In the absence of effective pharmacotherapy, there is an urgent need to test evidence-based dementia care interventions using pragmatic trial approaches. We present results from a study in which an evidence-based, nonpharmacologic intervention for persons living with Alzheimer’s disease and related dementia (ADRD) and their informal caregivers, Care of Persons with Dementia in their Environments (COPE), was tested in a Medicaid and state revenue-funded home and community-based service (HCBS) program.n = 145 dyads) or usual HCBS only . Outcomes were measured prerandomization, and 4 and 12 months postrandomization. Outcomes for persons living with ADRD included functional independence, activity engagement, self-reported quality of life, and behavioral and psychological symptoms. Caregiver outcomes included perceived well-being, confidence using dementia management strategies, and degree of distress caused by behavioral and psychological symptoms.Using pragmatic trial design strategies, persons living with ADRD and their caregivers were randomly assigned as dyads to receive COPE plus usual HCBS , and persons living with ADRD receiving COPE, compared to those receiving UC, showed a strong trend toward experiencing less frequent and less severe behavioral and psychological symptoms . After 12 months, persons living with ADRD receiving COPE were more engaged in meaningful activities  than those receiving UC.After 4 months, caregivers receiving COPE reported greater perceived well-being  than caregivers receiving UC (3.0; 2.9–3.0; Embedding COPE in a publicly funded HCBS program yielded positive immediate effects on caregivers’ well-being, marginal positive immediate effects on behavioral and psychological symptoms, and long-term effects on meaningful activity engagement among persons living with ADRD. Findings suggest that COPE can be effectively integrated into this service system, an important step towards widespread adoption.NCT02365051. Translational Significance: Using a randomized design, this study embedded an evidence-based, in-home dementia care program called Care of Persons with Dementia in their Environments (COPE) in a state-level Medicaid and state revenue-funded home and community-based service program. Findings revealed that family caregivers of older adults benefitted from COPE through improved overall well-being due to learned dementia management skills, while older adults living with dementia benefitted chiefly from sustained engagement in meaningful activities. This effectiveness study demonstrates that COPE can yield positive value when delivered in pragmatic fashion to older adults enrolled in a service system that operates in a large majority of states in the United States.caregivers), provide unpaid care to these individuals  functionally eligible for nursing home admission and financially eligible for Medicaid (Medicaid-funded); or (b) functionally eligible for nursing home admission but not financially eligible for Medicaid (state revenue-funded). We wanted to ensure that the COPE and usual care (UC) groups had approximately equal proportions of older adults who were Medicaid-funded and state revenue-funded because each category has a different monthly budget cap on the amount of CHCPE services allowed. Therefore, within their stratum, persons living with ADRD and their caregivers were randomly assigned as dyads to receive either: usual CHCPE services  with no COPE intervention or the COPE intervention plus usual care.The study’s target population was older adults (age ≥65 years) with dementia who received services from the CHCPE and their informal caregivers. The CHCPE is administered in Connecticut by four care management organizations, each responsible for a distinct geographic area, that employ care managers who plan and coordinate services for the CHCPE client population. For this study, we partnered with Connecticut Community Care, the largest of the four care management organizations in Connecticut. Established in 1979 as a pioneer care management organization for older adults, today Connecticut Community Care provides care management services to more than 8,000 CHCPE clients daily. Connecticut Community Care shares important features of organizations that are responsible for administering their states’ Medicaid- and state revenue-funded HCBS programs for older adults. Shared features include conducting uniform clinical assessments of clients for eligibility determination and care plan development, coordinating a range of direct service providers delivering HCBS, and monitoring the cost of care plans for each client. Accordingly, lessons learned in this study about the effectiveness of COPE will be of interest to organizations responsible for managing Medicaid- and state-funded HCBS programs throughout the United States.In keeping with a pragmatic clinical trials approach, study entry criteria were designed to accommodate data available from the Connecticut Community Care electronic database.Inclusion criteria for persons living with ADRD: (a) Active CHCPE client; (b) diagnosis of dementia or four or more errors on the Mental Status Questionnaire, considered moderate cognitive impairment Exclusion criteria for persons living with ADRD: (a) Diagnosed schizophrenia or bipolar disorder; (b) bedbound and unresponsive; (c) participation in concurrent experimental drug study designed to treat agitation; and (d) home environment deemed unsafe and/or unsanitary.Caregiver inclusion criteria: (a) ≥21 years of age; (b) willing and able to participate in all aspects of the study; (c) plans to live in area for 12 months; and (d) speaks English.Caregiver exclusion criteria: (a) Terminal illness with life expectancy of <12 months; (b) participation in concurrent nonpharmacologic trial designed to help caregivers of people living with ADRD; and (c) planning to admit person living with ADRD to a nursing home within 6 months.In keeping with our pragmatic trial approach, we embedded recruitment within the daily operations of Connecticut Community Care. During routine monthly clinical monitoring telephone calls, care managers at Connecticut Community Care explained key study features to provisionally eligible clients or their caregivers and referred interested dyads to the research study coordinator. Research staff then conducted telephone screenings with caregivers to determine whether clients and caregivers fulfilled all remaining inclusion and exclusion criteria. Consenting and prerandomization data collection occurred in the home setting. Randomization was stratified according to whether the CHCPE client received financial support from Medicaid funds or from state general revenues. The study protocol was approved by the UConn Health Institutional Review Board.Details about the COPE intervention as implemented in this study have been published elsewhere . BrieflyA single APN also received training for this study from the originators of the COPE intervention. In a separate home visit, timed to occur between the first and second OT in-home visit, the APN provided caregivers with information to help them identify and monitor common health-related concerns , how to be a medical advocate, and how to plan for the future of the person living with ADRD given the trajectory of the disease. The APN also obtained blood/urine samples if possible and examined for signs of unexpressed pain and dehydration. Laboratory evaluations included complete blood count, blood chemistry, and thyroid testing of serum samples, and culture and sensitivity of urine samples. Medications were reviewed for polypharmacy and dosing appropriateness. The purpose of these clinical assessments was to rule out or identify underlying medical conditions, infections, or medication issues that may adversely affect functioning at home, as found in previous work . The APNIn order to embed COPE within the routine operation of the CHCPE, the care manager responsible for the total care plan for each CHCPE client was notified by the study coordinator when a client was assigned to the intervention group, as well as the name of the assigned OT and APN for that client. All COPE Prescriptions addressed by the OT, as well as laboratory test results stemming from APN home visits, were provided to care managers and added to clients’ health records at Connecticut Community Care. Although they played no additional role in the COPE intervention, care managers were encouraged to refer to these COPE prescriptions as part of their ongoing client care management responsibilities. Additionally, care managers and the COPE APN and OTs were encouraged to maintain communication about clients’ conditions during the time clients received the COPE intervention.Dyads randomly assigned to UC received services from the CHCPE program only. Services available in the CHCPE include emergency response systems, respite care, home-delivered meals, homemakers and companions, adult day care, nonmedical transportation, mental health counseling, care management, and assistive technology. In keeping with a pragmatic trial design, we sought to determine the value of the COPE intervention when added to customary CHCPE program services.In-person baseline (prerandomization) and 4-month postrandomization structured interviews were conducted in the home setting by trained research assistants who, by study design, were blinded to group assignment. Structured interviews contained all measures explained in the following section of the paper. By study design, these structured interviews were conducted primarily with caregivers, and with persons living with ADRD who were able to conduct their components of the structured interviews. For 12-month postrandomization structured interviews, caregivers were interviewed by telephone.In this section, we briefly summarize outcome variables and their measurement; more details about measurement of outcome variables are found in functional independence, we used the 15-item Caregiver Assessment of Function and Upset as used in the original COPE efficacy trial   scale  , and, to (NPI-C)  was follD) scale . This mePerceived well-being, the primary outcome for caregivers as in the COPE efficacy