Correction to: Modulation of the cAMP Response by G[Formula: see text] and G[Formula: see text]: A Computational Study of G Protein Signaling in Immune Cells.

The original version of this article unfortunately contained mistakes.

Thresholding methods for lesion segmentation of basal cell carcinoma in dermoscopy images.

PURPOSE: Algorithms employed for pigmented lesion segmentation perform poorly on dermoscopy images of basal cell carcinoma (BCC), the most common skin cancer. The main objective was to develop better methods for BCC segmentation. METHODS: Fifteen thresholding methods were implemented for BCC lesion segmentation. We propose two error metrics that better measure the type II error: Relative XOR Error and Lesion Capture Ratio. RESULTS: On training/test sets of 305 and 34 BCC images, respectively, five new techniques outperform two state-of-the-art methods used in segmentation of melanomas, based on the new error metrics. CONCLUSION: The proposed algorithms, which include solutions for image vignetting correction and border expansion to achieve dermatologist-like borders, provide more inclusive and feature-preserving border detection, favoring better BCC classification accuracy, in future work.

Best cost-effectiveness and worker productivity with initial triple DMARD therapy compared with methotrexate monotherapy in early rheumatoid arthritis: cost-utility analysis of the tREACH trial.

OBJECTIVE: To evaluate direct and indirect costs per quality adjusted life year (QALY) for different initial treatment strategies in very early RA. METHODS: The 1-year data of the treatment in the Rotterdam Early Arthritis Cohort trial were used. Patients with a high probability (>70%) according to their likelihood of progressing to persistent arthritis, based on the prediction model of Visser, were randomized into one of following initial treatment strategies: (A) initial triple DMARD therapy (iTDT) with glucocorticoids (GCs) intramuscular (n = 91); (B) iTDT with an oral GC tapering scheme (n = 93); and (C) initial MTX monotherapy (iMM) with GCs similar to B (n = 97). Data on QALYs, measured with the Dutch EuroQol, and direct and indirect cost were used. Direct costs are costs of treatment and medical consumption, whereas indirect costs are costs due to loss of productivity. RESULTS: Average QALYs (sd) for A, B and C were, respectively, 0.75 (0.12), 0.75 (0.10) and 0.73 (0.13) for Dutch EuroQol. Highest total costs per QALY (sd) were, respectively, €12748 (€18767), €10 380 (€15 608) and €17 408 (€21 828) for strategy A, B and C (P = 0.012, B vs C). Direct as well as indirect costs were higher with iMM (strategy C) compared with iTDT (strategy B). Higher direct costs were due to ∼40% more biologic usage over time. Higher indirect costs, on the other hand, were caused by more long-term sickness and reduction in contract hours. iTDT was >95% cost-effective across all willingness-to-pay thresholds compared with iMM. CONCLUSION: iTDT was more cost-effective and had better worker productivity compared with iMM.

Modelling Ebola within a community.

The 2014 Ebola epidemic was the largest on record. It evidenced the need for improved models of the spread of Ebola. In this research we focus on modelling Ebola within a small village or community. Specifically, we investigate the potential of basic Susceptible-Exposed-Infectious-Recovered (SEIR) models to describe the initial Ebola outbreak, which occurred in Meliandou, Guinea. Data from the World Health Organization is used to compare the accuracy of various models in order to select the most accurate models of transmission and disease-induced responses. Our results suggest that (i) density-dependent transmission and mortality-induced behavioural changes shaped the course of the Ebola epidemic in Meliandou, while (ii) frequency-dependent transmission, disease-induced emigration, and infection-induced behavioural changes are not consistent with the data from this epidemic.

Adaptable texture-based segmentation by variance and intensity for automatic detection of semitranslucent and pink blush areas in basal cell carcinoma.

BACKGROUND: Pink blush is a common feature in basal cell carcinoma (BCC). A related feature, semitranslucency, appears as smooth pink or orange regions resembling skin color. We introduce an automatic method for detection of these features based on smoothness and brightness. We also introduce a neighborhood correction method for texture area correction. METHODS: Smoothness and brightness were analyzed over four bands: luminance, red, green, and blue, then merged using variance-based dynamic thresholding. Dermoscopic images of 100 biopsy-proven BCCs and 254 competitive benign mimics were used to train the algorithm. Sixteen color and texture features were extracted from the automatically detected areas. The confusion matrix for the algorithm showed 15 classification errors in the training set for the 354 images: three errors in the BCC set and 12 errors in the benign set. RESULTS: Logistic regression analysis on a separate 1024-image test set was able to achieve good separation of BCC from benign lesions with an area under the receiver operating characteristic curve (ROC) of 0.878 and 0.877 using manually-created and automatically-generated BCC border masks, respectively. CONCLUSION: This pilot study indicates that automatic detection of semitranslucent and pink blush areas in BCC is feasible using colors and first-order texture statistics.

