One of the most critical practices in mass casualty incident management is vacating the victims from scene of the incident and transporting them to proper healthcare facilities. Decision on distribution of casualties needs to be taken on pre-developed policies and structured decision support mechanisms. While many studies tried to present models for the distribution of casualties, no systematic review has yet been conducted to evaluate the existing models on casualty distribution following mass casualty incidents. A systematic review is therefore needed to examine the existing models of patient distribution and to provide a summary of the models. This systematic review protocol is aimed to examine the existing models and extracting rules and principles of mass casualty distribution.This study will comprehensively investigate existing papers with search phrases and terms including “mass casualty incident”, distribution, evacuation, and Mesh terms directly corresponding to search phrases. No limitations on the type of studies, date of publication, or language of the relevant documents will be imposed. PubMed, Web of Science, Scopus, and Google Scholar will be searched to access the relevant documents. Included papers will be critically appraised by two independent reviewers. The data including incidents type, scene characteristics, patient features, pre-hospital resources, and hospital resources will be categorized. Subgroup analysis will be conducted when possible.To the best of our knowledge, no study has yet addressed the effects and interaction of contributing factors on the decision-making processes for casualty’s distribution. This is the first study that comprehensively assesses and critically appraises the current models of casualty distribution. This study will provide evidences about models and criteria for casualty distribution following mass casualty incidents.CRD42016049115PROSPERO Registration Number: The online version of this article (doi:10.1186/s13643-017-0538-z) contains supplementary material, which is available to authorized users. The World Health Organization (WHO) defines a mass casualty incident as “an event which generates more patients at one time than locally available resources can manage using routine procedures” . The chaThe numerous definitions available for a mass casualty incident indicate an environment of limited resources that further challenges the management of such incidents . In massEvacuating the wounded from the scene of a mass casualty incident and transferring them to proper healthcare centers is a highly critical task , 7. To aThe decision about the distribution of patients among different hospitals is normally taken by the incident commander based on the availability of resources, details of the incident, and the triage data . The comResearch into real-time decision-making processes in dynamic situations suggests that most of these decisions are made based on previous experiences. With a greater experience of managing mass casualty incidents comes better decision-making in stressful conditions. Nonetheless, mass casualty incidents are a rare occurrence, and few emergency managers may face these incidents at a large scale during their career . ManaginStudies on the distribution of patients following mass casualty incidents suggest the need for policy-based decision instead of relying on the emergency managers’ experience and skills , 4, 6. GCompared to the other daily experiences of disaster managers and hospital staff, mass casualty incidents are relatively rare occurrences. Models provide a proper means of describing the effects of selecting different approaches and available resources. Models might help managers to identify deficiencies in the management of mass casualty incidents, which most of these deficiencies are not clear prior to the actual incident and during routine performances . AlthougInvestigating the criteria for casualty distribution in trauma-related mass casualty incidentsReviewing the existing models of casualty distribution in trauma-related mass casualty incidentsThe primary objectives of this systematic review include:Determining the criteria for patient distribution in trauma-related mass casualty incidents based on scene characteristics, patient features, pre-hospital, and hospital resources.Assessing the models and criteria for patient distribution in trauma-related mass casualty incidents by type of incident Assessing the models and criteria for patient distribution in trauma-related mass casualty incidents by method of model assessment The secondary objectives of this study include:This systematic review will be conducted using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015  OR  OR  OR  OR  OR  OR  OR  OR ))) AND ((distribut* OR evacuat*)) OR ALL OR ALL OR ALL OR ALL OR ALL OR ALL OR ALL OR ALL) AND (ALL(distribut*) OR ALL(evacuat*)) OR TS =  OR TS =  OR TS =  OR TS =  OR TS =  OR TS =  OR TS =  OR TS = ) AND (TS = (distribut*) OR TS = (evacuat*))The reviewers will briefly investigate the documents to identify relevant papers based on title and abstract. The results screened by title and abstract are entered into the EndNote and duplicates will be removed. Following determining the relevant papers, two well-informed reviewers about the study background will use the study’s eligibility criteria to examine the full-texts of any potentially pertinent studies identified so far. Any disagreement between the two reviewers is resolved through a group discussion and consensus. A third reviewer is asked for assistance in the case of an unresolved disagreement. To find other potentially relevant documents, the references of the extracted articles will also be examined. The corresponding authors of the articles included in the study will also be asked to introduce any studies which they know that are completed or still in progress and meet the eligibility criteria of the present research. Using the remarks made by specialists of this field, key journals of the field will also be identified and manually reviewed to find relevant papers published over a 10-year period. In addition to the above-mentioned items, textbooks introducing rules and principles will be reviewed to identify relevant documents.After completing the process of searching literature, data extractors will be given access to the full text of the studies. Each data extractor will extract the original data independently based on a pre-developed form. The study variables to be extracted include the country which the study is originated, the department conducted the study, the type and method of the study, the principles and rules of patient distribution regarding to scene characteristics, patient features, pre-hospital resources, and hospital resources.Given the lack of restrictions on the type of initial studies selected, no specific tools for quality assessment can be introduced in this step. To evaluate the methodological quality of the initial studies, however, quality assessment tools introduced in STROBE will be used depending on the type of the study. In this step, every study is presented along with its proper assessment tool to the two independent reviewers. Any disagreement between the reviewers about the quality of the study will be resolved by consensus; otherwise, a third reviewer will be asked for advice on the quality of the article.The corresponding author of included papers will be contacted by email and requested to get data, if failing to extract any of the intended data from the full text of the articles. The study will be excluded from the research if the missing data cannot be retrieved.The present study explores the existing criteria and models for the distribution of casualties and extracts model components. If possible, a subgroup analysis is conducted using the existing models and based on the casualty distribution method. If the outcomes of the model application have been reported, a comparison will be made. The components extracted from all the models will be classified in terms of incidents type, scene characteristics, patient features, pre-hospital resources, and hospital resources.The study has ethical approval from Institute Review Board of Tehran University of Medical Sciences with the registration Number IR.TUMS.SPH.REC.1395.509.Studies have shown that the management of patient distribution among healthcare centers is not a simple but rather challenging practice , 12, as Regarding to application of the models for casualty distribution following mass casualty incidents, above-mentioned criteria have long been considered important in the management of mass casualty incidents. However, no single model has yet addressed the effects and interaction of these factors on the general decision-making processes. Researchers therefore need to examine and analyze the different factors affecting patient distribution following mass casualty incidents in order to develop and test practical models for this purpose.The present study is a first step in developing a comprehensive model of casualty distribution following mass casualty incidents. Given the comprehensiveness of the methodology of the study and since it encompasses all the studies conducted on the subject of casualty distribution, it can be used in developing a practical model for the better management of mass casualty incidents.