trial, was measured using the 13-item Perceived Change Index ; racial and ethnic group membership ; caregiver familial relationship to person living with ADRD ; caregiver educational attainment  as a measure of socioeconomic status; and severity of cognitive impairment of persons living with ADRD at study entry, measured using the St. Louis University Mental Status (SLUMS) examination . These vDifferences between the COPE and usual care groups were determined using a modified intent-to-treat analytic approach, whereby persons with ADRD and caregivers were included in analyses if they had at least one recorded outcome measure postrandomization . We chose a modified intent-to-treat analysis approach because there is no consensus in the literature about how best to impute missing clinical outcome values for randomized individuals who are missing outcome data. Data were analyzed primarily using analysis of covariance (ANCOVA) methods in which baseline values of outcomes were used as covariates; this approach is more efficient than analysis of change scores . The treRegarding retention of randomized dyads for study interviews at 4 and 12 months after randomization, in cases where the person living with ADRD was admitted to a nursing home prior to the next scheduled interview, the research team completed interviews with caregivers by asking them to answer questions in reference to the month prior to nursing home admission. These are considered completed interviews. In cases where the person living with ADRD died prior to the next scheduled interview, an abbreviated interview was administered to the caregiver provided they were willing to complete such an interview; these are not considered completed interviews because abbreviated interviews did not include questions measuring study outcomes. If persons living with ADRD died or were admitted to a nursing home prior to the 4-month interview, 12-month interviews were not conducted (except in the one case noted in the footnote to the CONSORT chart). One caregiver died between the baseline and the 4-month follow-up research interview and another caregiver died between the 4- and 12-month interviews. Due to the nature of the study, and questions being administered to the caregiver during the research interviews, these cases are reflected as “drops” on the CONSORT chart.N = 291). Most were female (77.3%), widowed (51.5%) with a mean age of 85 years, and 16.5% were black. Most (70.5%) used Medicaid as the payment source for HCBS, representing the Medicaid waiver component of the CHCPE, while, for the remaining 30% of ADRD, state revenues paid for their HCBS. Nearly 30% has less than a high school education, and nearly 60% lived in the same household as their caregiver. p = .02). Caregivers in the usual care group showed higher levels of depressive symptoms based on Patient Health Questionnaire (PHQ-9) scores than COPE caregivers (p = .05). No other differences were found between COPE and usual care group caregivers .p = .07). Among caregivers, those receiving COPE reported statistically significantly greater perceived change for the better than usual care counterparts .p = .02). No other outcomes were statistically significantly different by treatment group. We also found, based on results from all mixed effects models, that no COPE effects observed at 4 months postrandomization were sustained at 12 months postrandomization .COPE was previously tested and shown to be efficacious on a number of outcomes related to persons living with ADRD and their caregivers. This is the first study to test COPE as an embedded program in a service delivery system, specifically a Medicaid- and state-revenue funded HCBS program, and to evaluate its effectiveness using the rigor of randomized trial methodology. Study participants included persons living with ADRD and their informal caregivers who received services from this HCBS program. We found that caregivers who received HCBS plus COPE, compared to those who received HCBS alone, improved significantly from baseline to 4 months postbaseline in their perceived well-being, specifically in their reported ability to manage day-to-day care challenges, their affective stance, and somatic well-being. We also found that persons living with ADRD who received HCBS plus COPE experienced decreased frequency and severity of behavioral and psychological symptoms after 4 months compared to those not receiving COPE, at a borderline level of statistical significance. Finally, we found that after 12 months, persons living with ADRD who received HCBS plus COPE had a significantly higher level of engagement in meaningful activities than those not receiving COPE.These findings suggest that COPE has added value for persons living with ADRD and their caregivers who already receive Medicaid- and state-revenue funded HCBS, such as care management, homemaker, personal care assistance, and adult day services. COPE demonstrated a positive effect on caregivers’ well-being related to managing dementia-related symptoms, the primary outcome for caregivers in this study, as it was found in the original COPE efficacy trial . This efThe lack of impact of the COPE intervention on functional independence, the primary outcome for persons living with ADRD which was found to improve among COPE recipients in the original COPE efficacy trial , deserveStudy findings have implications for efforts to expand the availability of the COPE intervention throughout Medicaid HCBS waiver programs for older adults at high risk for long-term nursing home admission. More than 40 states operate Medicaid HCBS waiver programs for older adults at risk for long-term nursing home admission  and, altThese implications for widespread adoption of COPE are highly relevant to the nascent field of pragmatic trials in the field of dementia care for community-dwelling older adults and their family caregivers. Research on dementia care is at an important inflection point where efficacious nonpharmacologic interventions must be made available to researchers and stakeholders in health care systems , as wellWe also emphasize successes in carrying out this study via the use of pragmatic trial elements when working in partnership with a large care management organization responsible for coordinating HCBS services for the target population. Study eligibility criteria for persons living with ADRD accurately reflected characteristics of clients served by the care management organization and were successfully identified at the client level using the electronic health records of the care management organization. Moreover, care managers were able to offer study participation to their clients and caregivers as part of their usual workflow, and COPE prescriptions developed by OTs as well as results of clinical assessments and laboratory results obtained by the COPE nurse were successfully transferred to the care management records of persons living with ADRD. These findings demonstrate that the practical logistics of embedding a dementia care intervention like COPE can be successfully designed to enable a health care system or social service organization with electronic health records to offer COPE to persons living with ADRD and caregivers in a pragmatic fashion. Further work is needed to incorporate additional pragmatic trial elements into efforts to fully embed COPE into service settings, such as defining and measuring outcomes that can be easily tracked within electronic health records of Medicaid and other publicly funded HCBS programs.This study had limitations that are relevant to future efforts to embed interventions such as COPE into health care systems and service settings such as Medicaid HCBS programs. First, this study included only English-speaking persons living with dementia and caregivers because at this time COPE is available only in English. Care managers from Connecticut Community Care urged the study team to develop a Spanish language version of the COPE intervention because of the growing number of Spanish-speaking clients and family members in their caseloads. Second, due to the practical realities of scheduling OT visits with caregivers of persons living with ADRD who were also receiving multiple in-home and community-based services from the Medicaid- and state revenue-funded HCBS program, it took longer than 4 months to complete all OT visits for the majority of dyads in the COPE group. This experience suggests that in pragmatic trials, the length of the OT component of the COPE intervention should be expected from the outset to have a longer duration than the 4 months as originally designed, and that evaluative strategies should be modified accordingly. Third, we were unable to discern specific type of dementia diagnosis, which remains an important challenge for future pragmatic trials when existing data might not contain dementia diagnostic codes. Finally, outcomes specific to persons living with ADRD and their caregivers used in this effectiveness study were chosen intentionally to closely mirror those used in the original COPE efficacy trial; however, future efforts to embed COPE in service systems should strongly consider using additional outcomes that are deemed relevant to persons living with ADRD, caregivers, and service system stakeholders in a constantly changing dementia care environment.In conclusion, in this study, we demonstrated that, through carefully designed partnerships between investigators and service providers, an efficacious dementia care intervention can be embedded and offered in a pragmatic fashion within a publicly funded HCBS program, with measurable benefit particularly to family caregivers of community-dwelling older adults living with dementia. Further research is necessary to understand cost and financial impact of COPE in this service environment; acceptability of the program by care managers, staff, and administrators; whether certain subgroups are more likely to benefit from receiving COPE; and strategies for scaling up and disseminating COPE in Medicaid- and other publicly funded HCBS programs throughout the country.igaa053_suppl_Supplementary_MaterialsClick here for additional data file.