THE EARLY BIRD CATCHES THE WORM: EARLY COST-EFFECTIVENESS ANALYSIS OF NEW MEDICAL TESTS.

OBJECTIVES: There is little specific guidance on performing an early cost-effectiveness analysis (CEA) of medical tests. We developed a framework with general steps and applied it to two cases. METHODS: Step 1 is to narrow down the scope of analysis by defining the test's application, target population, outcome measures, and investigating current test strategies and test strategies if the new test were available. Step 2 is to collect evidence on the current test strategy. Step 3 is to develop a conceptual model of the current and new test strategies. Step 4 is to conduct the early-CEA by evaluating the potential (cost-)effectiveness of the new test in clinical practice. Step 5 involves a decision about the further development of the test. RESULTS: The first case illustrated the impact of varying the test performance on the headroom (maximum possible price) of an add-on test for patients with an intermediate-risk of having rheumatoid arthritis. Analyses showed that the headroom is particularly dependent on test performance. The second case estimated the minimum performance of a confirmatory imaging test to predict individual stroke risk. Different combinations of sensitivity and specificity were found to be cost-effective; if these combinations are attainable, the medical test developer can feel more confident about the value of further development of the test. CONCLUSIONS: A well-designed early-CEA methodology can improve the ability to develop (cost-)effective medical tests in an efficient manner. Early-CEAs should continuously integrate insights and evidence that arise through feedback, which may convince developers to return to earlier steps.

Real-time supervised detection of pink areas in dermoscopic images of melanoma: importance of color shades, texture and location.

BACKGROUND/PURPOSE: Early detection of malignant melanoma is an important public health challenge. In the USA, dermatologists are seeing more melanomas at an early stage, before classic melanoma features have become apparent. Pink color is a feature of these early melanomas. If rapid and accurate automatic detection of pink color in these melanomas could be accomplished, there could be significant public health benefits. METHODS: Detection of three shades of pink (light pink, dark pink, and orange pink) was accomplished using color analysis techniques in five color planes (red, green, blue, hue, and saturation). Color shade analysis was performed using a logistic regression model trained with an image set of 60 dermoscopic images of melanoma that contained pink areas. Detected pink shade areas were further analyzed with regard to the location within the lesion, average color parameters over the detected areas, and histogram texture features. RESULTS: Logistic regression analysis of a separate set of 128 melanomas and 128 benign images resulted in up to 87.9% accuracy in discriminating melanoma from benign lesions measured using area under the receiver operating characteristic curve. The accuracy in this model decreased when parameters for individual shades, texture, or shade location within the lesion were omitted. CONCLUSION: Texture, color, and lesion location analysis applied to multiple shades of pink can assist in melanoma detection. When any of these three details: color location, shade analysis, or texture analysis were omitted from the model, accuracy in separating melanoma from benign lesions was lowered. Separation of colors into shades and further details that enhance the characterization of these color shades are needed for optimal discrimination of melanoma from benign lesions.

Derivation and experimental comparison of cell-division probability densities.

Experiments have shown that, even in a homogeneous population of cells, the distribution of division times is highly variable. In addition, a homogeneous population of cells will exhibit a heterogeneous response to drug therapy. We present a simple stochastic model of the cell cycle as a multistep stochastic process. The model, which is based on our conception of the cell cycle checkpoint, is used to derive an analytical expression for the distribution of cell cycle times. We demonstrate that this distribution provides an accurate representation of cell cycle time variability and show how the model relates drug-induced changes in basic biological parameters to variability in response to drug treatment.

Modulation of the cAMP response by Gαi and Gßγ: a computational study of G protein signaling in immune cells.

