding would be collected. Similarly, standard protocols for establishing postmarketing surveillance of pregnancy outcomes and safety and efficacy in the context of the roll-out of new products should be created and implemented.An online database could be established or an existing pregnancy database used to capture data across different studies and data on inclusion of pregnant and lactating women in research into long-acting products. This database could include a summary of preclinical reproductive toxicity of investigational agents; a record of the number of pregnant and lactating women being actively enrolled in trials and number becoming pregnant during a trial; details of cessation or continuation of study drugs; and a protocol for infant follow-up.Although some medical care providers and pregnant and lactating women might be more cautious in accepting a new treatment, these therapies are often used in clinical practice, once licensed and available in-country. Acceptability studies in people living with HIV for novel drug-device combinations are suggested but not required and could be nested within clinical trials.Establishing the fetal safety profile of a product is difficult before marketing, as sufficient exposure data across trimesters are needed. Women becoming pregnant on long-acting products during clinical trials are advised to stop the drugs early in pregnancy, limiting the extent of fetal exposure. However, with potentially longer drug half-life, more inclusive trial designs, and more widespread use of long-acting products in late pregnancy, newborn exposure data collection will be possible. Products given to pregnant women might cross the placenta into the fetal compartment; thus neonatal washout studies describing elimination from the newborn after in-utero exposure can provide valuable information on drug elimination in the first week of life. Such data can then be used in modelling studies to inform selection of initial doses in newborn prevention and treatment studies. Protocols should be developed that collect data on newborn exposure to long-acting products used for prevention of HIV transmission during pregnancy, at delivery, and post partum at the earliest opportunity, to support the continued use of these products in pregnant and lactating women, and ultimately their use in newborns.The risk of perinatal HIV acquisition in infants born to women with HIV can be substantially reduced with administration of antiretroviral prophylaxis to these infants.Accelerating the development of paediatric  antiretroviral drug products has been the focus of various international initiatives,For long-acting products to be effective in the paediatric population, qualitative studies should be done early in development to understand the attitudes of parents, care providers, and children of different ages and across different cultures to gauge interest in novel delivery systems. The inclusion of such studies within the paediatric clinical development plan will ensure that data are available to inform formulation development, help identify priorities and understand the likely market demand, and support more effective implementation within each target population.Research into the safety, efficacy, and acceptability of novel drug delivery systems has been suggested as one of the top five priorities relating to the treatment of adolescents living with HIV.Adolescent-specific dosing should also consider weight and not just age for enrolment. Pharmacokinetics in adolescents can be evaluated in adult phase 3 clinical trials, rather than in concurrent adolescent trials. Workshop participants suggested that if safety concerns are unlikely, the upper limit of target drug concentrations (area under curve and trough concentrations) could be widened for adolescents weighing 25–35 kg. Typically, adult doses and formulations are used in adolescent trials. Workshop participants agreed that adolescents must be included in adult phase 3 clinical trials of novel products to inform future use in this age group.Panel 2Recruitment•Recruit youth-friendly and peer staff.•Identify locations where adolescents can be approached.•Tap into social network and opinion leaders.Retention•Ensure regular contact with participants.•Take the intervention to the participant if possible.•Provide youth-friendly space and hours.•Develop an outreach package specific to the trial and population.General considerations•Ensure good links to other services, such as sexual health and HIV treatment services.•Ensure that providers (adult and paediatric) are educated about long-acting, extended release formulations and comfortable with the trial intervention.•Provide funding incentives for trial sites that adhere to youth-friendly practices.Workshop participants identified strategies to facilitate recruitment and retention of adolescents in clinical trials , and proIdeal requirements of long-acting products would include low volume and number of injections, high barrier to resistance, and product transport and storage conditions compatible with use in low-income and middle-income settings . Products and delivery systems that are feasible, acceptable, and affordable in such settings are key, given the location and size of the market for paediatric HIV treatment. Given the limited availability of oral antiretroviral products for children , availability of long-acting products for all paediatric weight bands is crucial. The need for an oral lead-in for long-acting antiretrovirals could delay the introduction of injectable long-acting products for paediatric use; products that do not require an oral lead-in are therefore desirable.Novel drugs with their associated delivery systems might improve treatment options for all, particularly if frequency of dosing could be further reduced, active pharmaceutical ingredients were combined into a single formulation, or injections were replaced with alternative delivery systems such as transdermal microneedle patches or implants.Early engagement between drug manufacturers and other stakeholders is important for the successful development of long-acting products for use across different population groups. Discussions with regulatory agencies will clarify the data required for licensing, and early engagement with communities will ensure that the needs of children, adolescents, and pregnant and lactating women are better understood and considered early in the development process.Given the differences between oral antiretrovirals and long-acting products in terms of both administration route and dose frequency, the introduction of these products into national treatment programmes must be carefully planned, with consistent messages across partners. Effective, centrally-led strategies must be in place before such products are launched, particularly in low-income and middle-income countries. This will require collaboration and coordination across sectors, from suppliers and international bodies to in-country health services, with appropriate training for clinic and community staff.Collection and dissemination of lessons learned from long-acting products developed for other diseases such as antipsychotics , particularly on the practicalities of launching a new treatment approach and its uptake by clinicians, could help facilitate the introduction of long-acting antiretroviral products. Monitoring of uptake and adherence will be needed to learn from early adopters, to inform the introduction of these products in other settings, and to plan at a global level to avoid stockouts or wastage. Additional considerations will be required if long-acting products are used for HIV prevention, particularly in understanding people's motivations in seeking prevention and how this drives demand.A harmonised approach would encourage engagement of innovator and generic companies by creating a more viable market, simplifying development in the long term and facilitating the introduction of long-acting antiretroviral treatment at the country level. These goals can only be achieved through coordinated action, with involvement of all key stakeholders from the start, and with alignment of donors to maximise support in the development and implementation phases. Good communication is needed across sectors to ensure that manufacturers are aware of the requirements for regulatory approval and to meet the needs of patients and providers regarding products and delivery systems.Experience with daily dolutegravir and its possible link to neural-tube defects in infants born to women taking it as part of standard of care, including at the time of conceptionPanel 3Pregnant and breastfeeding women•Studies of investigational agents in non-pregnant women should allow those becoming pregnant during the trial to remain in the study and on their assigned study drug, with additional informed consent, unless there is clear justification for exclusion.•Pregnant and breastfeeding women should be considered eligible for active enrolment in clinical trials unless clear justification for exclusion exists.