In the last twenty years, research using zebrafish as a model organism has increased immensely. With the many advantages that zebrafish offer such as high fecundity, optical transparency, ex vivo development, and genetic tractability, they are well suited to studying developmental processes and the effect of genetic mutations. More recently, zebrafish models have been used to study autophagy. This important protein degradation pathway is needed for cell and tissue homeostasis in a variety of contexts. Correspondingly, its dysregulation has been implicated in multiple diseases including skeletal disorders. In this review, we explore how zebrafish are being used to study autophagy in the context of skeletal development and disease, and the ways these areas are intersecting to help identify potential therapeutic targets for skeletal disorders. Autophagy is a catabolic process which enables the breakdown of cytosolic components into their basic biomolecular constituents by lysosomal degradation, so that they may be recycled for further use. It is an essential process required during cell differentiation and it contributes to the maintenance of cellular homeostasis where its primary function is to mobilise nutrients to sustain vital cellular functions during stress , microautophagy and macroautophagy; each being delineated by the method of cargo delivery to the lysosome. This review will focus on macroautophagy (hereafter termed autophagy), as this considered to be the major form of autophagy and remains the most widely studied (Mizushima The autophagy pathway is largely mediated by a family of highly conserved autophagy-related (ATG) proteins Klionsky , which wA comprehensive study of the full molecular machinery involved in the autophagy pathway is beyond the scope of this review  pathway and the cAMP-dependent protein kinase A (PKA) pathway , osteoclasts (bone absorbing cells), osteocytes (bone maintenance cells) and chondrocytes (cartilage secreting cells) Fig.  Aghajan. Post-deDuring embryonic development, the vertebrate skeleton, and its associated bone, cartilage, and connective tissues, are formed from mesenchymal stem cells (MSCs). These cells are originally derived from three distinct embryonic cell lineages which go on to establish different regions of the skeleton . During this process, studies have shown that autophagy is upregulated to help these cells survive the hypoxic bone environment and to combat oxidative stress , primarily residing in the bone marrow, can differentiate into osteoclasts and migrate to the bony tissue surface in a process mediated by colony-stimulating factor 1 (CSF-1) and RANK ligand (RANKL)  are being recognised as a useful alternative to rodent models for skeletal and autophagy research. Firstly, zebrafish are highly fecund, with a single pair able to lay up to 300 eggs a week, which develop externally as optically translucent larvae. This allows for the study of both cellular and gross morphological changes during early development, without the need for invasive experimental techniques or animal sacrifice. Secondly, zebrafish are highly genetically tractable, as through the use of genetic tools such as TALEN  promoter , and therefore prevent the turnover of Map1Lc3 puncta, can also be applied to assess autophagic flux   and red puncta , the level of autophagic flux activity can be estimated. Together, these tools provide a more accurate way to measure autophagy activity and differences in autophagy levels quantitatively between different fish. Indeed, these tools have been used in zebrafish studies to determine how autophagic flux is affected by specific genetic mutations within bone and cartilage cells (Hu et al. Recently, there has been increased interest in using zebrafish scales as model for imaging bone cell dynamics (Bergen et al. Over the last 20 years, zebrafish larvae have become an established model for high throughput chemical screens Cully . UtilisiAs mentioned previously, interest is growing in the use of zebrafish scales as an ex vivo model. This model has the advantage that screens can be performed on scales harvested from a single fish thereby reducing intra-individual variation, and it allows for compounds to be tested in the context of homeostasis within a mature tissue (de Vrieze et al. . explored the role of autophagy within this process and showed that the genetic and pharmacological inhibition of autophagy impairs fin regeneration (Varga et al. As zebrafish fins and scales remain optically accessible throughout adulthood, zebrafish provide a useful tool for dynamically observing the factors involved in bone regeneration and bone repair Fig. . SimilarZebrafish are also a useful model for fracture repair studies as they show a fracture healing response with callus formation which is very similar to mammals (Sousa et al. Existing studies have established zebrafish as a powerful model for studying vertebrate development and modelling genetic diseases, including various skeletal disorders (Carnovali et al. As these tools are further refined, the advantages of this model can be further exploited for autophagy research. For example, the development of conditional knockout lines of autophagy related genes for skeletal cells would enable the role of autophagy in these cells to be explored more accurately. Moreover, the development of inducible knockout lines would be especially helpful as the loss of essential autophagy proteins has proved to be developmentally lethal in several models (Dong et al. The use of cultured zebrafish scales as an ex vivo model is a very recent development that shows great potential for exploring the dynamics between autophagy and bone cell activity and function. As a flat but 3D whole skeletal preparation, autophagy assays similar to those done within in vitro models could be performed in zebrafish scales. This would help deepen our understanding of autophagy activity within osteoblasts and osteoclasts, and how different drugs or genetic mutations impact upon autophagy flux. The potential use of cultured scales in high throughput drug screening is also still yet to be fully explored. Together with zebrafish larvae, the scale system could help bridge the gap between modelling the complex biology of bones and rapidly testing and validating potential drugs.As the tools available for genetic manipulation and in vivo imaging in zebrafish continue to improve, this model will be fundamental to progressing our understanding of autophagy cell biology and the significance of its role in skeletal development and pathology. Whilst it should be appreciated that not all observations from zebrafish, as with any animal model, are translatable to the human condition, zebrafish can still make a valuable contribution towards understanding the interactions between the autophagy pathway and the skeletal system, and in developing new therapeutics.


In this mSphere of Influence article, he reflects on how “Gut microbiomes of Malawian twin pairs discordant for kwashiorkor ” by Michelle Smith et al.  made an impact on him by revealing the causal influence of microbial communities in the development of severe malnutrition.Michael Woodworth focuses on translational microbiome therapeutic research. In this mSphere of Influence article, he reflects on how “Gut microbiomes of Malawian twin pairs discordant for kwashiorkor Clostridioides (formerly Clostridium) difficile infection. As we learned about the therapeutic potential of feces, which had not been discussed in our pharmacology lectures, the energy in the room was palpable. The direct transfer of microbial communities to treat a disease that is strongly associated with antibiotics felt both rebellious and completely intuitive. Not long after this lecture, the paper “Gut microbiomes of Malawian twin pairs discordant for kwashiorkor” by Michelle Smith et al. elegantly demonstrated the causal role of the intestinal microbiome in the development of another vexing and burdensome disease, kwashiorkor  to treat Smith et al. performed a longitudinal comparative study of twin pairs in Malawi to examine the role of intestinal microbial communities in kwashiorkor . Prior wAmong others around the same time, this paper inspired me to work toward developing a translational research program with human microbiome transplantation studies. It demonstrated an approach with metagenomic and metabolic analyses to determine ecological dynamics in human-associated microbial communities. In larger themes, this work also exemplified the importance of team science in clinical microbiome science and helped me prioritize skill sets to seek.https://www.gatesnotes.com/Health/Professor-Hawking-Fellowship-lecture). Since “Gut microbiomes of Malawian twin pairs discordant for kwashiorkor” was published, a substantial body of high-impact microbiome work has been done. Recently, Raman et al. working in the same group described an approach to identify sparse covarying taxa that might signal emergent groups of microbial communities associated with normal development and acute malnutrition  MAs an infectious disease physician, my research is focused on understanding the role of intestinal microbial ecology in colonization with antimicrobial-resistant bacteria and translating this knowledge to new treatments for patients. We are focused on identifying causal components of FMT that contribute to its observed clinical efficacy for eradicating colonization with antimicrobial-resistant bacteria. Our phase 1 clinical trials improve understanding of the safety and efficacy of FMT while also expanding access to this treatment in structured research protocols. I am still motivated by this paper’s demonstration of the malleability of phenotypes associated with microbial communities. Making antibiotic recommendations is one of my most frequent clinical activities. However, I am hopeful that within the span of my career, safe and effective microbiome therapies will be available to complement the use of antibiotics and potentially address severe malnutrition.


Climate adaptation through phenotypic innovation will become the main challenge for plants during global warming. Plants exhibit a plethora of mechanisms to achieve environmental and developmental plasticity by inducing dynamic alterations of gene regulation and by maximizing natural variation through large population sizes. While successful over long evolutionary time scales, most of these mechanisms lack the short-term adaptive responsiveness that global warming will require. Here, we review our current understanding of the epigenetic regulation of plant genomes, with a focus on stress-response mechanisms and transgenerational inheritance. Field and laboratory-scale experiments on plants exposed to stress have revealed a multitude of temporally controlled, mechanistic strategies integrating both genetic and epigenetic changes on the genome level. We analyze inter- and intra-species population diversity to discuss how methylome differences and transposon activation can be harnessed for short-term adaptive efforts to shape co-evolving traits in response to qualitatively new climate conditions and environmental stress. However, such extensive diversification requires thousands or up to millions of years, either induced by incremental changes in the local environment or upon sudden exposure to a new terrain . These changes in local or global environment are usually perceived as stress conditions for adapted plant species. For this reason, plants have evolved complex stress response mechanisms and multiple traits as a survival buffer to generate enough plasticity when sudden environmental changes occur. Depending on the environmental cue and the plant species at hand, such mechanisms are either of physiological, epigenetic, or genetic nature and depend on the range, magnitude, and duration of the perceived stress. Whether this perceived stress and its response mechanisms are inherited through multiple generations (stress memory), however, depends on several endogenous and exogeneous factors that we review and examine in detail throughout this article. In particular, we focus on co-evolving traits and co-occurring stress response mechanisms to overcome the limited view of uncoupled stress variables. Additionally, we emphasize the need to introduce gene regulatory networks as a conceptual methodology to study the impact of rapid environmental changes such as global warming on the survival capacity of plant ecotypes or species. This notion of interconnected stress-response mechanisms against multiple external forces acting on plants, and the heritability of these traits can stimulate the development of a new generation of plant engineering tools. We envision that such data can be used to build predictive models able to optimize biotechnological efforts, ultimately for engineering coupled traits and improved stress response mechanisms. To achieve this goal, it is crucial to gain a detailed understanding of the interplay between physiological-, epigenetic-, and genetic- mechanisms in the context of within-individual genetic stress response variants subjected to natural selection. Furthermore, the epigenetic level itself can also be seen as a buffer zone acting as an interface between the environmental and genetic levels to create a transgenerational buffer while the physiological level represents the buffer zone that determines the adaptive flexibility of a plant species within a generation. We