Cyclic AMP is important for the resolution of inflammation, as it promotes anti-inflammatory signaling in several immune cell lines. In this paper, we present an immune cell specific model of the cAMP signaling cascade, paying close attention to the specific isoforms of adenylyl cyclase (AC) and phosphodiesterase that control cAMP production and degradation, respectively, in these cells. The model describes the role that G protein subunits, including Gαs, Gαi, and Gßγ, have in regulating cAMP production. Previously, Gαi activation has been shown to increase the level of cAMP in certain immune cell types. This increase in cAMP is thought to be mediated by ßγ subunits which are released upon Gα activation and can directly stimulate specific isoforms of AC. We conduct numerical experiments in order to explore the mechanisms through which Gαi activation can increase cAMP production. An important conclusion of our analysis is that the relative abundance of different G protein subunits is an essential determinant of the cAMP profile in immune cells. In particular, our model predicts that limited availability of ßγ subunits may both (i) enable immune cells to link inflammatory Gαi signaling to anti-inflammatory cAMP production thereby creating a balanced immune response to stimulation with low concentrations of PGE2, and (ii) prohibit robust anti-inflammatory cAMP signaling in response to stimulation with high concentrations of PGE2.

A model of the innate immune response to SARS-CoV-2 in the alveolar epithelium.

We present a differential equation model of the innate immune response to SARS-CoV-2 within the alveolar epithelium. Critical determinants of the viral dynamics and host response, including type I and type II alveolar epithelial cells, interferons, chemokines, toxins and innate immune cells, are included. We estimate model parameters, compute the within-host basic reproductive number, and study the impacts of therapies, prophylactics, and host/pathogen variability on the course of the infection. Model simulations indicate that the innate immune response suppresses the infection and enables the alveolar epithelium to partially recover. While very robust antiviral therapy controls the infection and enables the epithelium to heal, moderate therapy is of limited benefit. Meanwhile interferon therapy is predicted to reduce viral load but exacerbate tissue damage. The deleterious effects of interferon therapy are especially apparent late in the infection. Individual variation in ACE2 expression, epithelial cell interferon production, and SARS-CoV-2 spike protein binding affinity are predicted to significantly impact prognosis.

Perceived barriers to health care and health behaviours: implications for Native American elders' self-rated health.

Little is known about how Native American adults appraise their health in later life. Perceived barriers to health care and health behaviours were examined among 6813 Native elders to determine their unique associations with self-rated health (SRH). Hierarchical regression results showed inability to access needed medical care predicted poorer SRH. Statistically accounting for sociodemographics and barriers to care, health behaviours predicted SRH. The current findings suggest opportunities to improve Native elders' SRH particularly via exercise and good nutrition. In turn, enhanced SRH may lead to improved quality of life.

What explains the fall in child stunting in Sub-Saharan Africa?

There have been steep falls in rates of child stunting in much of Sub-Saharan Africa (SSA). Using Demographic and Health Survey data, we document significant reductions in stunting in seven SSA countries in the period 2005-2014. For each country, we distinguish potential determinants that move in a direction consistent with having contributed to the reduction in stunting from those that do not. We then decompose the change in stunting and in proximal determinants into a part that can be explained by changes in distal determinants and a residual part that captures the impact of unmeasured factors, such as vertical nutrition programs. We show that increases in coverage of child immunization, deworming medication and maternal iron supplementation often coincide with a fall in stunting. The magnitudes and directions of changes in two other proximal determinants -- age-appropriate feeding and diarrhea prevalence -- suggest that these have not been strong contributors to the fall in stunting. Utilization of maternity care emerges from the decomposition analysis as the most important distal determinant associated with reduced stunting, and also with increased coverage of iron supplementation, and, to a lesser extent, with child immunization and deworming medication. This circumstantial evidence is strong enough to warrant more detailed investigation of the extent to which maternity care is an effective channel through which to target further attacks on the blight of undernourished children.

Progress on catastrophic health spending in 133 countries: a retrospective observational study.