•Additional monitoring of maternal, pregnancy, and infant outcomes should be undertaken for all women who become pregnant during a clinical trial and all pregnant and breastfeeding women actively enrolled in trials with a standard protocol.Neonates (birth to 4 weeks)•Neonatal washout studies are needed that describe the disappearance of drug present at birth after in-utero exposure, followed by dosing studies to describe safety and pharmacology in neonates and young infants to allow use of novel formulations for neonatal and young infant prophylaxis and early treatment.Children (4 weeks to 10 years)•Protocols for trials of long-acting, extended release formulations in children should be developed alongside adult trials, and paediatric studies should be initiated as soon as early safety data from adult trials is released.•Paediatric clinical trials should simultaneously enrol all paediatric age and weight cohorts rather than sequentially enrolling cohorts of decreasing age or size.•Long-acting formulations for children should be harmonised across weight bands.Adolescents (10–19 years)•Adolescents should be included in adult clinical trials of long-acting antiretroviral agents, or in separate trials proceeding nearby.•Strategies to maximise recruitment and retention of adolescents in clinical trials should be employed.General recommendations•Acceptability studies should be done early in the development of long-acting formulations to understand the attitudes of care providers, children of different ages and their parents, and pregnant and breastfeeding women.•Coordinated action involving all key stakeholders is required from the early stages of development to maximise the chances of success.The research agenda can be tailored in various ways to generate data needed for regulatory approval of long-acting products for pregnant and lactating women, children of all ages, and adolescents .Panel 3KPregnancy intentions should not be a barrier to enrolment of women of childbearing potential, and we encourage inclusion of pregnant and lactating women in all appropriate phase 3 clinical trials. Paediatric studies inclusive of all age groups should be planned early in development, and if possible should be carried out as soon as preliminary adult safety and efficacy data are available from phase 1 and 2 trials. Products should be applicable across all weight bands, including adults, to facilitate implementation, ensure market viability, and maximise the chance of success of long-acting therapeutic strategies. Efforts should be made to include adolescents in adult clinical trials or to establish adolescent-specific trials in parallel where appropriate. These studies should use a range of methods to maximise recruitment and retention of patients, including good community engagement and adolescent-friendly approaches. Studies are also needed to understand the acceptability and feasibility of long-acting products in all populations, particularly in settings with high HIV burden.As we assess how best to study the use of long-acting products in children, adolescents, and pregnant and lactating women, and ultimately transition these new drug delivery products and systems into these populations, it is also worth considering which products would be best suited and of most benefit to specific populations. Although injectable products have the potential to improve treatment outcomes, particularly in groups with poor adherence, frequent injections could be a barrier in children. Delivery systems for long-acting products are needed that are less painful or require less frequent dosing—and are therefore more acceptable to children, adolescents, and their parents and care providers—such as implants and transdermal patches. New drugs and technological platforms are essential to support the development of long-acting treatment for infants, children, and adolescents. Removable microneedle patches have the potential to deliver long-acting antiretroviral agents without the pain associated with injections and could be applied at home or during a routine clinic visit. Long-acting oral preparations would also have potential, but systems developed to date are only in the preclinical phases. Research into alternative delivery mechanisms should therefore be encouraged.Planning for novel treatment approaches involves actively engaging with patients and communities from an early stage to understand patient desires and motivations, and with donors, regulatory agencies, and pharmaceutical companies to ensure alignment and commitment of key stakeholders from the outset to maximise success. By working toward a research agenda that includes, from an early stage, infants, children, adolescents, and pregnant and lactating women, we can ensure that benefits of long-acting antiretroviral agents extend to these key populations without the delays that have occurred in the past.


New imaging technologies like artificial intelligence and deep learning systems show a potential to screen populations at risk of retinal diseases at a large scale in a resource constrained setting.Retinal disorders are emerging as important causes of blindness in middle-income countries. In a recent rapid assessment of avoidable blindness plus diabetic retinopathy (RAAB plus DR) survey in western India, posterior segment disorders (PSD) were responsible for nearly 39 per cent of blindness next only to cataract (45 per cent).Challenges to provision of screening in resource poor regions such as Asia include lack of specialists and lack of equipment. Of the limited specialists, most practise in urban areas, whereas a large population resides in remote rural areas. Retinal imaging devices and telemedicine can help address the ‘rural-urban gap’,Several types of cameras can image the retina or optic nerve. Imaging a retina allows one to:screen various diseasesphoto document pathological lesionstrack disease processsee response to therapy overtimewww.peekvision.org). The advantage of these cameras is that a non-ophthalmologist can take pictures and, with some training, grade them as well.Fundus photography has transformed from electronic flashes to smart phone-based cameras to more recent portable eye examination kit (PEEK). PEEK is a smart phone-based application for comprehensive eye examination  or age-related macular degeneration (ARMD). However, there is a possibility of missing lesions in the retinal periphery.UWF camera helps to take images of peripheral retinal lesions like vein occlusions, vasculitis, posterior uveitis, breaks and detachments. UWF cameras provide a field of view of 200 degrees which is approximately 82 per cent of retina surface. Fundus fluorescein angiography (FFA) with such cameras helps to detect peripheral vascular lesions which are otherwise missed in a standard FFA. Angiography of the retina and choroid shows vascular diseases and inflammatory pathologies. FFA provides useful information on diabetic retinopathy, retinal vein occlusions and retinal vasculitis. For choroidal pathologies such as ARMD, the ICG angiography is a better tool. Areas where there is hypoperfusion, leakage or staining, show the anatomical location and pathological process. This helps to arrive at a conclusive diagnosis and plan for future management of a case.Fundus autoflourescence (FAF) is non-invasive and a quick method to assess the function of retinal pigment epithelium (RPE). FAF aids in diagnosis of optic nerve head drusen, Best's disease and hereditary macular dystrophies.The cameras we mention above need a person to sit in front of a camera aperture and fix their gaze on a target. This is impossible in a neonate or an infant. Certain wide field imaging systems like Retcam and Forus Neo help in such cases. Some of these cameras are portable and have a probe which resembles an ultrasound transducer. Paediatric retinal imaging is a contact technique and images up to the ora serrata can be taken under topical anaesthesia. Portability makes these tools an excellent choice for screening retinopathy of prematurity (ROP) and retinoblastoma.Optical coherence tomography (OCT) is equal to a histopathological section of a tissue. One can study individual layers of retinal cells and pathological lesions in them. OCT diagnoses many subtle pathologies which may be missed during a clinical examination. Artificial intelligence (AI) and deep learning system (DLS) have the potential to improve screening coverage in resource constrained settings. In DLS, neural networks read labels of images with normal and abnormal findings. It then starts to recognise patterns and groups similar images of a particular diagnosis. More the number of image sets, higher the precision and accuracy.In a study done in Singapore, researchers used AI and DLS to screen and identify DR and other eye diseases. The results of the study showed a very high sensitivity to vision threatening DR but a low sensitivity for diabetic macular oedema. Which makes it, one of the major limitations in a DR screening programme. However the study showed a high sensitivity and specificity for detection of glaucoma and ARMD.Advances in retinal imaging have led to a paradigm change in diagnosis and management of retinal diseases. In future, use of new technologies like AI and DLS in screening programmes is likely to help identify several blinding retinal conditions and treat them at an early stage.