test this hypothesis by reviewing published evidence in support of this notion and provide perspectives on experimental designs for future studies aiming to directly test this conceptual model. A mechanistic understanding of this stress-response interplay is crucial for developing the next generation of plant engineering tools.In this context, the epigenetic level which can also respond in tandem with stress physiology by selectively reshaping the epigenetic landscape is less likely to manifest these changes transgenerationally, as long as the physiological response is sufficiently strong in buffering the stress stimulus. Once this physiological buffer is saturated, the manifestation of a restructured epigenetic landscape is mostly caused by stress-induced structural variants (SVs) and in particular, transposable element (TE) mobilization that reshuffle genetic material and thereby draw the epigenetic toolkit to new loci while changing the global distribution of epigenetic marks in progeny. However, this genetic reshuffling is only possible when a stress stimulus is strong enough to severely reshape the epigenetic landscape, reactivating previously silenced loci and triggering a mobilization burst to subsequently affect the genetic composition of the germline.Consider a scenario where a generalist plant species is dispersed to a new terrain with increased average temperature levels. In this environment, one form of adaptation could be to slowly increase the basal expression of heat tolerance genes for continuously reducing the impact of this subtle heat ‘stress’ experienced by the plant. Eventually, if the trend of temperature increase continues over several generations, these regulatory changes will be ingrained and fixed on the genetic level.Yet, a plant that has to survive in a suddenly changing environment such as global warming where both the temperature and precipitation are drastically different and the salinity concentration of the soil increases rapidly, would need to alter several genes and pathways in tandem to maintain reproductive fitness. For most species, this would certainly be a stronger ‘accumulative stress’ experienced by the individual plant and requires more complex gene regulatory re-wiring for short-term adaptation. When experiencing accumulative stress, one possibility for the plant is to employ a combination of epigenetic and genetic mechanisms to maintain genome integrity without the risk of being subjected to several gene regulatory trade-offs when major physiological or developmental changes occur simultaneously. In this article, we examine the various outcomes of the interplay between epigenetic, genetic and physiological regulatory networks by first reviewing our current understanding of stress response mechanisms in plants and then providing future perspectives and applications within the (stress) epigenetics and plant engineering fields. In particular, we focus on DNA methylation as an epigenetic mark involved in gene expression regulation, and how these marks can trigger a cascade of effects that favor both short term (epigenetic response) and long term  adaptation to stress.DNA methylation marks (at 5’ cytosine positions) are epigenetic signatures encoding the state of a genome exposed to particular endogenous  and exogenous  factors throughout intra- and inter-generational time. A subset of these marks are sometimes closely dependent on histone modifications, and are often accompanied by other epigenomic features such as histone variants and chromatin accessibility . OverallWith regards to DNA methylation, such genome-wide changes are generally observed as differentially methylated regions (DMRs) that occur in tandem with transcriptomic or other epigenetic changes under a certain condition. These marks can also be found as heritable natural epigenetic alleles  . The metSince population diversity is largely governed by changes in the environment, a large spectrum of environmental stresses have been studied under controlled laboratory conditions. These include biotic and abiotic stresses which are strongly experienced both above and below ground level .While only a subset of all methylome signatures may directly trigger short-term stress response mechanisms, there is evidence that methylation changes are accompanied by other epigenetic changes that in turn can drive an adaptive process benefiting the plant in the long run . TechnolTogether, the tight interplay between plant stress physiology, epigenomic regulation, and adaptive evolution requires a new focus in the light of rapid shifts in global environmental conditions such as climate change. Learning from the examples presented in this work, we propose future directions for plant stress tolerance engineering that harness the naturally occuring activation potential of transposable elements (TEs)  and natuWhen sudden or severe changes occur, plants which usually grow in a constant environmental niche can overcome their basal physiological response mechanisms and induce transgenerationally stable changes to the epigenetic landscape . Such chAlthough comprehensive evidence of the inheritance of environmentally induced changes in DNA methylation remains to be collected , emerginDrosophila  have been shown to be differentially tolerant to salinity (in a hydroponic system), as observed by phenotypic and metabolic changes  and A. thaliana plants , in an attempt to resolve and compare the temporal hierarchy of stress response mechanisms between rice . TEs are mobile genetic elements that can change their genomic location by either exploiting a cut-and-paste mechanism (retro-elements) or by increasing their copy number via a copy-and-paste mechanism (DNA elements)  . Most oflements) . From adWhile we can monitor the mechanistic changes that occur over temporal scales, the intricate steps involved in instantaneous stress perception and the hierarchical order of cellular events leading to the manifestation of epigenetic marks, are still poorly explored. If we already know how DNA and RNA-level modifications occur upon stress, how do they interact with sensory and hormonal signaling networks?APOLO locus in A. thaliana, which is dynamically regulated upon changes in auxin concentration  synthesis pathways. pkl mutants are not only hypersensitive to salt, chilling and freezing stress , possibly by interacting with pathogen-responsive elements located in gene promoters . Revisitntration , 2020. Cg stress , but alsg stress , demonstAlthough there is still no clear characterization of a temporal hierarchy in stress response and their impact on the epigenetic landscape, these findings certainly illustrate the possibility of hormonal signaling networks initiating genomic and epigenomic changes, but also being tightly feedback-controlled by chromatin.A. thaliana show large differences in their methylomes  and a wild-type strain, carry a mosaic of DMRs originating from their parents. epiRILs provide a useful germplasm collection to mine for methylation variants or epialleles that influence gene expression for a desirable trait. The uniquely recombined methylation signatures harbored in individual epiRIL lines result in large phenotypic variation, possibly due to the mosaicity of epigenomes and mobilized transposable elements. This can be observed, for example, in progeny of met1-3 mutants and wild-type plants propagated over several generations. When infected with Pseudomonas syringae pv. tomato(Pst), a subset of these lines show increased resistance or susceptibility compared to their parental lines, representing approximately 58% of the resistance variation in 127 natural accessions of A. thaliana . Although several epiQTL loci were identified from the varying quantitative resistance between lines, regions that were epigenetically primed by the stress and inherited in the F10 generation were also found outside these associated loci. It was found that these primed DMRs largely overlap with TEs or TE- related genes and likely regulate in trans the expression of Hpa-resistance and defense genes. When a similar Hpa infection is introduced in A. thaliana mutants of various proteins involved in DNA methylation, systemic acquired resistance to the infection is impeded from transgenerational carry-over (rry-over . Most noPseudomonas syringae pv. tomato (Pst) infection in A. thaliana. Cambiagno et al. examined whether epigenetic induction of PRR/NLR genes affects pericentromeric TE expression during infection  mutant in which some pericentromeric TEs are expressed also activates the expression of unlinked PRR/NLR genes, priming these plants against Pst. infection. The cohort of sRNAs that commonly regulate both distal TEs and non-specific NLR genes upon re-establishment of methylation marks hint at the potential for transposable elements as triggers for initiating genome-wide immune responses, although the exact mechanisms remain unclear. From the plant’s perspective, controlling multiple loci carrying similar genetic/epigenetic motifs may be efficient, but this could also be facilitated by tuning a single master regulator causing diverse downstream outcomes.Biotic stresses can also induce TE-specific methylation changes, such as during nfection . Indeed,ONSEN (ATCOPIA78) family of TEs in A. thaliana  which could potentially contribute to higher transposition rates and increased copy number of ONSEN elements  and the ATENSPM3- family insertions enriched for H3K27me3 (histone methylation). Taken together, these results are indicative of the specificity with which certain TE families re-integrate their copies into the genome, preferentially favoring chromatin marks that lie within genes involved in environmental stress response.Delving further into possible links between chromatin and DNA methylation, nt H2A.Z . The autA. thaliana  also exhibit an increased tolerance to high temperatures, resulting from CHH hypomethylation that alters gene expression for stress-response. Ultimately, the tight inter-dependence between genetic and epigenetic pathways makes it challenging to identify which of these factors were first established during the evolutionary adaptation to temperature changes.The methylome landscape under high temperatures may also be controlled at the genetic level, driven by structural variations at methyltransferase genes, such as thaliana . cmt2 muA. thaliana only trigger minor changes to overall methylation patterns , eventually forming the endosperm and the embryo. The endosperm is largely hypomethylated compared to the embryo, resulting in the expression of several maternal epialleles (imprinted genes) and also paternally expressed genes  , linked stoichiometrically with the percentage of methylation levels. While this definition does not capture the exact origin of diversification , it will allow us to determine DMR hotspots  within the genome of a lineage. This refined definition can enable comparative analyses across species, to take into account the methyltransferase and demethylase enzymes which have evolved over time to create adapted variants of methylome landscapes and the efficiency with which they can methylate target cytosines. ‘Methylation diversity,’ on the other hand, is a metric we propose for studying the concentration of genome-wide methylation. This represents the relative abundance of methylated sites in each species, normalized by genome-size, and is representative of overall methylation levels, perhaps indicating the varying reliance on this epigenetic mark for gene regulation across species .mPong  gene in winter-annual Arabidopsis accessions  may therefore largely overestimate the robustness of temperature/precipitation adapted ecotypes during climate change while underestimating the co-adapted traits that could either buffer or facilitate extinction events on the gene regulatory network level . As a result, future population epigenomics studies and plant engineering efforts will have to rely on new methodologies able to quantify all environmental variables in parallel to assess how they penetrate the entire gene regulatory network encoding co-adapted traits rather than relying only on a strict reductionist view of uncoupled stress variables. Epigenetic signatures such as the genome-wide distribution of DNA methylation marks or methylome/methylation diversity patterns can act as markers for selecting natural variants within populations or between ecotypes that reflect a stabilized and robustly adapted state of several co-evolved traits for which more realistic predictions of survival capacity in various environmental change conditions can be developed. The topologies of gene regulatory networks underlying particular epigenetic signatures will be more powerful predictors of future plasticity and adaptability in rapidly shifting environmental conditions than models focusing on individual SVs and their substitution frequencies. Ultimately, we envision that individuals within a population or ecotype lineages with robust co-adapted traits and gene-regulatory networks can then be used as starting material for artificial TE mobilization efforts, further fine-tuning beneficial traits to be fit for the new environmental demands.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Both authors listed have made a substantial, direct and intellectual contribution to the work, and 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. The handling editor declared a past co-authorship with one of the authors H-GD.