We describe an unusual case of miliary tuberculous epididymo-orchitis following a BCG-therapy, mimicking malignancy at initial presentation. Genitourinary tuberculosis in a miliary pattern is rare and this case report emphasizes the importance of meticulous analysis of the patient’s clinical history combined with imaging findings in order to ensure an adequate diagnosis and treatment. In the literature, only a few cases of tuberculous epididymo-orchitis, as complication of intravesical Bacillus Calmette-Guérin (BCG) therapy for urothelial cancer of the bladder, are reported. The radiological appearance of tuberculous epididymo-orchitis can be difficult given similarity to testicular tumour, testicular torsion, bacterial epididymo-orchitis or sarcoïdosis .We describe a rare case with a characteristic appearance of tuberculous epididymo-orchitis in a miliary pattern which should alert the radiologist. This case report emphasizes the importance of meticulous analysis of the patient’s clinical history combined with imaging findings to ensure an adequate diagnosis and treatment.A 71-year-old Caucasian man presented to the emergency room complaining of left testicular swelling and tenderness for two weeks. The patient was afebrile and did not complain of any urinary symptoms. Past medical history was relevant: the patient had been diagnosed three years earlier with grade three papillary transitional cell carcinoma without involvement of the lamina propria and which had been treated by transurethral resection of the bladder tumour. After three years, he had a recurrence for which he had another resection and a treatment of intravesical instillation of Bacillus Calmette-Guérin. His last instillation was performed a month before his visit to the emergency department. Laboratory investigations revealed a slight elevated C-reactive protein  and A-FP . The rest of blood and urine examinations were unremarkable.Color Doppler ultrasound of the scrotum performed the day of the visit by a junior resident showed a heterogenous hypoechoic and hypervascularized enlargement of the left epididymis, a round, hypoechoic, hypovascularized area involving the hilum Figure  and multMycobacterium tuberculosis is rare, occurring in about 7% of patients [In the usual tuberculous infection, scrotal infection with patients  althoughpatients .In our case, the presence of miliary nodularity of the testis and the lack of response to conventional antibiotics should suggest the possible diagnosis of tuberculous epididymo-orchitis. Different echographic patterns have been described for tuberculous epididymitis and orchitis 3 includiIn a patient presenting with scrotal swelling, the US detection of miliary nodularity of the testis should alert the radiologist to the possible diagnosis of tuberculous epididymo-orchitis and consider Mycobacterium tuberculosis as the cause of epididymo-orchitis predominately after a BCG therapy and especially if there is no response to conventional antibiotic treatment.


Polydiacetylene (PDA) inserted in films or in vesicles has received increasing attention due to its property to undergo a blue-to-red colorimetric transition along with a change from non-fluorescent to fluorescent upon application of various stimuli. In this review paper, the principle for the detection of various microorganisms  and of antibacterial and antiviral peptides based on these responsive PDA vesicles are detailed. The analytical performances obtained, when vesicles are in suspension or immobilized, are given and compared to those of the responsive vesicles mainly based on the vesicle encapsulation method. Many future challenges are then discussed. The demand for new sensing technologies that can serve as alerts for bacterial contamination has significantly increased in recent years because of incidents of food poisoning, bioterrorism alerts, and anthrax scares. Numerous technologies for bacterial detection have been developed . NeverthPolydiacetylene (PDA) has attracted significant scientific and technological interest in recent years because of its unique chromatic properties. Specifically, PDA has been shown to self-assemble into organized vesicles and films, forming an ene-yne conjugated framework that absorbs light in the visible region of the electromagnetic spectrum and consequently appears intensely blue . FurtherSynthetic vesicles or liposomes based on phospholipids mixed with polyacetylene have been extensively used for mimicking cell membranes . For thiReviews of synthetic vesicles are mainly focused on vesicle encapsulation methods that enhance the sensitivity of sandwich immunoassays ,5. This Synthetic or natural surfactants that can self-assemble as bilayers are the elementary molecules of vesicles or liposomes. The most common surfactants forming liposomes are phospholipids, the surface-active compound present in cell membranes; liposomes can then mimic biological membranes . The strThe PDA vesicles are all unilamellar vesicles composed of one spherical mixed bilayer encapsulating probes or not. The general procedure for their preparation is summarized as follows: A mixture of phospholipids and diacetylenic acid is completely dissolved in chloroform , which iThe study of the influence of the UV doses on the stability of vesicles has shown that a higher degree of PDA polymerization improves their overall stability . MoreoveSize-controlled fabrication of supramolecular vesicles using a microfluidic chip has been described . The meaOne of the more fascinating aspects of polydiacetylene chemistry is the color and chromism of the materials. The energy of electronic excitations, and therefore the color of the material, can be dependent upon many factors such as the original packing state of the monomers and the exposure of the polymeric material to environmental perturbations such as heat (thermochromism), mechanical stress (mechanochromism) or solvent (solvatochromism). The blue-to-red transition is associated with a conformational change of the PDA backbone from planar to non-planar and then more conjugated, the side chains being more ordered in the red phase. The color transitions of the polymerized vesicles are monitored by visible absorption spectroscopy: 620–640 nm (PDA blue form) and 490–540 nm (PDA red form) .The format of the colorimetric/fluorescence assay can be as that of a multiwell plate when vesicles are free in solution . To minOf the many physicochemical characterization methods used thus far, light scattering and microscopy methods provide the clearest information regarding the morphology of vesicles.Dynamic light scattering (DLS) measurements allow the diffusion coefficient of the vesicles in the liquid suspension to be determined. This diffusion coefficient is converted into a mean diameter using the Stokes–Einstein relationship under the hypothesis that vesicles are spherical in shape. This assumption can be unsuitable when vesicles are flexible and their shape strongly fluctuates; this is the cases of large unilamellar vesicles. DLS does not allow the user to infer the shape or discriminate between unilamellar and multilamellar vesicles, nor does it allow detection of pores or holes through the lipid bilayer, nor discrimination between closed bilayer (vesicles) and fragments of bilayers (bicelles). DLS provides quite satisfactory data in the case of vesicles smaller than 1 µm. Nanoparticle tracking analysis (NTA), where the