Deficiency of protein and choline has been shown to upregulate DNA methyltransferases (DNMT), especially 1 and 3a; these can then methylate promoter region of PTEN and suppress its expression. Thus, the gene is tuned like a metabolic rheostat proportional to the availability of specific nutrients, and the resultant “dose” of the protein, which sits astride and negatively regulates the insulin-PI3K/AKT/mTOR pathway, decides energy usage and proliferation. This “fixes” the metabolic capacity of the organism periconceptionally to a specific postnatal level of nutrition, but when faced with a discordant environment, leads to obesity related diseases.The modern obesity epidemic with associated disorders of metabolism and cancer has been attributed to the presence of “thrifty genes”. In the distant past, these genes helped the organism to improve energy efficiency and store excess energy safely as fat to survive periods of famine, but in the present day obesogenic environment, have turned detrimental. I propose PTEN as the likely gene as it has functions that span metabolism, cancer and reproduction, all of which are deranged in obesity and insulin resistance. The activity of PTEN can be calibrated  This has been backed with epidemiological data (such as birth records in England) and is the basis for the Developmental Origins of Health and Disease (DOHaD) concept , which is a feature of fatty liver; the latter can also be produced by fructose (from high sugar intake) metabolism in liver  does not explain various features of the obesity epidemic . Thin liver . It follin utero due to deficiency of specific nutrients is the basis for fetal programming for a nutrient-poor postnatal environment. The modern epidemic of metabolic diseases and obesity related cancers (ORCs) results when a PTEN deficient organism, programmed for a nutrient-poor environment, with limited metabolic capacity, is exposed to nutrient-rich surroundings.It is proposed that PTEN is the primary thrifty gene. Epigenetic changes PTEN (phosphatase and tensin homolog deleted on chromosome 10) , 14 was - It is dominant negative: the inactive PTEN mutants hetero-dimerise with wild-type PTEN and reduce its phosphatase activity.- It is haploinsufficient: One copy of the gene is insufficient for proper function. Loss-of-function mutation results in a situation where the amount of protein product created from the remaining wild-type allele is not sufficient for normal cellular function.- It is quasi-insufficient : it cannThe expression and function of PTEN can be modified in a variety of ways, ranging from gene mutations, epigenetic regulation by promoter methylation, post transcriptional modifications and by microRNAs .It is proposed that deficiency of specific nutrients  leads to upregulation of DNA methyltransferases  by hypomethylation; this leads to promoter methylation of PTEN and varying degrees of suppression , resulting in fetal programming. Thus, nutritional supply decides the degree of PTEN expression (“dose”) and the thrifty phenotype, but when faced with post natal nutrition-rich environment, can lead to modern diseases such as metabolic syndrome and cancer.There are certain questions that need to be answered in support of this hypothesis.per se or lack of specific nutrients that lead to epigenetic changes? Interest in the field of nutritional epigenetics is expanding and there are multiple epidemiological studies and experimental animal models addressing the fetal and transgenerational outcomes of maternal dietary manipulation. Epigenetic changes, especially DNA methylation, in response to changes in maternal nutrition has been well documented (per se has been noted to lead to changes in gene expression (notable research being carried out in the hope of extending life span) but current interest is in teasing out the specific components of diet that contribute to altered gene expression. The current concept of “protein leverage  sensitive to nutritional changes? DNMTs are responsible for methylation of promoter regions and usually repress gene expression; the main ones are DNMT1, 3a and 3b. DNMT3a is consistently upregulated in calorie , proteinper se has been shown to downregulate Pten in fetal liver  inhibition of Pten in intestinal stem cells .- Calorie restriction reduced expression of Pten in silkworm larvae .- Maternal undernutrition reduced the expression of Pten in the liver of sheep offspring singletons .- Offspring of mice with gestational diabetes mellitus have raised Pten expression; calorie restriction downregulated this .- Pten was down regulated in fetal liver following a choline deficient, aminoacid defined (CDAA) diet in C57BL/6 mice .- Maternal protein deprivation resulted in upregulation of PI3K and GLUT4 in muscles of the offspring of rats  and increased insulin sensitivity into adulthood .Has altered PTEN expression been demonstrated in normal human tissue? Defining the “normal dose” of the protein is impractical as it varies across tissues; studies usually compare the expression of the PTEN protein to that of a protein from another gene (by immunohistochemistry). Not surprisingly, most reported studies are from cancer patients, where expression of PTEN in Tumor tissue has been compared to adjacent “normal tissue” . There ain utero.Interestingly, these are also obesity related cancers (ORCs), a point to which I will return to later. It is, of course, not known whether these individuals with loss in normal tissue were nutritionally deprived Information about methylated PTEN in normal tissue is even scarcer –61. Ther- Epigenetic change is not an “all or none” phenomenon—a promoter can be partially methylated in precursor lesions and then progress to full methylation and complete gene silencing. As noted earlier , subtle - Transcriptional silencing does not always require hypermethylation of the entire CpGisland, but methylation of a few specific core CpGdinucleotides may be sufficient.- Methylation can occur outside the promoter region (long range epigenetic silencing).If PTEN is indeed the 30 gene, how will a downregulated PTEN prime the offspring for a nutrition poor environment? The ideal thrifty gene makes efficient use of available energy to grow and reproduce . The infLoss of PTEN is associated with increased self-renewal, cell survival, and proliferation; this is seen in normal human embryonic stem cells , as wellPTEN loss is associated with resistance to starvation, by improved energy efficiency and macropinocytosis . Pten mutant Drosophilia flies survived starvation better than Pten wild . SimilarPTEN deficient cells are more energy efficient. Overexpression of Pten, by introducing an extra Pten, caused these transgenic mice , 74 to dPTEN loss permits safe storage of excess fat. Insulin is primarily a fat storage hormone and higher levels of insulin is a postulated reason for obesity (as per the carbohydrate-insulin model of obesity).“Safe” here means storage without inducing insulin resistance. This is best seen in Cowden syndrome that occurs due to germline mutation of PTEN where insulin sensitivity is maintained despite obesity . PTEN loPTEN deficiency leads to smaller size offspring. As noted by Prentice et al. , chronicPten deficiency induces Behavioral changes including hyperphagia ; it reduPTEN deficiency in murine oocytes causes the entire oocyte pool to become activated prematurely; this has the effect of females having a maximum of one normal-sized litter before they became infertile at 12–13 weeks of age . In nutrAnother evolutionary benefit is a shortened lifespan seen in Pten deficient mice, partly attributable to a higher incidence of cancer . PTEN caIn summary , subtle The key reason why we are currently concerned with identification of thrifty genes is their postulated role in human disease in a discordant, nutrient-rich environment. The ability of a thrifty gene to reduce energy expenditure and store fat, has distinct survival benefits in a nutrient-poor environment However, excess fat storage can lead to obesity. Fat stored in ectopic locations leads to insulin resistance (IR) and metabolic disorders  and obesity related cancers (ORCs) in an obesogenic environment. Whether hyperinsulinemia, a marker of IR, is the cause or effect of obesity is still a matter of debate .It has been proposed that the thrifty gene should have the property of plasticity to adapt to a nutrient-rich environment  but I beThe relationship between obesity, IR and metabolic syndrome is still a matter of discussion and controversy; the two leading hypothesis being the conventional “calorie imbalance  model” and the more recent “carbohydrate-insulin model.” Whether hyperinsulinemia, a marker of IR, is the cause or effect, is also debated . Until tsine qua non for insulin resistance (IR). It is generally accepted that it is the location, rather than the amount of stored fat that determines IR. Current dogma suggests that IR is due to ectopic fat deposition ; however, the data available is not sufficient to support such a possibility. Deletion of Pten in a subset of adipocytes leads to redistribution of body fat with lipomatosis and partial lipodystrophy ; howeverOrgan of involvement: Does downregulation of PTEN occur in all body tissues or in specific organs ? Downregulation in adipose tissue can explain most of the features of metabolic syndrome. AiPKO mice , where PIn a more recent study , fat depIt is tempting to