Peer specialists are individuals who have a lived experience with a mental health condition and who have received formal training to provide peer support and services to others. This symposium will examine the role of peer specialists in supporting aging adults’ recovery, quality of life, health behaviors, and health outcomes. Peer specialists have increasingly been integrated as formal service providers in health care systems in a wide variety of settings. In the Veterans Health Administration (VHA), over 1,110 Veterans work as peer specialists across the country. Findings from both VHA and community studies will be presented. First, Amanda Peeples will present findings from a mixed-methods evaluation study on the implementation of peer specialists to primary care teams in the VHA. Next, Anjana Muralidharan will present on the role of peer specialists in promoting health and wellness among aging veterans with serious mental illness using data from three VHA studies on peer-led interventions. Finally, Karen Fortuna will present on PeerTECH, a digital peer support self-management intervention that teaches older adults with mental health conditions how to co-manage psychiatric illness and chronic health conditions. Together, these three presentations will explore the ways in which “peerness” is defined in different populations and in diverse contexts. Laura Wray, geropsychologist and Executive Director of the VHA Center for Integrated Healthcare, will serve as discussant. She will comment on the role of peer specialists in supporting the recovery and wellness of aging persons in VHA and beyond.


Identifying critical source areas (CSAs) of a watershed by phosphorus (P) loss assessment tools is essential for optimal placement of beneficial management practices (BMPs) to address diffuse P pollution. However, lack of significant progress in tackling diffuse P pollution could be, in part, associated with inefficacy of P loss assessment tools for accurately identifying CSAs. Phosphorus loss assessment tools have been developed to simulate P loss from the landscape where runoff is mainly driven by rainfall events. Therefore, they may underperform in cold climates where the land is often frozen during winter and runoff is dominated by snowmelt. This paper (i) reviews the strengths and weaknesses of current P loss assessment tools and their underlying assumptions in simulating soil P dynamics and P transfer to runoff, and (ii) highlights a number of challenges associated with modeling P transfer from agricultural land to surface waters in cold climates. Current P loss assessment tools do not appear to fully represent hydrological and biogeochemical processes responsible for P loss from CSAs, particularly in cold climates. Effort should be made to develop P loss assessment tools that are capable of considering P dynamics through the landscape as a result of abiotic perturbations that are common in cold climates, predicting runoff and P movement over frozen/partially frozen soils, and considering material-P connectivity between landscape and surface waters. Evaluating P loss assessment tools with water quality data is necessary to ensure such modifications result in improved identification of CSAs. Phosphorus (P) export from agricultural land has been identified as a primary cause of water quality impairment as P plays an important role in freshwater eutrophication  where large P sources could coincide with hydrological flows across small portions of the watershed  which represents the mass of P in soil solution once a relative equilibrium between solution P and active P pools is established. Sharpley et al. , 1989 prThis highlights the crucial need for updating P routines of the process-based tools, and PSP values in particular, to accurately simulate soil P dynamics in agricultural watersheds. A significant research gap is a lack of effort to examine P routines of the Jones et al.  and the Hypothetically, soil P processes in cold climates are different from those processes in more temperate climates because in cold climates the soils often experience substantial abiotic perturbations. Frequent abiotic perturbations can potentially affect physical and biological properties of the soils, and consequently the mass of P loss in runoff  do not attempt to model soil P dynamics to predict P loss in runoff. These tools are simplified to operate with a limited number of input parameters, so that they can practically be used by landowners or consultants rather than researchers and represent the annual risk of P loss rather than a calculated amount for each runoff event. Several P indices estimate the inherent risk of dissolved P losses from a field by multiplying agronomic soil P test value  by an extraction coefficient and runoff potential. Particulate P loss is also determined by multiplying the quantity of soil loss by mean P concentration in sediments  DEM and the multiple triangular slope algorithm to compute slope, the TI approach at its very best appeared to be capable of explaining only 60% of soil moisture patterns  of agricultural landscapes in south-central New York, USA. where saturation-excess is the dominant runoff process  model  or grid cells contribute equally to runoff generation and P loss and are not capable of simulating hydrological connectivity between discrete units of the landscape , and infiltration into partially frozen soils (see for example, Wang and Melesse There is lack of information in the literature on the ability of P routines of process-based tools to accurately initialize the quantity of soil P pools in cold climates; neither is there any attempt to update the equations used to estimate PSP values from soil properties in cold climates. In cold climates, the soils undergo several freezing-thawing and drying-rewetting cycles which could affect the quantity of soil P pools and subsequently the potential of P loss to runoff. Further research is needed to understand the quantity of soil P pools and the interactions between soil P biomass and P concentration in runoff for soils that experience substantial abiotic stresses.There is a crucial need for developing P loss assessment tools capable of considering the magnitude, duration, and frequency of material-P connectivity between the landscape and surface waters under different conditions of topography, soil texture and chemistry, and management in cold climates. To develop such P loss assessment tools, techniques should be used to identify and quantify parts of the landscape that generate both surface and subsurface runoff under seasonally varying weather conditions. Furthermore, P loss assessment tools need to be improved to consider P retention or remobilizations as runoff moves through the landscape during rainfall and snowmelt runoff events.Finally, while the process-based P loss assessment tools may better describe runoff and P loss from the landscape compared with empirical tools, they are complex and require a wide range of inputs that may not be readily available. Further, complex tools do not necessarily provide better information regarding runoff and P loss than simple P index approaches under diverse soil, climate and topography. Recent findings in the USA show that many P indices could provide information comparable with the complex, data-intensive process-based models (Osmond et al.