trajectories of individual scattering objects are observed under a microscope and their displacement is related to each object’s size, is considered the gold standard technique for PDA vesicle characterization. Both techniques are influenced by shape in the same manner.Transmission electron microscopy (TEM) provides high resolution pictures of the vesicles, allowing the discrimination of unilamellar and multilamellar vesicles, and possibly the thicknesses of the lipid bilayers and the water layers in between them (in the case of multilamellar vesicles). Classical TEM requires the samples to be dried before observation, so drying is not expected to change the organization, and the images should reveal the structure present in the aqueous suspension. It is often useful to enhance the contrast using heavy metal staining agents such as uranyl acetate. Again, it is hoped that staining will not disturb the structure. Either cryo-TEM or TEM of a replica prepared by the freeze-fracture technique allows more reliable observations of the structure prevailing in the liquid suspension. An example of such images of large unilamellar and multilamellar giant vesicles, made of bilayers of synthetic double chain zwitterionic surfactants , is giveThe colloidal stability of PDA vesicles requires strong enough repulsions between them to prevent coagulation. Quite strong electrostatic repulsions come from the presence of the anionic carboxylic groups as heads of PDA chains. Electrostatic effects can be assessed by electrophoretic measurements of the zeta potential. Since most charged species are salts of weak acids, it is wise to measure the zeta potential as a function of pH and determine the isoelectric point. Efficient electrostatic stabilization requires the pH to be shifted by at least one or two units from the isoelectric point.The most interesting formulations of lipid components on the organization of lipid membranes could also be investigated by compression in a Langmuir trough. The pressure-area isotherms of mixed monolayers including the same lipid components are registered, giving information on the overall lipid compaction. The elasticity of a PDA mixed Langmuir film was studied in Ref. .Atomic force microscopy  and Tota(1)Biomimetic PDA vesicles, PDA being used as a transducer for biological sensing, have been used as useful platforms for analysis and rapid screening of biomolecular recognition events . Conjuga(2)Other types of responsive vesicles are based on the vesicle encapsulation method: fluorescent dye or redox species being encapsulated in the vesicle. These assays were mainly for the detection of species presenting pore-forming functions such as bacterial toxins or antibacterial substances .Two main transducing principles are implemented in responsive biomimetic vesicles:An example of fluorescent vesicle-based biosensor for organophosphorous pesticides (OP) detection was developed by encapsulating the enzyme acetylcholine esterase and the pyranine fluorescent indicator in an egg phosphatidylcholine liposome. The enzyme substrate passes through porine channels and induces a decrease of pyranine fluorescence signal by decreasing the local pH. When the enzyme is incubated with OP, its activity decreases, inducing an increase of the fluorescence signal in the presence of the same concentration of substrate . AnotherThe published papers dealing with the direct detection of bacteria that use mixed PDA vesicles are based on optical detection: colorimetric detection due to blue–red transition of PDA under mechanical stress or fluorescence detection in the presence of a fluorophore grafted on a diacetylenic acid chain . The int(1)either inserted in the bilayer membrane: long chain glucoside ,26,28 an(2)or grafted on the diacetylenic acid chain: antibody  and apta4 CFU/mL of E. coli) ..47].Assays providing rapid, easy evaluation of the interactions between antimicrobial substances and PDA bilayer-based vesicles as the cell membrane model could significantly improve screening of substances with effective microbial properties, as well as contribute to the elucidation of their structural and functional properties.Porphyridium cruentum strain 1380.1/PDA vesicles were tested for the colorimetric detection of melittin and of polymixin B [Due to their optical properties, polydiacetylene based vesicles were generally used for the design of these assays . The firymixin B . When thPhospholipid vesicles inserting highly fluorescent dye allowed the very sensitive detection of alamethicin, an antibiotic peptide .sn-glycero-3-phosphoethanolamine (DMPE)/10,12-tricosadiynoic acid (TRCDA) vesicles treated with 50 µL cell-free supernatant of 54 lactic acid bacteria strains.The antimicrobial properties of metabolites of soil microfungi were tested through a colorimetric assay using PDA-based vesicles . This asIt appears that for lactic acid bacteria strains LV39 (well 34), LB52 (well 40) and LB64 (well 47) the colour change is weak, compared to that of the other strains. These strains were considered to be bacteriocin non-producers and some of the other strains with a colorimetric response higher than 50%, as bacteriocin producers.PDA based liposome arrays for antibiotic detection, with PIP2 phospholipids as neomycin receptors, were schematized .7 virus particles was obtained through colorimetric measurements. The same strategy was also proposed in Ref. [PDA vesicle-based assays were developed mainly for the detection of influenza viruses cf . Influen in Ref. ,57,58: s in Ref. ,60 and p in Ref. . This review presents the state-of-the-art of mixed PDA based vesicles formulated to mimic cell membranes and how they constitute actual nanosensors for the direct detection of bacteria or viruses, of bacterial toxins  and of antibacterial and antiviral peptides, through direct blue–red transition or through the passive release of encapsulated probes. The colorimetric assays based on these PDA based vesicles are very cheap and easy to handle. They have been applied to the high throughput screening of toxins of natural origin (fungi  and bactHowever, there are still important bottlenecks that limit the development of PDA vesicle-based bioassays. In aqueous solution, the sensitivity of PDA vesicles is usually unsatisfactory for the main applications in medical diagnostic and food safety. To increase the color change, a high concentration of analyte is required. The reversibility of PDA vesicle-based bioassays is also attractive to obtain a reusable sensor. Reversible responses can only be achieved by heating, pH change or UV light and no PDA sensors for biochemical analytes are actually reversible. Rigorous theoretical studies and simulations of the important transitions, leading to the color change are required to develop a clearer understanding of their origin. Improvement of stability under various conditions is a major concern, particularly rehydration efficiency to enable dry sensor forms to be developed that would be a necessary step towards the potential commercialization of point of care systems based on microarrays of PDA vesicles. Some cryoprotectants could be used for this purpose .The ultimate solution to all these issues will enable the development of highly sensitive PDA vesicle-based biochips for the commercialization of convenient rapid tests, such as points-of-care for medical diagnostics, intelligent wound dressing or colorimetric tests for food safety.