suggest that PTEN downregulation in nutrionally stressed organism occurs preferentially in subcutaneous adipose tissue (SAT), priming the organism for safe fat storage. Evolutionarily, SAT has been the organ around which the “fasting vs. feasting” revolves. As the study by Huang et al.  indicateInterestingly, new born Indian babies, though lighter, have increased fat storage (“thin-fat babies”) and this has been correlated with increased risk of metabolic syndrome in adulthood . AlthougAmericans have higher rates of T2DM than Europeans ; AmericaThe relationship between PTEN and insulin sensitivity has been demonstrated in other studies. A Korean study reported that the commonly used oral hypoglycemic agent, metformin, downregulates PTEN via AMPK in preadipocytes and sensitizes them to insulin .per se, where excess FFA released by overloaded adipocytes of SAT can downregulate PTEN in liver via FFA; this of course, will be associated with insulin resistance). An organism born with PTEN insufficiency is thus prone to fatty liver, a major component of metabolic syndrome.Liver specific knock out of Pten in mice lead to fatty liver with maintained insulin sensitivity . Obese ZIt may appear paradoxical but one study showed higher levels (more than 3 fold) of Pten mRNA and protein in skeletal muscle of obese Zucker rats , and leaThe status of PTEN in humans in relation to obesity and Type 2 diabetes mellitus (T2DM) has not been studied well  and the - A bioinformatics analysis of the search for the CpG islands in the promoter regions of obesity-related genes has identified PTEN as being hypermethylated   in obese patients with endometrial carcinoma .- A study on Uyghur Muslims  showed l- A PTEN-polymorphism that results in higher expression of PTEN showed significant correlation with T2DM in Japanese , marginaObviously, the maternal nutrition or intrauterine history of the subjects in the above studies is not known.Downregulation of PTEN represses the ability of body to burn of excess calories. The ability to burn off excess calories is crucial, because, as per the “protein leverage theory,” organisms will continue to ingest food till a certain level of proteins  is acquired . In thisIn summary, underexpression of PTEN would promote fat storage due to a more efficient insulin-PI3K/AKT/mTOR pathway, and an inability to burn of excess calories. The reasons for progression to IR must remain speculative. PTEN is certainly not the sole factor determining insulin response. It is possible the PTEN remains underexpressed and is bypassed/ overcome in creation of IR in a nutrient-rich environment. Hyperinsulinemia, which accompanies IR, could be the cause, rather than the effect of obesity . The posIt is theoretically possible that the offspring born with low “dose” of PTEN, when faced with a nutrition rich environment, upregulates PTEN, leading to IR and its ill effects. This would imply plasticity of the gene, which is against the basic premise of this hypothesis; obesity related diseases results from a fixed metabolic capacity at birth, and an inability to adapt. PTEN can be upregulated in obesity to create IR via free fatty acids (FFA)  and seveThe only study aimed at finding PTEN level in relation to maternal diet comes from the laboratory of Dr. Susan Ozanne and has been referred to earlier . A materThe data regarding the role of PTEN in cancer is abundant and reviewed , 131 andin utero influences or even weight of the patients. One study on endometrioid endometrial cancer (which is strongly correlated with obesity) showed “increased AMPK phosphorylation and IGFBP2 expression were observed in obese patients with PTEN loss. These findings are markers of nutrient deprivation, which is unexpected in the context of obesity” mice resulted in higher incidence of breast cancers in their offspring; this was associated with downregulation of Pten . SimilarNutrition (lack and excess) has significant effect on reproductive functions  and the The role of PTEN in the ovary is pleiotropic and appears to be cell dependent. Essentially, the ovarian follicle has three types of cells—the oocyte, the granulosa cells and the covering theca cells.a. As seen earlier , Pten deb. In granulosa cells of PCOS patients, PTEN expression was reported as reduced  but in ac. In theca-interstitial cells, Pten deletion produced features of PCOS including hyperandrogenism and early fertility loss . Animal It would appear that, just in case of cancer, downregulation of PTEN in specific cells of ovary creates a permissive background for PCOS, which is precipitated by a high-nutrition environment. It, of course, remains to be demonstrated that maternal protein restriction results in PTEN downregulation in the ovary, especially the theca cells. Curiously, NAFLD is another condition with PTEN downregulation (in hepatocytes)which is associated with peripheral insulin resistance , and botin vitro fertilized mice showed acetylation of Txnip gene (involved in metabolism); the adult mice had upregulated mRNA and protein expression of the Txnip as compared to controls  in response to nutritional constraint. Pten haploinsufficient or KO mice are not appropriate models to decide this and unfortunately, there is no low protein (LP) or maternal methionine-choline deficient (MCD) diet models where Pten has been analyzed across different tissues. There is indirect evidence to suggest PTEN expression can be variable. For instance, analysis of metabolically stressed controls . But thecontrols . Similarcontrols , low procontrols . It woulThere are enough gene expression and methylome profiles existing of both human and animal models of nutrition deprivation that can be analyzed for PTEN expression; the difficulty would be in defining the normal expression since there is no “on” or “off” level, only degrees of activity. It would be particularly interesting to see the Pten levels in normal tissue of the low protein model  generateIt is proposed that PTEN is the primary thrifty gene . EpigeneThe author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Many neurodegenerative conditions are characterized by the deposition of protein aggregates (mainly amyloid-like) in the central nervous system (CNS). In post-mitotic CNS cells protein aggregation causes cytotoxicity by interfering with various cellular functions. Mutations in different genes may directly cause protein aggregation. However, genetic factors together with aging may contribute to the onset of protein aggregation also by affecting cellular degradative functions, in particular the autophagy-lysosomal pathway (ALP). Increasing body of evidence show that ALP dysfunction and protein aggregation are functionally interconnected and induce each other during neurodegenerative processes. We will summarize the findings supporting these concepts by focusing on lysosomal storage diseases (LSDs), a class of metabolic inherited conditions characterized by global lysosomal dysfunction and often associated to a severe neurodegenerative course. We propose a model by which the inherited lysosomal defects initiate aggregate-prone protein deposition, which, in turns, worsen ALP degradation function, thus generating a vicious cycle, which boost neurodegenerative cascades. These genes are directly involved in the “amyloidogenic cascade” by which the APP protein is sequentially cleaved and processed to generate aggregate-prone Aβ peptides , which lead to the abnormal aggregation of the protein (PRNP gene (encoding the PrP protein) produce altered misfolded-prone versions of PrP, thus causing prion disease  are associated with FTD and ALS (APP gene (on chromosome 21) leads to increased production of APP-βCTF  . ALP is Autophagy-lysosomal pathway decline may be caused by genetic factors (LOF – mutations inherited in a dominant or recessive fashion), environmental factors (mainly aging) which are known to impact on degradative capability of cells  or by prPSEN1 show lysosomal and autophagic dysfunction  are associated with lysosomal dysfunction and defective autophagosomes clearance in PD  or PARKIN (PD protein) genes cause PD forms characterized by defective mitophagy , a lysosomal enzyme involved in the degradation of glucosylceramide. When GBA is mutated in homozygosis causes the Gaucher’s diseases, while when it is mutated in heterozygosis represents a major risk factor for PD , impaired autophagosome clearance (as we demonstrated in MPSs) and, likely, others. These mechanisms generate a vicious loop that boost neurodegenerative processes in LSDs, thus allowing, on the other hand, the possibility to identify new attractive therapeutic targets to treat these severe neurological conditions.The datasets generated for this study are available on request to the corresponding author.The animal studies were conducted in accordance with the guidelines of the Animal Care and Use Committee of TIGEM in Naples and authorized by the Italian Ministry of Health.AF conceived and wrote the manuscript. AM contributed to conceiving the manuscript and co-wrote the manuscript. All authors listed approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sperm cells have long been known to be good producers of reactive oxygen species, while they are also known to be particularly sensitive to oxidative damage affecting their structures and functions. As with all organic cellular components, sperm nuclear components and, in particular, nucleic acids