BACKGROUND: The goal of universal health coverage (UHC) requires inter alia that families who get needed health care do not suffer undue financial hardship as a result. This can be measured by the percentage of people in households whose out-of-pocket health expenditures are large relative to their income or consumption. We aimed to estimate the global incidence of catastrophic health spending, trends between 2000 and 2010, and associations between catastrophic health spending and macroeconomic and health system variables at the country level. METHODS: We did a retrospective observational study of health spending using data obtained from household surveys. Of 1566 potentially suitable household surveys, 553 passed quality checks, covering 133 countries between 1984 and 2015. We defined health spending as catastrophic when it exceeded 10% or 25% of household consumption. We estimated global incidence by aggregating up from every country, using a survey for the year in question when available, and interpolation and model-based estimates otherwise. We used multiple regression to explore the relation between a country's incidence of catastrophic spending and gross domestic product (GDP) per person, the Gini coefficient for income inequality, and the share of total health expenditure spent by social security funds, other government agencies, private insurance schemes, and non-profit institutions. FINDINGS: The global incidence of catastrophic spending at the 10% threshold was estimated as 9·7% in 2000, 11·4% in 2005, and 11·7% in 2010. Globally, 808 million people in 2010 incurred catastrophic health spending. Across 94 countries with two or more survey datapoints, the population-weighted median annual rate of change of catastrophic payment incidence was positive whatever catastrophic payment incidence measure was used. Incidence of catastrophic payments was correlated positively with GDP per person and the share of GDP spent on health, and incidence correlated negatively with the share of total health spending channelled through social security funds and other government agencies. INTERPRETATION: The proportion of the population that is supposed to be covered by health insurance schemes or by national or subnational health services is a poor indicator of financial protection. Increasing the share of GDP spent on health is not sufficient to reduce catastrophic payment incidence; rather, what is required is increasing the share of total health expenditure that is prepaid, particularly through taxes and mandatory contributions. FUNDING: Rockefeller Foundation, Ministry of Health of Japan, UK Department for International Development (DFID).

Twenty Years of Progress on Maternal and Child Health in the Philippines: An Equity Lens.

This article assesses trends and inequalities in maternal and child health in the Philippines between 1993 and 2013, using 6 national household surveys, and also compares the Philippines' performance to 15 other Asia-Pacific countries. Thirteen indicators of child health outcomes and maternal and child health interventions are examined. Two measures of inequality are used: the absolute difference between the poorest and wealthiest quintile, and the concentration index. Coverage of all indicators has improved, both on average and among the poorest quintile; however, increases are very small for child health interventions (especially immunization coverage). By the first measure of inequality, all indicators show narrowing inequalities. By the second measure, inequality has fallen only for maternal health interventions. Compared with other 15 other developing Asia-Pacific countries, the Philippines performs among the best on the child health outcomes examined and above average on maternal health interventions (except family planning), but only at or below average on child health interventions.

Financial protection from health spending in the Philippines: policies and progress.

The objective of this article is to assess the progress of the Philippines health sector in providing financial protection to the population, as measured by estimates of health insurance coverage, out-of-pocket spending, catastrophic payments and impoverishing health expenditures. Data are drawn from eight household surveys between 2000 and 2013, including two Demographic and Health Surveys, one Family Health Survey and five Family Income and Expenditure Surveys. We find that out-of-pocket spending increased by 150% (real) from 2000 to 2012, with the sharpest increases occurring in recent years. The main driver of health spending is medicines, accounting for almost two-thirds of total health spending, and as much as three-quarters among the poor. The incidence of catastrophic payments has tripled since 2000, from 2.5% to 7.7%. The percentage of people impoverished by health spending has also increased and, in 2012, out-of-pocket spending on health added 1.5 percentage points to the poverty rate, pushing more than 1.5 million people into poverty. In light of these findings, recent policies to enhance financial risk protection-such as the expansion of government-subsidized health insurance from the poor to the near-poor, a policy of zero copayments for the poor, a deepening of the benefit package and provider payment reform aimed at cost-containment-are to be commended. Indeed, between 2008 and 2013, self-reported health insurance coverage increased across all quintiles and its distribution became more pro-poor. To speed progress toward financial protection goals, quick wins could include issuing health insurance cards to the poor to increase awareness of coverage and limiting out-of-pocket spending by clearly defining a clear copayment structure for non-poor members. An in-depth analysis of the pharmaceutical sector would help to shed light on why medicines impose such a large financial burden on households.

Clinical Practice Variation Needs to be Considered in Cost-Effectiveness Analyses: A Case Study of Patients with a Recent Transient Ischemic Attack or Minor Ischemic Stroke.