The expression measurements of thousands of genes are correlated with the proportions of tumor epithelial cell (PTEC) in clinical samples. Thus, for a tumor diagnostic or prognostic signature based on a summarization of expression levels of the signature genes, the risk score for a patient may dependent on the tumor tissues sampled from different tumor sites with diverse PTEC for the same patient. Here, we proposed that the within-samples relative expression orderings (REOs) based gene pairs signatures should be insensitive to PTEC variations. Firstly, by analysis of paired tumor epithelial cell and stromal cell microdissected samples from 27 cancer patients, we showed that above 80% of gene pairs had consistent REOs between the two cells, indicating these REOs would be independent of PTEC in cancer tissues. Then, by simulating tumor tissues with different PTEC using each of the 27 paired samples, we showed that about 90% REOs of gene pairs in tumor epithelial cells were maintained in tumor samples even when PTEC decreased to 30%. Especially, the REOs of gene pairs with larger expression differences in tumor epithelial cells tend to be more robust against PTEC variations. Finally, as a case study, we developed a gene pair signature which could robustly distinguish colorectal cancer tissues with various PTEC from normal tissues. We concluded that the REOs-based signatures were robust against PTEC variations. Based on gene expression profiles of clinical tumor tissues, many transcriptional signatures for cancer diagnoses  and progSeveral approaches have been proposed to reduce the influence of the PTEC in tumor tissues, including sampling with quality control, using the laser capture microdissection (LCM) technology to isolate pure tumor epithelial cells and using the deconvolution algorithm to estimate gene expression profiles of tumor epithelial cells from bulk tumor tissues. However, all these approaches have critical limitations. For sampling with quality control, the requirement of at least 60%  or 70% , 11 of tIn general, experimental batch effects make a major barrier to the application of the type of prognostic signatures based on risk scores summarized from the expression level measurements of signature genes. Especially, current data normalization algorithms for adjusting batch effects will introduce substantial uncertainty for the prognostic prediction of patients  and the In this article, considering that tumor stromal cells and tumor epithelial cells show a mass of similar differential REOs of gene pairs in comparison with their normal controls , we suppUsing 278 colon cancer samples with PTEC data from TCGA, we found the expression measurements of 2271 genes see  were sigP-value<2.2×10−16, see Materials and Methods). We did the same analysis using the nine paired profiles of the tumor epithelial cell and stromal cell of invasive breast cancer from the GSE14548 dataset. The result showed that, among the 4288 DEGs between the tumor epithelial cells and stromal cells , the expression measurements of 567 genes were also correlated with PTEC  and the concordance score of positive correlations with up-regulations and negative correlations with down-regulations was 94.53% . Similarly, we also detected 8728 DEGs  between the 10 paired profiles of epithelial cells and tumor stromal cells for triple negative breast tumor from the GSE81838 dataset  and median [Rij(T)] represent the medians of absolute rank differences of the gene pair  in all normal samples and all tumor samples, respectively. Then, we calculated the arithmetic mean of the median [Rij(N)] and the median [Rij(T)] to evaluate the reversal degree of the gene pair. The larger this arithmetic mean, the larger the reversal degree of the REO for the two genes between the disease and normal tissues.Let median [Finally, among all the reversal gene pairs, the gene pair with the largest arithmetic mean of the absolute rank differences in normal and cancer samples was selected as the signature. For a given sample, if the REO of the signature gene pair in the sample is the same with the REO pattern of the normal training samples, the samples was identified as the normal tissue; otherwise, the tumor sample.


Cardiac magnetic resonance imaging (MRI) is now routinely being used for the evaluation of the function and structure of the cardiovascular system. Chamber segmentation from cardiac MRI datasets is an essential step for the computation of clinical indices such as ventricular volume, ejection fraction, mass and wall thickness as well as analysis of wall motion abnormality.Manual delineation by experts is currently the standard clinical practice for performing chamber segmentation. However, manual segmentation is tedious, time consuming and prone to intra- and inter-observer variability. Therefore, it is necessary to reproducibly automate this task to accelerate and facilitate the process of diagnosis and follow-up.Due to the several technical difficulties, automatic chamber segmentation from cardiac MRI dataset is still a challenging problem. Current automated techniques suffer from poor robustness and accuracy and require large training datasets and user interaction.In this study we developed and evaluated an accurate, fast and robust method for the fully automatic segmentation of the right ventricle (RV) and the left ventricle (LV) from cardiac MRI datasets. We tackled the complex problem of RV/LV segmentation by mimicking the function of human brain using deep learning. Deep learning is a branch of machine learning that aims to learn abstract concepts from high-dimensional data using multiple-layer computational models. Our method is composed of three stages Figure . First, Good agreement with the ground truth was obtained. Quantitative results for RV segmentations are summarized in Table Chamber segmentation from MRI datasets can be fully automated using our deep learning approach. The proposed method outperforms the state-of-the-art methods in terms of accuracy, robustness and computational time. The high correlation between the automatic and manual references shows the accuracy and clinical applicability of the proposed framework for automatic evaluation of the heart function.