undergo oxidative alterations that have recently been shown to be commonly encountered in clinical practice. This review will attempt to provide an overview of this situation. After a brief coverage of the biological reasons why the sperm nucleus and associated DNA are sensitive to oxidative damage, a summary of the most recent results concerning the oxidation of sperm DNA in animal and human models will be presented. The study will then attempt to cover the possible consequences of sperm nuclear oxidation on male fertility and beyond. These molecules are unstable and propagate instability by trying to capture a stabilizing electron, which leads to the oxidation of other molecules which, in turn, seek other targets [Oxidative stress is inherent in the consumption of oxygen by aerobic organisms that metazoans have made their “fuel” for the production of energy via the cellular mitochondrial respiratory chain. In doing so, cells produce active oxygen derivatives commonly referred to as reactive oxygen species (ROS) which include free radicals  and antioxidant enzymes (superoxide dismutase (SOD), glutathione peroxidases (GPxs), Catalase, peroxiredoxins (PRxs), glutaredoxins (GRx)) ,3 that i2O2 is an ROS at the crossroads, both an intra- and extracellular signaling molecule, a powerful bactericidal agent also acting as an important player in our inflammatory/immune responses [Although ROS have long been considered as aggressors leading to cell death and pathophysiology, their important physiological actions should not be neglected . Indeed,esponses ,8, and aesponses , whetherThe balance between the production and recycling of ROS is, therefore, a key element of cell homeostasis. An excess of ROS (whether due to overproduction or lack of recycling) can then lead to a situation known as “oxidative stress.” This is accompanied by a set of alterations to cellular components, which affect cellular structures and functions and ultimately lead to cell death . AlthougThe answer is both easy and complicated in that almost all of a mammal’s interactions with its environment are likely to generate both local and systemic oxidative stress  for protection. This situation of fragility in relation to oxidative stress is also aggravated by the peculiar lipid composition of the plasma membrane of the spermatozoon. Of all the differentiated cells in a mammal, spermatozoa contain the highest level of polyunsaturated fatty acids (PUFAs) in their membranes , which aLast, but not least, one of the major consequences of oxidative stress on sperm cells involves damage to the paternal genetic material. 2O2 to cross the plasma membrane and the difficulty spermatozoa experience in defending themselves against such attacks. Finely controlled post-testicular oxidation processes are therefore at work to define an optimal state of nuclear condensation of the sperm nucleus. This is of paramount importance as the high compaction of paternal DNA is one of the means chosen by evolution to protect sperm DNA from mutagenic alterations. The process is finely balanced because not all free thiols of cysteine-rich protamines are affected by disulfide bridging. Some thiols are associated with zinc, thus preventing a number of them from being involved in disulfide bridges. It is therefore assumed that it is important not to over-condense the already highly compacted sperm nucleus so that the oocyte does not have too much difficulty post-fertilization, in creating the male pronucleus, a process that has recently been shown to be controlled by thiol-reducing activity [Although, as mentioned above, sperm structures and functions are easily threatened by oxidative alterations, oxidative processes contribute to the production of fully mature sperm cells. In the late 1980s, it was elegantly reported that during post-testicular maturation of sperm cells , sperm proteins undergo high disulfide bridging activity . In shoractivity . This beThe fact that it has long been reported that sperm cells are themselves very good producers of ROS , a logicWe have already mentioned above, that whenever ROS homeostasis is modified around sperm cells, there is a risk of excessive oxidation that can affect its structures and functions. In this section, we will focus on the oxidation of sperm DNA and, in particular, where it occurs in the mammalian sperm nucleus from recent data coming from animal and human studies ,24,25,26Identical investigations conducted on human spermatozoa confirmed these observations . In the gpx5−/− mouse model , it is ironment ). Considironment , two conentation . Neverthentation . This clapurinic endonuclease 1 (APE1) and X-ray repair complementing defective repair in Chinese hamster cells 1 (XRCC1) activities [It has been shown that the sperm nucleus contains only the first step of the base excision repair pathway (BER) represented by the activity of 8-oxoguanine DNA glycosylase 1 (OGG1 ). It apptivities . Only thtivities ), there tivities ) that witivities . Dependitivities ,39,40. Ttivities . Aberrantivities .If sperm DNA is sensitive to oxidative attacks, this is also the case for the other components of the nuclear compartment, i.e., the nuclear proteins and the recently characterized nuclear complement of non-coding RNA (ncRNAs). Together with methylation of cytosine residues, nuclear protein modifications and the ncRNA profile represent the three levels of epigenetic information carried by the spermatozoon.Spermatozoa cytosine hypomethylation has been associated with infertile patients with oxidative DNA damage (mainly DNA fragmentation) and elevated seminal ROS; a situation that has been corrected by antioxidant supplementation . It has gpx5−/− mice, we are presently carrying out sperm chromatin immunoprecipitation experiments using antibodies specific for meC and hmeC to identify chromatin regions subjected to differential methylation/hydroxymethylation of cytosine residues.In addition to the impact of an oxidized G residue on the methylation process, there is a second question to consider theoretically if a post-testicular oxidative stress situation occurs. It concerns the oxidation of methylcytosine (meC) residues carried by the spermatozoa to create hydroxymethylcytosine residues (hmeC). It is interesting to note that the generation of hmeC is the first step in an enzymatically-mediated oxidation process (via the TET enzymes: Ten of Eleven Translocases) which is used to remove meC marks  during tSperm nuclear proteins can also be affected by oxidative alterations as is the case for any protein. Protein oxidation essentially results in protein carbonylation  and redogpx5−/− KO mice [gpx5−/− Not surprisingly, our preliminary results [Over the past decade, there has been considerable evidence that sperm cells provide the oocyte with a complex and highly dynamic load of non-coding RNA (ncRNA), which represents another aspect of the paternal epigenetic heritage. Two recent studies have shown that environmental constraints such as a particular diet or exposure to behavioral stress modify the profile of sperm RNA ,54. Thes KO mice . As the  results  confirm Whether they are unrepaired or falsely repaired oxidized bases promoting the creation of de novo mutations in the embryo, multiple epigenetic alterations , it is obvious that oxidative stress will have a profound impact on the sperm structures and functions as well as on the messages it carries in the oocyte and embryo. These are important questions that still need to be better assessed, especially with regard to the clinical consequences of ART. As sperm DNA oxidation is much more common in infertile patients than sperm DNA fragmentation, a better understanding of its consequences on the embryo and the future individual is needed. In particular, artificial oxidative situations generated in the context of ART should be seriously evaluated, as they may partly explain the low success rate associated with this technology, which has not improved significantly over the past 25 years.


Sleep is a significant contributor to health and wellbeing across the lifespan, especially in later life. Poor sleep is common among older adults and can be both a risk factor for and consequence of numerous physical and mental health-related outcomes. In this symposium, we will present novel results from four studies that will advance understanding of the biological, psychological, and social factors that may contribute to or result from poor sleep in older adults. Specifically, Study 1 will present findings tying objectively measured sleep to performance on cognitive tasks administered using ecological momentary assessment (EMA) in the day-to-day lives of older adults with or without mild cognitive impairment (MCI). Study 2 will examine associations of personality dimensions and facets with insomnia symptoms in well-functioning older adults. Study 3 will examine psychological pathways linking parent-child relationships to subjective and objective sleep characteristics among older parents. Finally, study 4 will examine use patterns of cannabis for the treatment of sleep problems in older adults, and the ways in which this might differ from patients using cannabis for other reasons . Together, this symposium will highlight novel links of an array of factors with sleep health in the aging population and their implications for prevention. Sleep, Circadian Rhythms and Aging Interest Group Sponsored Symposium.