Maternal mortality is notoriously difficult to measure because even in high-mortality areas maternal deaths are relatively rare. These difficulties are further compounded in low-income and conflict-affected settings such as Afghanistan.Between 2002 and 2018, maternal mortality estimates for Afghanistan have been provided by six surveys, using a variety of costly methodologies yet yielding contradictory and sometimes implausible results.The ‘failure’ of household surveys to provide robust data on maternal mortality in Afghanistan is a call to reconsider the value of maternal mortality measurements to assess safe motherhood interventions in low-income and conflict-affected settings.We encourage stakeholders involved in the commissioning and use of maternal mortality estimates in Afghanistan and similar contexts to take stock of experiences so far and carefully consider how to best make use of existing resources.In the short-term efforts to measure improvements in maternal health should be redirected towards measurements of access, use and quality of services for pregnant women and women giving birth, with longer-term investments towards civil registration as a source of robust maternal mortality data.New York Times article captures how women’s health became, and still is, a cornerstone of development aid in Afghanistan. As a result, maternal health measurements have become an important tool for ‘evidence-based advocacy’,3‘Particularly hard hit by Afghanistan's 23 years of war, civil strife and Taliban misrule are Afghan women, who are experiencing what health officials call ''catastrophic'' death rates associated with pregnancy and childbirth’.Sixteen years later, we released the results of the Afghanistan Health Survey (AHS) 2018.In this commentary, we contextualise our experience within the history of previous efforts to measure maternal mortality in Afghanistan. We review our own lessons learnt and reflect, more globally, on their implications. We argue that our Afghanistan case-specific experience exemplifies the well-known shortcomings of surveys to measure maternal mortality and should act as a call to reconsider its value in assessing safe motherhood interventions in Afghanistan and other low-income and conflict-affected settings.due to the pregnancy as opposed to merely happening during the pregnancy  problems finding deaths, particularly encountered in settings such as Afghanistan, where geography and security can severely hinder access to households.The maternal mortality ratio (MMR) is defined as the number of maternal deaths during a given time period per 100 000 live births during the same time period.Between 2002 and 2018, maternal mortality estimates for Afghanistan have been provided by six surveys funded by external donors  and implemented by or in close collaboration with international institutions . The surThe first MMR estimates produced for Afghanistan came from the Reproductive Age Mortality Survey (RAMOS) 1 study in 2002. The study reported a national estimate of 1600 deaths per 100 000 live births and four subnational estimates, ranging from 418 in Kabul to 6507 in Ragh.9Against this backdrop, the two AHS estimates (276 in 2015 and 153 in 2018) were criticized for being too low. Concerns regarding the AHS estimates were founded on anomalies in data collection. We conducted further analyses in 2018 which confirmed the likely underestimation of the AHS 2018 MMR see . Local p10.1136/bmjgh-2019-002126.supp1Supplementary dataDespite the wide variation in MMR estimates over time, a descending trend can be discerned. This is in line with evidence of remarkable increases in access to care and coverage of several maternal care interventions .6Are we doing things right?). Double-loop learning goes a step further and questions methodologies and analytical frameworks (Are we doing the right things?). Finally, triple-loop learning is deeper questioning of purpose and legitimacy .After over a decade of trial and error, the time has come to review lessons learnt before further attempts to estimate maternal mortality in Afghanistan. The triple-loop learning frameworkOur review of AHS 2015 and AHS 2018 data and processes revealed that a number of deaths were probably missed. Following fears of data fabrication in hard-to-access areas in 2015, we significantly tightened quality control for theAHS 2018. This included (1) enlisting a team of external independent monitors  to randomly revisit households and (2) rapid statistical review of selected data before data entry to ensure data credibility. Yet, in spite of these improvements, it appears that deaths were still under-reported in 2018. This could be due to further issues in our survey operations. Indeed, we did not use field-check tables, which could have helped to ensure internal consistency between births and related events for children and mothers. However, more profound reasons such as grief or shame may also be at play,‘do things right’ when measuring maternal mortality in Afghanistan. Survey implementers should therefore carefully design, implement and describe their quality assurance mechanisms so as to enable users to contextualise the magnitude of their maternal mortality estimates.In short, it is difficult to There is a reasonable consensus that surveys are not suited to measure statistically rare events such a maternal deaths.In other words, the failure of household surveys to provide robust data on maternal mortality confirms that they are not ‘the right thing’. However, it is not obvious what the right thing exactly is, especially in the short to medium term. Nevertheless, there is a strong case to strengthen national civil registration and national statistics in Afghanistan.As has already been argued since the mid-1990s, the measurement of MMR using surveys is not a good use of scarce resources.2In summary, diverse calls question the usefulness of the MMR to monitor safe motherhood interventions, suggesting that perhaps we ‘should not be doing anything at all’ to measure it in Afghanistan.What have we learnt from 16 years of maternal mortality surveys in Afghanistan? Not much about actual mortality levels—though contextual evidence suggests they are declining—but enough to know that survey methodologies are not providing robust MMR estimates. While the arguments we presented are not new, the Afghanistan experience exemplifies the well-known shortcomings of surveys to measure maternal mortality, particularly exacerbated in fragile and conflict-affected settings. Before further efforts to measure maternal mortality are undertaken in Afghanistan, we encourage stakeholders involved in the commissioning and use of these estimates to take stock of experiences so far and to carefully consider how to best make use of existing resources. Based on our experience, we believe the time has come to temporarily halt attempts to measure maternal mortality in Afghanistan through surveys and to explore alternative methods. In the short term, efforts to measure improvements in maternal health should be redirected towards measurements of availability, access and quality of services for pregnant women and women giving birth, with a longer-term investments towards CRVS systems as a source of robust maternal mortality data.


Mitochondria are key determinants of cellular health. However, the functional role of mitochondria varies from cell to cell depending on the relative demands for energy distribution, metabolite biosynthesis, and/or signaling. In order to support the specific needs of different cell types, mitochondrial functional capacity can be optimized in part by modulating mitochondrial structure across several different spatial scales. Here we discuss the functional implications of altering mitochondrial structure with an emphasis on the physiological trade-offs associated with different mitochondrial configurations. Within a mitochondrion, increasing the amount of cristae in the inner membrane improves capacity for energy conversion and free radical-mediated signaling but may come at the expense of matrix space where enzymes critical for metabolite biosynthesis and signaling reside. Electrically isolating individual cristae could provide a protective mechanism to limit the spread of dysfunction within a mitochondrion but may also slow the response time to an increase in cellular energy demand. For individual mitochondria, those with relatively greater surface areas can facilitate interactions with the cytosol or other organelles but may be more costly to remove through mitophagy due to the need for larger phagophore membranes. At the network scale, a large, stable mitochondrial reticulum can provide a structural pathway for energy distribution and communication across long distances yet also enable rapid spreading of localized dysfunction. Highly dynamic mitochondrial networks allow for frequent content mixing and communication but require constant cellular remodeling to accommodate the movement of mitochondria. The formation of contact sites between mitochondria and several other organelles provides a mechanism for specialized communication and direct content transfer between organelles. However, increasing the number of contact sites between mitochondria and any given organelle reduces the mitochondrial surface area available for contact sites with other organelles as well as for metabolite exchange with cytosol. Though the precise mechanisms guiding the coordinated multi-scale mitochondrial configurations observed in different cell types have yet to be elucidated, it is clear that mitochondrial structure is tailored at every level to optimize mitochondrial function to meet specific cellular demands. Mitochondria are no longer known simply as the powerhouse of the cell as they have now been shown to play a key part in several cellular processes including metabolite biosynthesis and signaling beyond their classical role in energy metabolism. However, the relative mitochondrial contribution to each of these different cellular processes is determined by the specific demands placed on the cell. For example, the primary function of striated muscle cells is to generate force through muscle contraction. As a result, the main role of mitochondria in striated muscle cells is to convert fuel into the energy needed to sustain this relatively high energy demand task. In contrast, the liver plays a much larger role in the synthesis of proteins, carbohydrates, and lipids, among other products. In support of this increased cellular synthesis demand, the mitochondria in the liver have a relatively greater capacity for metabolite biosynthesis and lower energy conversion capabilities compared to striated muscle mitochondria . While iWithin the mitochondrial outer membrane lies a tortuous mitochondrial inner membrane which can be further separated into an inner boundary membrane running parallel to the outer membrane and the cristae folds protruding into the mitochondrial matrix . The criIndividual cristae can take several different shapes which are regulated in part by the mitochondrial contact site and cristae organizing system (MICOS) and Opa1 . The strInvestigations into mitochondrial cristae morphology have traditionally required the use of electron microscopy on fixed specimens to achieve the resolution necessary to observe these structures which are often 30 nm or less in diameter . As a re2+) exchange. Thus, it may be advantageous for a relatively large cell which faces rapid changes in energy demand, such as the skeletal muscle, to maintain a uniform membrane potential throughout the entire mitochondrion in order to more optimally respond to cellular energy demands.It has long been assumed that the protonmotive force generated across the mitochondrial inner membrane is uniform throughout the entire organelle thereby making a single mitochondrion akin to a single cell battery. Indeed, it has been proposed that elongated mitochondria can act as a power cable to distribute the electrical component of the protonmotive force, the membrane potential, across long cellular distances . In suppIn a cell, mitochondrial shapes and dynamics are finely tuned by fusion and fission proteins whose molecular actions are dependent on the presence of GTP. Mitochondrial elongation is initiated by a gradual merge of the outer mitochondrial membranes (OMM) of two individual mitochondria, for which mitofusin (Mfn) proteins, Mfn1 and Mfn2, are required. Afterward, the inner mitochondrial membranes (IMM) are fully joined by the action of OPA1, and the cristae from separate mitochondria are formed