In China’s industrialization process, the effective regulation of energy and environment can promote the positive externality of energy consumption while reducing negative externality, which is an important means for realizing the sustainable development of an economic society. The study puts forward an improved technique for order preference by similarity to an ideal solution based on entropy weight and Mahalanobis distance (briefly referred as E-M-TOPSIS). The performance of the approach was verified to be satisfactory. By separately using traditional and improved TOPSIS methods, the study carried out the empirical appraisals on the external performance of China’s energy regulation during 1999~2015. The results show that the correlation between the performance indexes causes the significant difference between the appraisal results of E-M-TOPSIS and traditional TOPSIS. The E-M-TOPSIS takes the correlation between indexes into account and generally softens the closeness degree compared with traditional TOPSIS. Moreover, it makes the relative closeness degree fluctuate within a small-amplitude. The results conform to the practical condition of China’s energy regulation and therefore the E-M-TOPSIS is favorably applicable for the external performance appraisal of energy regulation. Additionally, the external economic performance and social responsibility performance  based on the E-M-TOPSIS exhibit significantly different fluctuation trends. The external economic performance dramatically fluctuates with a larger fluctuation amplitude, while the social responsibility performance exhibits a relatively stable interval fluctuation. This indicates that compared to the social responsibility performance, the fluctuation of external economic performance is more sensitive to energy regulation. High-energy consumption, high pollution, and low energy efficiency in China have been more prominent due to various factors including extensive production modes, the absence of energy regulation, and incomplete policy execution. Although energy management practice and the improvement of energy efficiency bring about a significant marginal improvement, numerous energy-intensive enterprises do not carry out effective energy management practices due to diverse reasons such as the lack of a synergistic effect between various stakeholders and having little competitive pressure when conducting the environment-friendly management practices ,2. ThereExtensive previous literatures about energy regulation mainly analyzed influences and methods of energy regulation. Scholars hardly appraise the quality level of global energy industry regulation in terms of the external performance of the energy regulation. Through empirical analysis, Cubbin and Stern pointed out that the quality level of regulation has a significant positive correlation with the productivity per capita and the utilization of productive capacity in an empirical analysis . It indiThe rest of the study is organized as follows: Energy regulation refers to a series of activities aiming to promote the positive externality while reducing and even eliminating the negative externality by implementing the regulation function in energy field. An increasing number of scholars have investigated the influence of energy regulation. For example, Matsumura et al. internalized the negative externality of energy consumptions by introducing the Pigovian tax to further analyze the influence of additional energy regulation on welfare effects . Their rApart from the aforementioned researches on the influence analysis of the energy regulation, specific energy regulation methods have also gradually become a research hotspot. Abrardi and Cambini suggested that an optimal tariff structure is able to drive the regulated public utilities to decrease energy consumption and enhance energy efficiency so as to obtain a low oil price for attracting consumers . Under tAn external performance appraisal of China’s energy regulation is a multi-attribute decision making problem and there are numerous multi-attribute decision making methods ,14. TherAfterwards, the TOPSIS method was integrated within different weighting methods for further utilization. For example, You et al. determined the weights of indexes using the best-worst method (BWM) to establish the BMW-TOPSIS method for appraising the operation performance of power grid enterprises . By combTOPSIS is a widely-used method for solving uncertain multi-attribute decision making problems due to its superiorities including its rational and understandable logic, limited subjective input, and the ability to identify the best alternative quickly and incorporate relative weights of criterion importance ,33,34,35Specifically, it is assumed that there are  follows ,24,25,26A. The standardized decision matrix B. The weighting standardized decision matrix C. The positive . All index data have been subjected to a descriptive statistical analysis and the specific descriptive statistical results are shown in The data are taken from China Stock Market & Accounting Research (CSMAR) database, Wind database, and annual It can be seen that the maximum and minimum of all indexes existed within a reasonable interval and the mean of indexes was far larger than the standard deviation, implying that there was a low dispersion degree of data. Moreover, the probability with the extreme outlier was at a low level. The mean, median, and mode of the dust emission amount per GDP As shown in In 2 emission amount per GDP It can be seen from Moreover, all index data were subjected to the Pearson correlation analysis for testing the correlation between indexes, and the correlation results are shown in 2 emission amount per GDP It can be seen that a common correlation between various performance indexes exists and 71% of correlation coefficients between indexes show significant statistics under 5% of the significant level. Especially, the indexes including output of energy consumption per unit Based on the designed appraisal method for the external performance of energy regulations and selected appraisal indexes, the study evaluates the external performance of China’s energy regulation using the E-M-TOPSIS.Firstly, this study calculated information entropies of various indexes according to Formulas (7) and (8) to further determine the weights of the appraisal indexes by analyzing the information entropies in Formula (9). The various weights are represented as weight vector Afterwards, the decision judgment matrix is established to determine the positive (Finally, the study separately calculated the Mahalanobis distances between It can be speculated from the table that the presence of the correlation between indexes leads to sorting results of the external performance of energy regulations calculated using two different appraisal methods that havei a significant disparity. The E-M-TOPSIS method considering the correlation between the performance indexes concerning external economic and social responsibility exhibits a lower relative closeness degree compared with the E-TOPSIS method due to avoiding the information overlap problem. This also implies that the correlation between indexes cannot be ignorable to some extent. Therefore, due to taking the correlation between various performance indexes into account, the M-TOPSIS method can truly show the external performance characteristic of the energy regulation and reflect the performance level of energy regulation. On this basis, the method can be used for scientific decision-making formulations. As shown in Additionally, by comparing the