The field of health services research is broad and seeks to answer questions about the health care system. It is inherently interdisciplinary, and epidemiologists have made crucial contributions. Parametric regression techniques remain standard practice in health services research with machine learning techniques currently having low penetrance in comparison. However, studies in several prominent areas, including health care spending, outcomes and quality, have begun deploying machine learning tools for these applications. Nevertheless, major advances in epidemiological methods are also as yet underleveraged in health services research. This article summarizes the current state of machine learning in key areas of health services research, and discusses important future directions at the intersection of machine learning and epidemiological methods for health services research. Machine learning methods have been used less frequently in health services research, but are growing in health care spending, outcomes and quality.Many applied questions in health services research intersect with the methodological expertise of epidemiologists.Machine learning tools have promise for burgeoning areas in health services research, including methodology for difference-in-differences study designs. Health services research is a broad area focused on the health care system, including costs, quality, access to providers and services, and health outcomes following care. The field benefits from the interdisciplinary expertise of health policy scholars, clinicians, health economists, statisticians and public health researchers, as well as engagement from community members, policy makers and other stakeholders. Work in health services research is also published across an array of journals. While epidemiology is a distinct discipline studying the distributions, determinants and control of health events, there is an intersection with health services research, and epidemiologists have conducted key studies in health services research.Data sources in health services research are not typically classical epidemiological cohorts, and often use health care billing claims, registry data, surveys or electronic health records. The latter three data sources are increasingly used in epidemiology, but health care billing claims, a staple of health services research, are less common in epidemiology. Each of these data sources has well-known advantages and disadvantages,,For analysis, parametric regression techniques, rather than machine learning, are the standard in health services research. Machine learning methods aim to ‘smooth’ over the data, as traditional approaches also do, but they are often more flexible and may make fewer assumptions, typically operating in nonparametric or semiparametric models. Popular machine learning tools, such as tree-based techniques, neural networks and penalized regressions, have been used for classification questions and to identify high-risk individuals for health care interventions, but they have not been extensively integrated in health services research, especially not causal inference. The ‘promise and perils’ of these newer statistical learning tools for health services research have been discussed, with particular focus on the size of data repositories and sparsity of information.Better But Not Well, authors Richard Frank and Sherry Glied discuss advances in mental health care over five decades that came not from new treatments but rather payment reforms and increased competition across providers, among other organizational changes.,The financing of the health care system has many implications, including how health services for enrollees are provided and incentivized. Financing changes can also lead to improved health outcomes and access to care. For example, in ,Plan payment risk adjustment aims to predict individual health spending Machine learning has thus far been applied only sparingly in the plan payment risk adjustment literature, and is often published in health services journals. The regression problem for machine learning is given as:,,Recent plan payment risk adjustment papers implemented ensembles of various learners to predict total paymentsMachine learning has also been deployed in the past 3 years in other health care spending application areas outside risk adjustment formulas. This includes demonstrating that health insurers can identify unprofitable enrollees in the unregulated United States Marketplace drug formularies, despite protections for pre-existing conditions.2 was reported), as well as in external validation datasets. Evaluating algorithms using cross-validated metrics is good practice, but does not tell us how the prediction function will perform in data from subsequent years or if a prediction function created in Medicare fee-for-service enrollees is applicable to enrollees in private managed care Medicare plans.Whether the machine learning approaches for health spending discussed in this section appreciably improved on standard methods varied by study, and not all compared with a traditional approach. The practical utility of machine learning versus parametric regression is context-specific and may involve assessing the prediction functions along additional metrics not included in each article  estimated cancer mortality risk differences by emergency department presentation with double robust machine learning.,et al.Comparative effectiveness research asks causal questions that consider the benefits and harms of health interventions and features substantial contributions from both health services scholars and epidemiologists.POST represents the post-intervention time period. It is important to stress that causal interpretation of this parameter requires thoughtful consideration of the required causal assumptions.et al.Policy evaluation is a major facet of health services research. One prevalent design to estimate the impact of new policies is a difference-in-differences approach. The policy intervention may be implemented at a particular level of geography with several other ‘units’ at the same geographical level selected to form a comparison group. Data from before the intervention and after intervention are required to estimate the parameter of interest. This parameter is often the difference between the intervention group in the post-intervention and pre-intervention periods minus the difference between the comparison group in both time periods, hence the name ‘difference-in-differences’. The difference-in-differences parameter can be written causally and recognized as an average treatment effect among the treated:Health services research as a field is less flashy than many domains publicizing dramatic advances using ‘artificial intelligence’ methods, but this is not to say that careful, reasoned machine-learning work will not lead to progress in improving health care costs, quality, access, outcomes and additional areas not discussed in this piece. A focus on the external validation, generalizability and reproducibility of research results is crucial for health services findings to lead to actual successes in practice. Additionally, any time we are using data not collected for research purposes—common in health services research—we must pay extra attention to identifying the underlying processes that generated the data, which is aided by working with a diverse interdisciplinary research team.The expertise of epidemiologists will be valuable in these teams as use of machine learning increases in health services research. This article described several areas where epidemiological methods can contribute, including causal inference, techniques for time-to-event outcomes and the inclusion of social determinants of health. However, working across disciplines is challenging. Epidemiologists may need to learn new machine learning concepts and jargon in order to communicate across these barriers, as well as additional programming languages (e.g. R and Python). Knowledge of the intricacies of the health care system is also paramount to avoid spurious results—from minutiae like changes in billing code standards to broad issues such as physician behaviour.et al.Growth areas for machine learning in health services research will likely encompass study designs and parameters frequently seen in the economics and policy literature, including difference-in-differences approaches discussed earlier, and instrumental variablesHealth services research often examines or seeks to inform policy, and machine-learning studies have strong potential to contribute to comprehensive evidence synthesis for such policy changes. Although far from comprehensive in its scope, this article has summarized key intersections between machine learning and epidemiological methods for health services research. There is great promise for progress in the future, made even more likely by further leveraging the expertise of epidemiologists.This work was supported by the National Institutes of Health through an NIH Director’s New Innovator Award (DP2-MD012722).None declared.


Individuals displaced due to humanitarian disasters—currently 70.8 million —suffer fIn the early years of humanitarian psychosocial interventions , it was common practice when assessing mental health in disaster- and conflict-affected populations to limit psychometric assessment of measurement tools to simply reporting Cronbach’s alpha—a necessary but hardly sufficient practice when working with novel populations. If an adequate alpha were reported, the validity and reliability of the measure were typically assumed across populations. A few measurement tools were developed and validated for specific forcedly displaced populations ; howeveConflict and Health that focuses on the psychometrics of commonly used measurement tools in disaster contexts, we hoped to provide the field in general with an opportunity to reflect on current approaches to developing valid measures for use in disaster contexts, and a touchstone for moving forward. We aimed to showcase state-of-the-art methodologies that are being used to support the use of such tools in humanitarian disaster settings. We hope that readers of this special collection will be able to identify the appropriate methodological approaches that suit their needs, and have a clear sense of the specific steps they need to take to support the use of a measure for the specific population in which they are working.Researchers and practitioners who focus on populations impacted by humanitarian disasters and civil conflict have started to pay more attention to the psychometric properties of the measures they use e.g., , 11). Th. Th11]).The six papers contained within this special collection span a wide range of populations impacted by humanitarian disasters, a wide range of tools measuring a variety of psychological constructs, and a wide range of psychometric approaches used to evaluate the use of these tools within these populations. Samples include young adult secondary school students in Haiti , internaEfficiently identify salient problems in populations impacted by humanitarian disasters, and create valid, reliable and concise measures of mental distress. In many cases, psychosocial practitioners entering a new post-disaster context have to quickly assess the salient psychosocial problems facing those populations and develop accurate assessments of those problems that are brief and not too burdensome on respondents. Doty and colleagues [lleagues  providedlleagues  to gain Establish measurement invariance of translated measures. Displaced and conflict-affected populations are almost invariably from cultures outside of those from which common measures of psychological distress have been developed. If practitioners wish to compare scores from these measurement tools between individuals or samples from different cultural groups, they must be confident that the tools are measuring the construct of interest in the same way. In other words, they must establish that these measurement tools have measurement invariance . Tay and colleagues [lleagues  demonstrTest the validity of new models of established diagnostic constructs. PTSD has had its diagnostic criteria revised multiple times since it was introduced into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) [Anhedonia model, comprising the symptom clusters of re-experiencing, avoidance, negative affect, anhedonia, dysphoric arousal and anxious arousal, fit the data better than the 4-factor DSM-5 model, replicating a number of studies published since the advent of DSM-5  . The mosDSM-III)  made sigDSM-III)  evaluateiew, see .Identify scale scores that identify clinically significant distress. Total score “cut-offs” developed for one particular population may not be indicative of clinically significant mental distress in another population. This can be the case even for a measure that has been developed for a closely related population, using the same culturally contextualized idioms of distress. Legha and colleagues [lleagues  used ROCEstablish validity of measures of general well being developed in North America and Europe. More and more psychologists are examining the role that psychological constructs related to resilience play in determining the mental health of disaster-impacted populations . Ge. GeEstabs (e.g.,  assessedUse of novel statistical techniques to identify individuals with clinically significant mental distress. Although the research literature generally focuses on identifying patterns of relationships between reflective indicator measures of mental health and functional impairment across studies, the non-latent assumptions of network analysis may be better suited to the practical needs of specific settings. Using archival data of Darfur refugees living in Chad Mootoo and colleagues [hozun, a local depression-like construct, and proposed that such analyses might be particularly useful in formative evaluations. Mootoo and colleagues [lleagues  demonstrlleagues  comparedThe articles in this special collection address a series of key issues faced by practitioners attempting to measure mental health constructs accurately and identify those in need of intervention. They are:It is our hope that these papers will provide researchers and practitioners of psychosocial humanitarian aid with a sense of the state-of-the-art psychometric tools at their disposal. Although in no way exhaustive, we feel that this collection presents a useful introduction to the range of approaches available for who need to measure mental health in disaster- and conflict- affected populations.