BACKGROUND AND OBJECTIVE: The cost-effectiveness of clinical interventions is often assessed using current care as the comparator, with national guidelines as a proxy. However, this comparison is inadequate when clinical practice differs from guidelines, or when clinical practice differs between hospitals. We examined the degree of variation in the way patients with a recent transient ischemic attack (TIA) or minor ischemic stroke are assessed and used the results to illustrate the importance of investigating possible clinical practice variation, and the need to perform hospital-level cost-effectiveness analyses (CEAs) when variation exists. METHODS: Semi-structured interviews were conducted with 16 vascular neurologists in hospitals throughout the Netherlands. Questions were asked about the use of initial and confirmatory diagnostic imaging tests to assess carotid stenosis in patients with a recent TIA or minor ischemic stroke, criteria to perform confirmatory tests, and criteria for treatment. We also performed hospital-level CEAs to illustrate the consequences of the observed diagnostic strategies in which the diagnostic test costs, sensitivity and specified were varied according to the local hospital conditions. RESULTS: 56 % (9/16) of the emergency units and 63 % (10/16) of the outpatient clinics use the initial and confirmatory diagnostic tests to assess carotid stenosis in accordance with the national guidelines. Of the hospitals studied, only one uses the recommended criteria for use of a confirmatory test, 38 % (6/16) follow the guidelines for treatment. The most cost-effective diagnostic test strategy differs between hospitals. CONCLUSIONS: If important practice variation exists, hospital-level CEAs should be performed. These CEAs should include an assessment of the feasibility and costs of switching to a different strategy.

Cost-Effectiveness Model for Evaluating New Diagnostic Tests in the Evaluation of Patients With Inflammatory Arthritis at Risk of Having Rheumatoid Arthritis.

OBJECTIVE: New opportunities have emerged for early diagnosis with the arrival of new technologies that assess the impact of genomics, proteomics, metabolomics, and cytomics on rheumatoid arthritis (RA) risk. This early health technology assessment study assesses the short-term cost effectiveness of 4 add-on diagnostic tests in early inflammatory arthritis patients at risk of RA. METHODS: We modeled 4 diagnostic add-on tests to the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria, covering the first year after diagnosis, using Rotterdam Early Arthritis Cohort data. Sensitivity, specificity, and costs were assigned to the magnetic resonance imaging of hands and feet (sensitivity 0.90, specificity 0.60, cost €756), interleukin-6 (IL-6) serum level test (sensitivity 0.70, specificity 0.53, cost €50), B cell-related gene expression (sensitivity 0.60, specificity 0.90, cost €150), and gene assay for RA (sensitivity 0.40, specificity 0.85, cost €750), based on literature and expert opinion. Outcomes were evaluated using the unweighted diagnostic net benefit (UDNB) and the incremental cost-effectiveness ratio (ICER) in all patients (n = 552), intermediate-risk patients (n = 263), and seronegative patients (n = 329). RESULTS: The highest UDNB was found when using the B cell assay in intermediate-risk patients (43%, ICER €5,314), while the IL-6 test in seronegative patients resulted in the lowest UDNB (-11.4%, ICER €7,650). If a threshold of €20,000 is applied, the B cell assay would be preferred over the other alternatives, with a 78% probability of being cost effective for intermediate-risk patients, 57% for all patients, and 73% for seronegative patients. CONCLUSION: Diagnostic add-on tests favoring specificity over sensitivity with a headroom less than €370 per test are cost effective, with the largest diagnostic benefit occurring in intermediate-risk patients.

A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis.