appraisal results of the E-TOPSIS method and the equivalent-weighting traditional TOPSIS method, it can be seen that determining weights by using information entropy does reflect its reasonable and objective characteristics to some extent. Therefore, the E-M-TOPSIS method is applicable for the external performance appraisal of the energy regulation after solving the correlation problem between indexes and determining weights through information entropy. This exerts a practical significance on the scientific appraisal and decision-making of energy regulation policies.Compared with the traditional TOPSIS method, the E-M-TOPSIS method is more applicable for evaluating the practical condition of the external performance level of China’s energy regulation, which can provide profound policy enlightenment for the management practice of energy regulation.As shown in the fluctuation trend of the relative closeness degree using the E-M-TOPSIS method in Additionally, the weight of the performance index system for external responsibility of energy regulation based on the information entropy can be determined. The output of energy consumption per unit is shown to be the most important index influencing the external performance level of energy regulations, which reflects the utilization degree and output efficiency of energies in economic activities. Therefore, it is also an orientation index affecting the utilization efficiency and intensity of energies. Hence, improving the utilization efficiency of energies and reducing the energy intensity both exert a direct effect on improving and enhancing the external performance level of energy regulation and vice versa.The energy industry exhibits significant positive and negative externalities and the purpose of energy regulation is to promote the positive externality, reducing and even eliminating negative externality by implementing regulations. Appraising the external performance of China energy regulation will provide appraisal indexes and methods for reasonably, effectively, and orderly conducting the energy regulation and has a practical significance to further improving the quality level of energy regulations. The external performance appraisal of China’s energy regulation involves multi-attribute decision making in essence. However, inconsistent with the practical data, existing multi-attribute appraisal methods assume that the sample data are all independent and identically distributed. Therefore, in order to avoid the information overlap resulting from the correlation of indexes, the study evaluated the external performance of China’s energy regulation using the E-M-TOPSIS method. The appraisal results indicate that the presence of the correlation between indexes causes a great difference of appraised external performance levels of China’s energy regulation between the E-M-TOPSIS and traditional TOPSIS method. Compared with the traditional TOPSIS method, the E-M-TOPSIS method that considers the correlation between indexes softens the closeness level overall and causes the closeness to fluctuate within a small-amplitude interval. The appraisal result obtained using the E-M-TOPSIS method is consistent with the practical condition of China’s energy regulation. Moreover, the E-M-TOPSIS method is favorably applicable in the external performance appraisal of energy regulation, which exerts a practical significance to the scientific appraisal and decision making of energy regulation policies.The study appraises and analyzes the performance level of China’s energy regulation from the aspect of external performances. Another important factor influencing the performance level of energy regulation is the fact that the indexes related to the internal performance are not introduced into the performance index appraisal system of this research due to the limits of availability and completeness of data, which will be primarily considered in the appraisal of the performance level of China’s energy regulation in the future.


Myotis genus has been unclear due to the scarcity of laboratory confirmed cases and the challenges encountered in species identification of poorly preserved diagnostic submissions by morphological traits alone. This study has employed a collection of rabid bat specimens collected across Canada over a 25 year period to clearly define the role of particular Myotis species as rabies virus reservoirs. The virus was characterised by partial genome sequencing and host genetic barcoding, used to confirm species assignment of specimens, proved crucial to the identification of certain bat species as disease reservoirs. Several variants were associated with Myotis species limited in their Canadian range to the westernmost province of British Columbia while others were harboured by Myotis species that circulate across much of eastern and central Canada. All of these Myotis-associated viral variants, except for one, clustered as a monophyletic MYCAN clade, which has emerged from a lineage more broadly distributed across North America; in contrast one distinct variant, associated with the long-legged bat in Canada, represents a relatively recent host jump from a big brown bat reservoir. Together with evidence from South America, these findings demonstrate that rabies virus has emerged in the Myotis genus independently on multiple occasions and highlights the potential for emergence of new viral-host associations within this genus.As rabies in carnivores is increasingly controlled throughout much of the Americas, bats are emerging as a significant source of rabies virus infection of humans and domestic animals. Knowledge of the bat species that maintain rabies is a crucial first step in reducing this public health problem. In North America, several bat species are known to be rabies virus reservoirs but the role of bats of the  Myotis genus has been unclear due to the very limited number of laboratory confirmed rabies cases detected in these bats and the challenge in assigning species to poorly preserved bat carcasses. Our study utilised a collection of rabid bats collected across Canada over 25 years to address this issue. Genetic barcoding was used to identify the specimens to species and the virus was characterised by partial genome sequencing. Host barcoding proved to be crucial for correct species assignment to many specimens and allowed the identification of certain Myotis species as reservoirs for several genetically distinct variants of the rabies virus. The geographical distribution of these viral variants, and its correlation with the ecological and taxonomic properties of the hosts, are described. While most of these variants belong to a single rabies virus lineage, one variant associated with the long-legged bat appears to have emerged relatively recently following transmission from a big brown bat reservoir. Consistent with this observation, comparison of the rabies viruses associated with Myotis bats in North and South America clearly shows that rabies has emerged in members of this genus on several separate occasions.Reducing the public health burden of rabies is most effectively achieved by elimination of the disease from its hosts. While the role of dogs and many wild carnivore species in maintaining and transmitting rabies virus is well established, our understanding of the role of many bat species in this regard is still incomplete. Several North American bat species are known to be rabies virus reservoirs, but the role of bats of the  Lyssavirus genus, the etiological agents of rabies, are associated with various bat species in many parts of the world [With