BJPsych Open that contribute to a greater understanding of the complexity of ‘Cognition in Mood Disorders’.Cognitive impairment plays a key role in determining the course of illness and functional outcomes in mood disorders. This article summarises and discusses important papers within this thematic series of  BJPsych Open addresses both aspects of cognition.Aspects of cognitive functioning play a vital role in determining the course of illness and functional outcome for individuals with mood disorders. Broadly speaking, cognitive functioning can be divided into emotional processing, or what has been termed ‘hot’ cognition, and non-emotional or ‘cold’ cognition. The distinction is not absolute, but in general it appears that abnormalities or biases in emotional processing may be more closely related to current mood state in mood disorders, and it is suggested that normalisation of these biases may be important for response to treatment. Cold cognition may have some relationship to mood state, particularly when this is severely perturbed, but abnormalities in these aspects of cognitive function have been found to persist into remission or euthymia. This thematic series of 1 Studies in depression have led to the cognitive neuropsychological hypothesis,2 which posits that negative biases in emotional processing are an important part of the pathophysiology of depression, and that successful treatments for depression reverse these, allowing more rewarding interactions and providing a positive feedback loop that continues the process of recovery from an episode of depression. According to this theory, potential treatments for depression could be screened based on whether they reverse emotional processing deficits, and if they do not, then they are unlikely to be effective antidepressants. Furthermore, the hypothesis that changes in emotional processing are a first step toward more positive social interactions and full recovery has begun to be investigated. Hobbs et al3 (this series) present data on the effects of citalopram in healthy volunteers in a randomised between-group study. In computerised paradigms evaluating referential affective processing, social cognition and expression of prosocial behaviour, participants who received a single dose of citalopram showed greater prosocial behaviours toward others. Exploratory analyses also suggested increased positive affective biases and increased positive recall after administration of citalopram, suggesting, as per the cognitive neuropsychological hypothesis, that there is a shift with this antidepressant toward a more positive appraisal of the environment.Significant evidence has accumulated regarding abnormalities in emotional processing in depression. Less clear evidence has been produced in bipolar disorder, although abnormalities in facial expression recognition and implicit emotion regulation have been more consistently found.4 (this series) examine evidence for changes in emotional processing in late-life depression and anxiety disorders. This is reviewed in light of the ‘positivity bias’  in emotion processing that is observed in older adults.5 This might be expected to have a differential effect on emotional processing in late-life depression and anxiety compared with depression and anxiety in younger people. The review found relatively little evidence of impaired emotional processing in late-life depression, although changes in brain circuitry in this group were found to be broadly similar to those seen in younger patients. Evidence was more consistent in late-life anxiety and post-traumatic stress disorder, where there was clearer evidence of a bias toward attending to negative or threat-related stimuli, as in younger people.Much of the research on emotional processing biases in depression and anxiety disorders has been conducted in younger people. However, with an ageing population, it is important to consider older adults, particularly given well-established data on changes in emotional processing with ageing. Gray et al7 more recent research has focused on understanding the very significant heterogeneity in the degree of cognitive impairment seen in mood disorders.8 In attempting to understand this, several studies have used cluster analytic techniques to generate groups with different cognitive profiles. These have generally characterised three or four profiles, of which one has been a group of patients with relatively normal cognitive function compared with population norms or healthy controls, whereas one group has generally been characterised by global cognitive impairment. In Tsapekos et al9 (this series), to attempt to understand the predictors of these cognitive profiles, four separate profiles were identified in patients with bipolar disorder. Interestingly, but perhaps not surprisingly, lower cognitive reserve was associated with membership of higher impairment groups. The only other factor identified was the use of antipsychotics, which was significantly lower in the intact group.Although meta-analyses have consistently suggested that impairment in cold cognition persists into euthymia,10 (this series) examined studies that measured cognitive function at baseline and at follow-up, after treatment of an episode of major depression. Once again, age was a significant issue in the review, with studies being best understood by a split into younger and older patients. There was some evidence that increased severity of depression at baseline and increased severity of cognitive impairment at baseline both predicted a greater degree of cognitive change with treatment. These variables may be features that could be used in selecting suitable patients for future trials of, for example, cognitive remediation.In an attempt to understand what predicts improvement in cognitive function in the treatment of major depressive episodes, Barczyk et al11 For example, expectations may be important in determining subjective assessment of cognitive function. An interesting recent report in BJPsych Open12 suggested that patients who held a negative expectation of the effect that electroconvulsive therapy would have on their memory were more likely to have subjective memory worsening. Less research about subjective cognitive function has been conducted in youth depression samples, whose experience of cognitive problems associated with depression may be different if depression onset is relatively recent. In their analysis of depression symptoms over 3 months, and perceived change in subjective cognitive function, Allott et al13 (this series) reported that improvement or reduction in self-rated depression symptoms was highly associated with change in subjective ratings of cognitive function in their youth sample. That is, patients who reported improvement in their mood also felt their cognitive functions had strengthened. This was the case even though severity of depression in this young sample was moderate. A further interesting finding was that those with greater severity of depression at baseline were more likely to report a decline in subjective cognitive functioning over the subsequent 3 months. Much research to date has focused on objective cognitive functioning, but subjective cognitive functioning may be equally important in determining outcomes for patients.14 Therefore, development of interventions aimed at improving patients’ perception of cognitive functions may be helpful in enhancing recovery from mood disorders.It is increasingly recognised that people's subjective view of their cognitive ability may have considerable importance, even if this does not accord with results of objective cognitive testing. Research has focused on factors that make people more likely to experience subjective compared with objective impairment.15 However, negative trials may be explained to an extent by methodological issues. Guidelines have been written regarding appropriate methodology for cognitive enhancement trials in bipolar disorder,16 which have emphasised the need to screen for significant cognitive impairment and to wait until euthymia is achieved before commencing cognitive remediation strategies. Some recent studies, however, are attempting to treat cognitive impairment even when patients are still acutely depressed, with cognitive exercises hypothesised to be working by activating prefrontal brain areas.17 Cognitive remediation may also be useful in patients who are chronically depressed and have ongoing cognitive impairment. The field is relatively new, and it is therefore timely to produce recommendations and a review of methodology of cognitive enhancement studies in major depressive disorder. Douglas et al18 (this series) do this, not only examining methodologies for trials, but also attempting to give some guidance for clinicians who may wish to provide cognitive interventions for patients who are particularly impaired.To date, there is relatively little evidence for treatments that might improve cognitive function in the group of patients for whom this is impaired long-term.19 Barczyk et al10 (this series), in their review of factors that predict cognitive change, note that in some longer-term