into a new crista structure wherein mtDNA, ions, and other small molecules can be shared. On the contrary, a single elongated mitochondrion can be fragmented into smaller structures through recruiting a group of proteins including a dynamin-like protein Drp1 and its associated proteins such as Mff, Fis1, and Mid49/51. For detailed molecular mechanisms behind mitochondrial fusion and fission systems, see . In addiMitochondrial fusion-mediated elongation is accomplished by the cooperative action of outer  and inner  membrane machineries, by which mitochondrial function and homeostasis are maintained . MitochoMitochondrial fission plays a significant role in both mitochondrial oxidative function  and initThe mitochondrial dynamics system is also known for regulating the response to various physiological challenges. Upon starvation, mitochondria form tubular, elongated structures, which have been identified to protect cells from autophagosomal degradation  and promMitochondrial morphology and function are both notably altered during cellular development and senescence. Recently, it was shown that proliferating cells accomplish increased mitochondrial oxidative capacity not by mitochondrial biogenesis but by mitochondrial elongation . As compIn addition to aging, pathological conditions have also shown significantly altered mitochondrial dynamics and morphology, as well as mitochondrial dysfunction . For insAdditionally, it is important to note that mitochondrial shape can also be regulated independently of mitochondrial fission/fusion proteins. Dysfunctional mitochondria have been shown to be disconnected from the mitochondrial networks found in skeletal muscle cells in a manner inconsistent with mitochondrial fission . LocalizSeveral studies have displayed “ring” or “donut”-like mitochondrial structures in different cell types, which seems to be associated with mitochondrial oxidative stress . For insTwo or more individual mitochondria can communicate with each other via thin, tubular connections called mitochondrial nanotunnels, although free-ended extruding mitochondrial nanotunnels are also observed . With miTissue-specific mitochondrial morphologies have been identified and suggested to be important for particular tissue functionality and vitality , yet theIn cells, mitochondria can exist as either punctate, individual mitochondria or branched, highly connected architectures  termed tThe mitochondrial reticulum enables flow of ions, proteins, metabolites, and mtDNA as well as efficient conduction of energy. The relatively stable, highly connected nature of mitochondria in both cardiac and skeletal muscles near the sarcolemma and between the myofibrils have been shown to support distribution of the electrical energy of the mitochondrial membrane potential rapidly throughout the cell . HoweverFurthermore, in response to external stimuli, cells can also alter their functional state via changes in mitochondrial network configuration. In yeast, there is an increase in mitochondrial networks and mitochondrial protein contents when yeast cells are in transition from a non-respiratory to respiratory state . SimilarIn vitro culture of HL-1 cells with differentiated cardiac phenotype reveals a regular mitochondrial arrangement dissimilar to the native cardiac tissue mitochondrial structure, wherein dynamic dense mitochondrial reticulum undergo continual displacement and reorganization (short spheres or long filamentous mitochondria)  . These p2+ entry)  . Perinuc+ entry) . In panc+ entry) . Specifi+ entry) . A wide + entry) . These fIn vitro experiments using digitonin-permeabilized cells fueled with substrates for ETC complexes I, II, and IV revealed that mitochondrial fragmentation caused by deficiency or absence of fusion factors like OPA1 and MFN1/2 results in significant reduction in mitochondrial respiratory capacity  structure-function relationships  supports many cellular processes and closely works with the mitochondria to synchronize several biosynthesis and cell signaling pathways. Contact sites between mitochondria and the ER have been reported for decades across many cell types , and theMitochondria contact the ER more than any other organelle in the cell , and in 2+ signaling has been historically appreciated (2+ exchange at the mitochondria-ER contact sites is enabled by voltage-dependent anion channels (VDACs) and mitochondrial-calcium uniporter (MCU) on the outer and inner membrane of the mitochondria, respectively, as well as the inositol-1,4,5-trisphosphate receptors (IP3R) and the sarcoplasmic reticulum ATPase (SERCA) expressed on the outer membrane of the ER  during muscle contraction, but in this system, the Ca2+ extrusion from the SR is regulated by the ryanodine receptors (RyR). The RyR is expressed on the outer membrane of the SR and is activated in either a Ca2+ (heart) or voltage  dependent manner following action potential propagation down the T-tubule (TT) system. Mitochondria-ER contact sties in striated muscle cells localize mitochondria to the dyad and triad SR-TT structures in heart and skeletal muscle, respectively, creating a mitochondria-SR-TT microdomain  and phosphatidic acid that serve as precursors for phosphatidylethanolamine (PE) and cardiolipin, respectively, and therefore rely on the ER-mediated biosynthesis of these lipids. While high resolution images have revealed that mitochondria-ER contact sites are not coupled to the ribosome secretory pathway , mitochoIn addition to ion and lipid trafficking, mitochondria-ER interactions can facilitate mitochondrial dynamics and events and studies in yeast and mammalian fibroblasts have found that more 80% of mitochondrial fission events occur at mitochondria-ER contact sites . Live ceMitochondria metabolize, synthesize, and structurally incorporate lipids, and it is therefore not surprising that mitochondria-lipid droplet interactions are predominant across numerous cell types including fibroblasts, striated muscles, brown fat, and others. While mitochondria-lipid droplet interactions represent a significant portion of the organelle interactome, these interactions are dynamic and the frequency and function of mitochondria-lipid droplet interactions vary across cell types and metabolic states. Lipid droplets serve as cellular storage for fatty acids (FAs) in the form of triacylglycerides (TAGs), but the biological function of mitochondria-lipid interactions may support either metabolism or synthesis of TAGs depending on the cell type and metabolic status. For example, in cells with high energy demands, mitochondria-lipid interactions support cellular energy homeostasis by breaking TAGs down into FAs and importing them into the mitochondria to be used in FA-oxidation . AlternaDepending on the function of mitochondria-lipid droplet interactions, the frequency and structure of these contact sites can be modulated to sustain energy homeostasis across different cell type and metabolic states. Studies evaluating lipid-organelle interactions in primate fibroblasts have found that 20% of the lipid droplets form contact sites with mitochondria and demonstrated that these interactions directly facilitate the transport of FAs from LDs into mitochondria for FA-oxidation . MoreoveWhile altering the frequency of contact sites between mitochondria and lipids provides a mechanism for throttling cellular FA flux, the precise functions of mitochondria-lipid interactions are determined by the protein expression and morphology of the mitochondria participating in these points of contact. Although less is known about mitochondrial tethering mechanisms associated with lipids compared to the ER, it has been shown that mitochondria express tethering proteins such as Plin5 and Mfn2 on the OMM at lipid sites , and incMitochondria in contact with lipid droplets also exhibit distinct morphology that supports the function of the interaction. In mature muscle cells, large, elongated mitochondria wrap around the lipid droplets to increase surface area of contact between the organelle  and are 2+ concentrations, and functional studies across multiple mammalian cell lines have found that mitochondrial movement along MTs is inhibited by increases in Ca2+ concentrations  and plasma membranes (PM). The capacity to transport and spatially distribute mitochondria within the cell allows for localized regulation of metabolism and calcium buffering as well as proper distribution of mitochondria during cell division. Long-distance transport of mitochondria is largely supported by mitochondria-MT interactions where anterograde and retrograde movement of mitochondria along microtubules is powered by kinesin and dynein motors . In hightrations , providi synapse , 2007. I synapse .in vivo imaging studies of mouse salivary glands demonstrated that a subpopulation of highly fused mitochondria localize to the basolateral plasma membrane, indicating that mitochondria-PM interactions may also support subcellular distribution and functional specialization of mitochondria in non-dividing mammalian cells as well  that are featured by high electron density in electron microscopy images , though 2+ cycling capacities of various muscle types (The diversity of functions exhibited across the various mitochondria-organelle contact sites demonstrates the complex role of subcellular architecture in cell-type specialization. Although the importance of structure-function relationships within the mitochondrial-organelle interactome is just beginning to be uncovered, it is clear that mitochondria-organelle interactions are a key determinant of cell function. Because of the finite surface area of mitochondrial outer membrane within the given cell, establishing contact sites physically reduces the potential for interactions with other organelles as well as with the cytosol, which may limit other functionalities. Thus, the topology of the mitochondria-organelle interactome must be optimized to accommodate the specific functions of a cell. This trade-off is well represented in the interactivity of mitochondria in striated muscles where interactions with lipid droplets and SR are evidently tuned to meet the Cale types . HoweverAs discussed above, physiological modulation of mitochondrial structure in support of the functional specificity of a cell can occur at several different spatial scales. While there have been many studies and subsequent reviews focusing on mitochondrial structure at each individual level, there have been relatively fewer which investigate how mitochondrial structure may be coordinated across scales within a cell  and evenMulti-scale coordination of mitochondrial structure-function relationships can also occur on an acute timescale. Using a postprandial model in mice, mitochondrial morphology across spatial scales was compared in hepatocytes 2 and 5 h after feeding in order to relate energetic and biosynthetic function under conditions of varying anabolic/catabolic states in the liver . As mTORMitochondria are remarkable organelles capable of remodeling their structural organization, sometimes in a nearly continuous fashion, in order to optimize mitochondrial function in support of cellular demands. As discussed above, the structural configuration of mitochondria can be regulated at several different levels to specifically tune mitochondria to the needs of the cell in which they reside. In a physiological setting, altering mitochondrial structure is associated with various functional trade-offs at each spatial scale. Indeed, the morphology within the interior of mitochondria, particularly the relative proportion and shape of mitochondrial cristae, determines the space available for enzymes involved in different functional pathways. While the overall volume of an individual mitochondrion is reflective of its internal functional capacity, the shape of a mitochondrion plays a large role in its ability to interact with the surrounding cellular environment. Moreover, cells can form mitochondrial networks with varying sizes, shapes, and dynamics each of which contribute to the overall functional capacity of mitochondria within the cell. Additionally, interactions between mitochondria and other organelles are modulated by distinct tethering proteins which regulate the specific functional coupling that occurs at these organelle contact sites. Finally, emerging evidence suggests that mitochondrial functional specificity of cells within tissues occurs through coordinated, multi-scale regulation of mitochondrial structure.All authors drafted and edited 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.