the emergence of several recently identified viruses, including Hendra, Nipah and SARS viruses, members of the order Chiroptera have assumed significant importance as the presumptive reservoirs of many zoonotic diseases . Most ofhe world . Moreovehe world ,4 while he world . In the he world –11. Sinche world , increashe world –14.Eptesicus fuscus); its proclivity to roost in human dwellings, sometimes in colonies of some size, results in relatively frequent contact with humans and may possibly contribute to its perceived importance as a RABV reservoir. Five distinct viral variants (BB1 to BB5) are known to circulate within this species [Lasiurus cinereus), red  and silver-haired (Lasionycteris noctivagans) bats, each of which harbours its own distinctive RABV variant [Perimyotis subflavus), previously referred to as the eastern pipistrelle (Pipistrellus subflavus), harbours a variant closely related to that of the silver-haired bat both in Canada and the United States [Myotis genus has been more difficult to define. The gregarious little brown bat (M. lucifugus) can form colonies of some size but submissions are only rarely rabid so their role as disease reservoirs remained unclear for some time.Compared to the rest of the Americas, climatic and habitat limitations have significantly restricted the number of bat species indigenous to Canada. Only 18 species are considered indigenous and most are restricted in range to southern regions of the country . The spe species . Less fr variant , while td States . In contMyotis bats identified a variant designated as the MYCAN type [Myotis species.Antigenic and genetic analysis of a small group of heterogeneous RABVs associated with Canadian CAN type . UnfortuMyotis species exhibiting only subtle morphological differences overlap in range [Myotis specimens were included and the study identified the Yuma bat (M. yumanensis) as a RABV reservoir for the first time.The advent of genetic barcoding to facilitate species identification  has provin range . Incorpoin range . While sMyotis genus recovered from across Canada over a 25 year period, defines several distinct localised viral variants that are associated with particular species. Despite some pronounced east-west segregation, all of the Myotis-associated viral variants, except for one, group within a strongly supported monophyletic clade. Comparison with many viral isolates collected from bats in the United States confirms that many of these variants circulate south of the border. Phylogenetic examination of all chiropteran RABV variants of the Americas clearly demonstrates that Myotis-associated RABV lineages have emerged independently on multiple occasions throughout the continent.In this study, phylogenetic characterization of RABVs, associated with a collection of rabid barcoded bats of the All biological specimens employed in this study had been submitted post-mortem for rabies diagnosis by the Rabies Laboratories of the Canadian Food Inspection Agency. The authors had full access to this collection. The procedures used to propagate virus in mice were approved by the institutional Animal Care Committee at the CFIA’s Ottawa Laboratory Fallowfield and followed the guidelines set by the Canadian Council on Animal Care.All bat specimens employed in this study were collected through a passive surveillance process and submitted for rabies diagnostic testing to one of two Canadian Food Inspection Agency (CFIA) laboratories located in Ottawa, Ontario, and Lethbridge, Alberta. Submissions were first evaluated morphologically to determine species and rabies diagnosis was then performed on brain smears using the standard direct fluorescent antibody test (FAT), as described . CarcassMyotis samples included in the study. Specimens are designated as follows: a two digit number to indicate year of recovery, a two letter code representing province of origin, followed by a four or five digit submission number and finally a three letter suffix designating the bat species according to either morphological or barcoding analysis, as indicated in the figure legends. The provincial codes are: AB, Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan. Bat species abbreviations are defined in A listing of all available specimens collected between the early 1990s until 2015 is provided in To confirm species identification, genetic barcoding that targeted a portion of the cytochrome oxidase subunit 1 (COI) gene was performed. The DNA was extracted from tissue  recovered from each carcass, and employed as template for COI amplification as previously described  or, in shttp://www.boldsystems.org/index.php/Login/page.The final dataset comprised 516 bp sequences from the 5’ terminal region of the COI gene. Specimens were analysed phylogenetically by comparison to a set of 17 vouchered reference sequences, as well as selected samples examined previously . Amplification of the RABV N gene was achieved by a reverse transcription using the forward sense primer, RV-For2 (5’- GTACGCTTAACAACAARAYCARAGAA-3’) that targets the 3’ terminal sequence of the RABV genome, followed by PCR using primers RV-For2 and RabN5 essentially as described  to generMEGA v5.1 software  was usedhttps://catalogue.data.gov.bc.ca/dataset/ecoprovinces-ecoregion-ecosystem-classification-of-britishcolumbia under an open government license.Maps illustrating the distribution of the RABV variants identified in the study were produced using the ArcView GIS v.10 software. Data on ecoprovince distribution for British Columbia were obtained from the Ministry of Environment, BC, at Myotis species, several specimens represented species of other genera. Thus, the dataset comprised 10 silver-haired bats, of which five had been included as specimens unidentified to species due to poor sample preservation, while the remaining five had been identified originally as little brown bats. In addition, of 12 specimens that were barcoded as big brown bats, two had been included as unidentified species while the rest were also originally assigned as little brown bats. One specimen tentatively identified as a western big-eared bat was confirmed in this study.Of 161 bat specimens included in this study  comprising three distinct groupings: an outlying branch comprising three reference specimens  of the eastern small-footed bat, as well as two isolates from southwestern Ontario (03ON8135lbb and 06ON0035lbb), originally identified as little brown bats (bt of 85); a group of two reference western small-footed bats (ASNHC12082WSB and F54054WSB) together with one sample (15AB0782wsb) from this study (bt of 58); a large group of samples including 6 reference sequences that represent the California bat (bt of 68). Within the M. lucifugus complex, one large clade of bats from across Canada, but mostly from the eastern provinces (bt of 99), and a smaller clade of bats recovered exclusively from BC (bt of 99), were identified as representing the little brown bat. These assignments were well supported by comparison with sequences in BOLD. The remaining members of this complex formed a well-supported clade (bt of 84), the majority of which were identified as Western long-eared bats based upon morphological re-examination of some of the specimens, as well as the known range of this species. Within this group, two distinct clusters representing other species were identified. The Keen’s bat, which has a highly restricted range in the coastal region of British Columbia, was represented by a group of specimens originating from this area and that clustered closely with a vouchered specimen (UAM23338KEB) identified to