studies in late-life depression, cognitive change is predominantly negative. These studies examine what predicts a decline, finding that, for example, the number of deep white matter lesions appears to be a significant factor. A factor whose association with dementia is well established is apolipoprotein E ε4 (APOE*ε4) allele. The relationship between APOE*ε4 and depression is less clear. Burns et al20 (this series) showed convincing longitudinal evidence across the adult lifespan that in cognitively intact, non-depressed adults at baseline, APOE*ε4 was not associated with incident depression risk. As with in younger adult samples, further research examining cognitive trajectories in old-age depression samples would be beneficial in determining whether presence of certain factors (e.g. APOE*ε4 or deep white matter lesions) would affect cognitive remediation strategies.In late-life depression and bipolar disorder, understanding cognitive function is complicated by the relationship between the mood disorders and dementia, with episodes of mood disorder being associated with risk of dementia.BJPsych Open touches on all these subtleties, as well as suggesting future research directions, particularly in the area of cognitive remediation.In summary, research examining the issue of cognitive impairment in mood disorders has revealed increasing complexity in recent years. Distinctions include between hot and cold cognition, between objective and subjective cognitive impairment, and between cognitive impairment associated with euthymia and that associated with the episodes of illness. It has become apparent that the degree of cognitive impairment is variable between individuals, with the beginnings of evidence regarding what predicts who will suffer from significant impairment. Studies have begun to examine techniques to treat cognitive impairment, but the methodological issues are complex. As patients age, this affects the profile and likely outcome of cognitive impairment associated with mood disorders. This thematic series of


The molecular processes regulating molluscan shell production remain relatively uncharacterized, despite the clear evolutionary and societal importance of biomineralization.Laternula elliptica) mantle gene expression data produced over an age-categorized shell damage-repair time-course. We used previously published in vivo in situ hybridization expression data to ground truth gene interactions predicted by the GRN and show that candidate biomineralization genes from different shell layers, and hence microstructures, were connected in unique modules. We characterized two biomineralization modules of the GRN and hypothesize that one module is responsible for translating the extracellular proteins required for growing, repairing or remodelling the nacreous shell layer, whereas the second module orchestrates the transport of both ions and proteins to the shell secretion site, which are required during normal shell growth, and repair. Our findings demonstrate that unbiased computational methods are particularly valuable for studying fundamental biological processes and gene interactions in non-model species where rich sources of gene expression data exist, but annotation rates are poor and the ability to carry out true functional tests are still lacking.Here we built the first computationally predicted gene regulatory network (GRN) for molluscan biomineralization using Antarctic clam (The raw RNA-Seq data is freely available for download from NCBI SRA (Accession: PRJNA398984), the assembled and annotated transcriptome can be viewed and downloaded from molluscDB (ensembl.molluscdb.org) and in addition, the assembled transcripts, reconstructed GRN, modules and detailed annotations are all available as Supplementary Files.Bioinformatics online. The evolution of biomineralization in the late Precambrian corresponded with a huge expansion in morphological diversity. Representatives of all Kingdoms form biominerals, they are a substantial feature of life as we know it. One phylum which owes its success to biomineralized shell is the Mollusca . With ov3) and 1–5% organic matrix. In order to build their shells, molluscs transport minerals, proteins, glycoproteins, lipids and carbohydrates across the mantle to the extrapallial space, where mineral components are laid down as organized crystals onto an organic matrix. Over the last decade, mantle transcriptomes and shell proteomes have been described for many mollusc species  to 87% in the Pacific oyster  using a previously described protocol for shell damage and mantle tissue collection , which we have previously shown to have overlapping expression in the calcifying epithelium of the mollusc mantle  all of which encode proteins that are present in the nacreous shell proteome  contained four of our biomineralization markers  which have specific expression in the mantle epithelial/shell secreting cells but are absent from the nacreous shell proteome  contained two of our biomineralization markers , as well as genes that have a well-established role in biomineralization in other organisms but, have not previously reported in molluscs (such as SLC23A1).Both of the biomineralization modules were toll-like receptors that have been previously found in many molluscan mantle transcriptomes, where they are hypothesized to be functioning as pattern recognition receptors for the identification of pathogens as part of the innate immune system  development  motifs matching just the extracellular domain of notch, rather than the full complement domains. We therefore speculate the new candidates could be novel receptors involved in cell-cell communication. Two additional genes that are known to be involved in the development of vertebrate teeth and bones were highlighted from module 1; forkhead box protein J1  is a vitamin C transporter which mediates the uptake of Vitamin C in exchange for sodium ions. In vertebrate bone Vitamin C is an essential cofactor for collagen assembly . And thirdly, pendrin (SLC26A4) is a sodium-independent transporter of various ions, including bicarbonates required for shell biomineralization. Mutations to the pendrin gene in mice and humans lead to a variety of deafness phenotypes, such as reduced calcification of the inner ear bones   in molluscan biomineralization is relatively unexplored. Our previous work has demonstrated high levels of runcata) , 2018. IEnzymes are crucial for the production of all biominerals , they caCarbonic anhydrase catalyzes the hydration of carbon dioxide and accelerates the formation of bicarbonate ions, it is thought of as a deeply conserved requirement for biomineralization across many taxa . Given we cannot use database methods to assess the likely functional role of these genes it is difficult to highlight specific candidates of interest for future work. Clearly these unannotated genes are important for biomineralization, as our network analysis has included them in biomineralization modules of the GRN and we therefore propose another screening criteria for unannotated genes so that they can also be included in future functional work. Firstly the time-dependent damage-response analysis could be used to filter the list of unannotated genes, and secondly genes with a high threshold of connectivity to our biomineralization markers and new priority candidates could be selected.btz754_Supplementary_DataClick here for additional data file.


This symposium interprets GSA’s 2020 leading conference theme, “Why Age Matters”, as touching upon fundamental existential questions about the meaning of old age. Although meanings of aging have always been implicitly present in a variety of disciplinary gerontological studies, scholars from the humanities and arts have traditionally taken the lead in the field to provide thorough reflections and analyses about what makes later life meaningful. In this symposium, we aim to present a selection of perspectives from the humanities and arts that explore how meaningful aging can be realized in circumstances of the increasing vulnerability that inevitably accompanies old age. First, Hanne Laceulle uses a practice-theoretical philosophical framework to argue that the common assumption that vulnerability constitutes a threat to meaningfulness deserves to be nuanced, because meaning can also occur in the process of integrating vulnerability in one’s life. Second, Theresa Allison, Jennie Gubner and Alexander Smith show how vulnerable older adults living with dementia and their caregivers seek meaning in daily life, adapting meaningful activities to circumstances of increasing vulnerability. Third, Kate de Medeiros and Ulla Kriebernegg discuss how a dialogue between facts and fictions, narrative and literary gerontology, can contribute in seeing vulnerability as a form of resistance. Fourth, Margaret Perkinson illustrates the power of visual images as elicitors of reflections on meaning among the older inhabitants of a Guatemalan village. Documenting villagers’ own perspectives through PhotoVoice methodology underscores the fundamental importance of taking first-person perspectives into account when studying meaning.