BACKGROUND: There is a lack of information about the sensitivity, specificity and costs new diagnostic tests should have to improve early diagnosis of rheumatoid arthritis (RA). Our objective was to explore the early cost-effectiveness of various new diagnostic test strategies in the workup of patients with inflammatory arthritis (IA) at risk of having RA. METHODS: A decision tree followed by a patient-level state transition model, using data from published literature, cohorts and trials, was used to evaluate diagnostic test strategies. Alternative tests were assessed as add-on to or replacement of the ACR/EULAR 2010 RA classification criteria for all patients and for intermediate-risk patients. Tests included B-cell gene expression (sensitivity 0.60, specificity 0.90, costs €150), MRI (sensitivity 0.90, specificity 0.60, costs €756), IL-6 serum level (sensitivity 0.70, specificity 0.53, costs €50) and genetic assay (sensitivity 0.40, specificity 0.85, costs €750). Patients with IA at risk of RA were followed for 5 years using a societal perspective. Guideline treatment was assumed using tight controlled treatment based on DAS28; if patients had a DAS28 >3.2 at 12 months or later patients could be eligible for starting biological drugs. The outcome was expressed in incremental cost-effectiveness ratios (€2014 per quality-adjusted life year (QALY) gained) and headroom. RESULTS: The B-cell test was the least expensive strategy when used as an add-on and as replacement in intermediate-risk patients, making it the dominant strategy, as it has better health outcomes and lower costs. As add-on for all patients, the B-cell test was also the most cost-effective test strategy. When using a willingness-to-pay threshold of €20,000 per QALY gained, the IL-6 and MRI strategies were not cost-effective, except as replacement. A genetic assay was not cost-effective in any strategy. Probabilistic sensitivity analysis revealed that the B-cell test was consistently superior in all strategies. When performing univariate sensitivity analysis for intermediate-risk patients, specificity and DAS28 in the B-cell add-on strategy, and DAS28 and sensitivity in the MRI add-on strategy had the largest impact on the cost-effectiveness. CONCLUSIONS: This early cost-effectiveness analysis indicated that new tests to diagnose RA are most likely to be cost-effective when the tests are used as an add-on in intermediate-risk patients, and have high specificity, and the test costs should not be higher than €200-€300.

Hospital costs of ischemic stroke and TIA in the Netherlands.

OBJECTIVES: There have been no ischemic stroke costing studies since major improvements were implemented in stroke care. We therefore determined hospital resource use and costs of ischemic stroke and TIA in the Netherlands for 2012. METHODS: We conducted a retrospective cost analysis using individual patient data from a national diagnosis-related group registry. We analyzed 4 subgroups: inpatient ischemic stroke, inpatient TIA, outpatient ischemic stroke, and outpatient TIA. Costs of carotid endarterectomy and costs of an extra follow-up visit were also estimated. Unit costs were based on reference prices from the Dutch Healthcare Insurance Board and tariffs provided by the Dutch Healthcare Authority. Linear regression analysis was used to examine the association between hospital costs and various patient and hospital characteristics. RESULTS: A total of 35,903 ischemic stroke and 21,653 TIA patients were included. Inpatient costs were €5,328 ($6,845) for ischemic stroke and €2,470 ($3,173) for TIA. Outpatient costs were €495 ($636) for ischemic stroke and €587 ($754) for TIA. Costs of carotid endarterectomy were €6,836 ($8,783). Costs of inpatient days were the largest contributor to hospital costs. Age, hospital type, and region were strongly associated with hospital costs. CONCLUSIONS: Hospital costs are higher for inpatients and ischemic strokes compared with outpatients and TIAs, with length of stay (LOS) the most important contributor. LOS and hospital costs have substantially declined over the last 10 years, possibly due to improved hospital stroke care and efficient integrated stroke services.

Persistent inequalities in child undernutrition: evidence from 80 countries, from 1990 to today.

BACKGROUND: Global progress in reducing the burden of undernutrition tends to be measured at the population level. It has been hypothesized that population-level improvements may mask widening socioeconomic inequalities, but little attempt has been made to assess whether this is true. METHODS: Original data from 131 demographic health surveys and 48 multiple indicator cluster surveys from 1990 to 2011 were used to examine trends in socioeconomic inequalities in stunting and underweight, as well as the relationship between changes in prevalence and changes in inequality, in 80 countries. Socioeconomic inequality is measured using the corrected concentration index. RESULTS: Countries with a higher prevalence of stunting tend to have larger socioeconomic inequalities in stunting (Spearman rank correlation = -0.27 P = 0.014). In most countries, there has been no change in inequality in stunting: in 31 out of 53, the 90% confidence intervals around the changes overlap the zero value. In the remaining 22, there was a reduction in inequality in 11 and an increase in 11. The distributional patterns underlying the summary inequality statistics vary considerably across countries, but in most there have been considerable gains to the poorest quintile. CONCLUSIONS: Reductions in the prevalence of undernutrition have generally not been accompanied by widening inequalities. However, inequalities have also not been narrowing. Rather, the picture is one of a strong persistence of existing inequalities. In addition, there are different distributional patterns underlying changes in the summary indices of inequality which will need to be taken into consideration in designing programmes to reach the poor.