Consistent with Freyberg et al. and Castillo et al. presented further evidence supporting the shared common intrinsic susceptibility factors between schizophrenia and metabolic syndrome through alterations in sphingolipid metabolism. As major components of cell membranes and its participation in the formation of membrane “lipid rafts,” disturbance of sphingolipid homeostasis may lead to both neuropsychiatric disease and metabolic syndrome, therefore the authors proposed a specific sphingolipid profile from peripheral tissue (such as skin and blood) as biomarkers for schizophrenia and/or metabolic syndrome in an early schizophrenia diagnosis to help clinicians anticipate cardiometabolic complications in this patient group . On the other hand, Zuccoli et al. provided proteomic evidence from post-mortem brains indicating the energy metabolism dysfunction in the brain contributing to neuropathology underlying three major psychiatric disorders—schizophrenia, bipolar disorder, and major depressive disorder. It is interesting that similar alterations of five proteins involved in the main axis of metabolic pathways for ATP production are identified in all three disorders, while there are 32 altered proteins  shared between schizophrenia and bipolar disorders, 10 altered proteins (such as phosphoglucomutase 1) between schizophrenia and major depressive disorder, and 7 between bipolar disorder and major depressive disorder . Since the human brain accounts for only 2% of whole body weight, but utilizes over 20% of the body's energy, it is understandable that deficits in energy metabolisms could be a key pathophysiological aspect of these major psychiatric disorders.This Frontier Research Topic has brought together a group of leading experts in the field to address these critical issues in four reviews, one perspective, one theoretic, and one original article. Three of these articles investigated how, and to what degree, the pathophysiology of psychiatric disorders bidirectionally interacts with metabolic dysfunction. del Campo et al. introduced a novel approach to study the alteration of the mitochondrial dynamics caused by olanzapine in an in silico experiment for revealing interactions between the insulin receptor and olanzapine. Their preliminary data suggested that a mitochondrial fission/fusion ration imbalance and inefficient mitochondrial phenotypes of muscle cells may lead to insulin resistance and hyperglycaemia . Chen et al. extensively reviewed the literature and summarized the findings into three mechanisms for antipsychotic-induced diabetes, in which the cellular signaling pathways responsible for insulin resistance due to the direct effect of antipsychotics (particularly olanzapine and clozapine) or indirectly via antipsychotic-induced obesity were clearly elucidated. Furthermore, it has been found that antipsychotics can also decrease insulin secretion by damaging pancreatic β-cells via direct (mediated by ATP) and indirect  signaling pathways, as well as activating apoptosis pathways, that may also be the mechanisms underlying antipsychotic-induced hyperglycaemic emergency . It has been reported previously that olanzapine and clozapine-induced lipid disturbance via AMP-activated protein kinase (AMPK) pathways .Over the past decade studies from a number of laboratories have largely improved our understanding of the neuropharmacological and neuroendocrinological regulation of antipsychotic-induced weight gain and obesity that have been reviewed previously , suggesting insulin regulation as a possible explanation .Finally, there is a lasting debate on whether antipsychotic-induced weight is a completely negative side-effect, or whether it has some therapeutic benefits in the treatment of psychiatric disorders. To address this issue, Raben et al.). Therefore, early diagnosis and prevention of metabolic dysfunction are important and critical for the management of antipsychotic medication in psychiatric patients. We believe that this Frontier Research Topic will stimulate additional studies to take innovative approaches for further revealing interactive neuropathogenetic mechanisms of psychiatric disorders and metabolic disorders, and to identify novel targets of the pathophysiology of psychiatric disorders with limited metabolic side-effects, while more efforts in the development of pharmacological and non-pharmacological interventions preventing/treating metabolic disorders in psychiatric patients are also important.In summary, studies published in this Research Topic provided a picture of complex bidirectional interactions between the pathophysiology of major psychiatric disorders, metabolic dysfunction, and antipsychotic medication. Deficits in some common signaling pathways  may contribute to both intrinsic and antipsychotic-induced metabolic dysfunction, as well as the pathophysiology of these psychiatric disorders. Although a correlation between antipsychotic-induced weight gain and therapeutic benefit has been reported, current evidence does not support weight gain as necessary for therapeutic benefit (CD drafted the manuscript. During the course of this Research Topic, JY passed away suddenly. JY has made significant contributions to all aspects of this Research Topic, from forming the idea of the Topic proposal to inviting contributing authors and editing 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.


At the present time it is clear that our global healthcare community was not prepared to face the COVID-19 pandemic. Hospitals in the hardest hit areas have been transformed to COVID centres. Surgical societies have recommended postponing non-emergency surgery, and have given recommendations for triaging the ever- growing backlog of patients. However, simply resuming these non-emergency surgeries may lead the healthcare system into a second disaster. If healthcare policymakers around the world do not systematically consider how to resume normal surgical services, hospitals will be quickly overwhelmed, vital resources will be depleted, and patients and providers alike will face an increased exposure risk. This perspective serves to highlight certain aspects of returning to normal that physicians and hospital administrators alike must consider to avoid potential catastrophe. Corona Virus Disease-19 (COVID-19), the illness caused by the novel coronavirus, SARS-CoV-2, has disrupted global healthcare delivery so much so that caring for patients may never be the same. Moreover, global economies are in turmoil – supply chains are frozen, vital resources for both healthcare delivery and everyday life have become dangerously scarce, and unemployment claims are unprecedented, as businesses remain shuttered. As death rates climb, much of our focus, rightfully so, has centred on present-day issues: Are we flattening the curve? How long will vital healthcare resources last? When can we resume our normal lives? However, there remains a largely unaddressed and equally important question: Are we prepared for healthcare delivery after we flatten the curve?It is indisputable that global healthcare systems are poorly prepared to face this pandemic. Retirees are reentering the workforce, ungraduated medical students are being sent to the front lines, and physicians are practicing in areas of medicine outside of their specialty – we are in a crisis . Many heMany surgical societies and the Centers for Disease Control and Prevention have published recommendations to postpone elective surgeries during the COVID-19 pandemic . Those rExisting patients have been rescheduled, and providers are currently adding to their backlog of postponed surgeries via telehealth. The first preparatory step towards optimising hospital capabilities will be to maintain a triaging system for elective surgeries once restrictions are lifted. Such systems need to be implemented to determine the urgency of any given procedure based on the weighted assessment of morbidity associated with continued delay. We cannot know what ramifications our actions will have by perpetuating both benign and malignant diseases. Not all surgeries during the COVID-19 pandemic were cancelled equally; determinations must be made on which procedures can safely be delayed and which cannot.Surgical societies must come together and develop standardised metrics by which surgeons and hospitals can determine how to reschedule procedures. Metrics to be taken into consideration should include the morbidity associated with the primary diagnosis, the projected morbidity caused by the delay, the underlying health of the patient and likelihood of poor perioperative outcomes, the risk of COVID-19 exposure to both patients and healthcare workers, available resources in a geographic location, and the impact of the procedure on those resources. Healthcare resources will be in an extremely vulnerable position, as the reinstatement of elective surgery will not necessarily coincide with the return of normal supply chain function. Hospital inventories must be considered, factoring in potential delays on needed surgical equipment as this wave of demand hits a crippled supply. Surgeons must be prepared to use unfamiliar equipment, circumvent medication shortages, anticipate delays in accessing the operating room, and minimise their strain on their institution. Hospitals may increase operating room access by extending surgical hours during weekdays and consider performing elective procedures on weekends. To ensure the safety of all non-COVID patients and staff, hospital leadership should consider section division within their institution. Hospital systems with more than one location should consider a COVID-19 dedicated facility to keep the other sites COVID-19-free. COVID-19 positive patients will continue to need hospitalisation, and we must keep healthy patients and staff separated from contact with the virus. Separate closed units, operating rooms, hospital entrances, and resource storage should be created so that we work to minimise cross-contamination.Given the asymptomatic carrier profile of the disease, we must ensure the safety of our patients and our providers during this time . PatientNext, we must focus on how to minimise hospital resource utilisation. Surgeons should reduce strain on hospitals by increasing their utilisation of Ambulatory Surgery Centres (ACS) when possible. Outpatient procedures performed in ACS will not affect hospital resources. Ample evidence supports the excellent outcomes following ambulatory surgery. In the United States (US), nearly 50% of outpatient surgical procedures are performed in ACS . This peLastly, we suggest that surgical procedures during this transition period be performed by subspecialty- trained or high-volume surgeons. Data from a large number of publications highlight the improved patient outcomes and lower healthcare resource utilisation when procedures are performed by high-volume minimally invasive surgeons . HoweverRecovering fully from COVID-19 is going to be challenging and will likely require a unified global effort. Full recovery is undoubtedly going to be a slow process, and as we try to return to normality we must minimise the potential for a second wave of disease. We must learn from our mistakes for a stronger recovery, and be better prepared for what lies ahead. We can better position ourselves by creatively triaging our postponed non-emergency surgeries, increasing utilisation of ACS or considering sectioning of hospitals, developing metrics that consider not only surgeon volume but perioperative outcomes, and then funneling the bulk of necessary surgeries to these surgeons. Surgeons must advocate for their institutions, their patients, and themselves. Creative thinking is needed to ensure that we do not come out of one catastrophe only to learn that our actions have created another.