this species (bt of 98); a single sample from Washington state, which clearly clustered with this group but was identified as a western long-eared bat (WA2020LEB), may be misidentified since the Keen’s bat range is known to extend to part of that state. Notably, all the test specimens within this clade had originally been identified as the western long-eared bat. Another clade of six bats, which received only modest support (bt of 54), comprised all four reference sequences for the fringed bat as well as two reference specimens of the western long-eared bat, thereby indicating the challenges posed in differentiating these species; three of the reference fringed bats which formed a strongly supported group (bt of 99) may truly represent this species. Based on the relative rarity of the fringed bat in British Columbia, where its range is restricted to the dry interior, the large cluster of genetically similar specimens located within the FRB/LEB clade most likely represented the western long-eared bat.Identification of bats within the eviously . Single Myotis genus, the most common misidentifications involved incorrect assignment of specimens as the little brown bat; misidentification was most pronounced for bats of British Columbia because of the much greater species variety encountered in this province.Barcoding supported changes to the species assignment for 56 of 149 bats examined by this method compared to their original designations determined using morphological keys .A numberMyotis dataset, A ML phylogenetic analysis was performed using the RABV N gene sequences associated with 160 bat specimens , togetheThe greatest richness of variants is distributed in southern British Columbia. The KE variant was recovered from a relatively restricted area comprising the eastern and southern areas of Vancouver Island and the southwestern corner of the province surrounding the city of Vancouver. The YU and CL variants exhibited a more extensive range being distributed further northwards along the coast and into the southeastern British Columbia interior. Representatives of the LE-1 variant came exclusively from the British Columbia mainland, mostly from the southern interior area and extending into the central interior ecological zone, except for one isolate, identified in a long-legged bat that came from the eastern side of Vancouver Island. The LE-2 variant was recovered across the southern interior region of British Columbia and extending into the mountainous zone in the south-eastern corner of the province. Further geographical localisations were evident for certain clusters of isolates within these groupings. For example, within the CL group three sub-groups, CLa, CLb and CLc, were strongly supported with bt values of 93, 99 and 100, while the YU group was subdivided into four sub-groups, YUa, YUb, YUc and YUd, with bt values of 94, 99, 79 and 99 respectively; the potential significance of these subdivisions is described more fully in the discussion. The viral groups comprising the MYO-II clade also exhibit some regional localisation. The NL-EAST variant is found exclusively throughout the Maritime provinces of eastern Canada and in southern Quebec with a few specimens coming from southern Ontario. There appeared to be a clear dichotomy between samples from the province of Nova Scotia (bt of 98) and the remaining specimens of this group (bt of 95). The LB-EAST variant is the predominant type across southern Ontario. A group of six samples recovered from across a geographically wide area from western Ontario, through the western provinces of Alberta and Saskatchewan and into British Columbia, formed the distinct MY-CENTRAL group. The two small MY-WEST groups form outliers within the MYO-II clade. Four samples, two from Alberta and two from the British Columbia interior, three of which were retrieved from communities located close to the Canada-United States border, formed the MY-WEST1 group. Barcoding of the bat hosts for this variant identified one LBB, two CLBs and one WSB, with no identification of the likely host reservoir for this RABV variant. Two MY-WEST2 samples, both isolated from LEB specimens, were recovered from more northern communities in the British Columbia interior.The phylogeny presented in A more complicated situation was found within the clade representing the BB1 variant (bt of 71). Two isolates, 89BC1780leb and 00BC1855LEB harboured viruses that clustered closely but on a different branch to the BB1 reference sequence (bt of 100). Three closely related viruses (bt of 100), apparently representative of a much more divergent outlying variant, designated here as LL, were associated with long-legged bat specimens  recovered from central and eastern areas of the southern British Columbia interior including one recovered close to the Alberta-British Columbia border . The relMyotis-associated RABV lineage within a broader continental perspective, additional phylogenetic analysis was conducted using partial N gene sequences from a wide range of bat-associated viruses recovered from the NCBI database. To accommodate sequences from as broad a range of isolates as possible, datasets of various lengths were used for phylogenetic analysis and the information gained from use of two of these datasets is described. Inclusion of short sequences (<400bp) expanded the geographical and host species coverage but compromised the robustness of the trees that could be generated.To further explore the epidemiological relationship of the Canadian Myotis-associated RABVs and 42 sequences representative of the viral variants associated with other insectivorous bats of the Americas  clade that includes the MYCAN lineage and several isolates from the United States as described below; a variant represented by a single pallid bat isolate (PLB); the eastern North American Eptesicus fuscus-associated (NA EF-East) variants together with a single outlying M. austroriparius isolate; a large group associated with Myotis bats, particularly M. nigricans, of South America, collectively referred to as MYSA and a variant recovered from E. furinalis bats of Brazil (SA EFu). AB II includes the following main groups: variants associated with T. brasiliensis with a major dichotomy between those of North and South America; a group of viruses from Molossus species of South America and a distinct outlying branch comprising a single isolate from L. intermedius; another group (SA insectivorous variant) composed of viruses associated with South American Histiotus and Nyctinomops species; a group of viruses recovered from silver-haired and tri-coloured bats; a clade of Lasiurus isolates from North and South America; the US-YU variant that included a distinctive outlier from a M. velifer bat from Arizona; the LL variant; the western North American Eptesicus fuscus-associated (NA EF-West) variants.icas see . This trMyotis samples from Colorado (comsp2057 and comsp5264) while one additional Myotis specimen from Colorado (comsp2057) and one from a M. velifer specimen of Texas (96TX4258mv) clustered as outliers to this clade. Two closely-related Myotis-associated specimens from Arizona (95AZ335MYO and 99az488MYO) segregated on a separate outlying branch of the NA EF-West (BB1) clade.A ML phylogeny was generated using a second dataset (RAMP2) that included an additional 54 isolates but covered a sequence length of just 234 bp . While mM. austroriparius formed a third outlying branch (US-AUS1) while another virus from M. austroriparius lay on a distinct branch (USAUS2) that appeared to be more closely related to the pallid bat specimen. Collectively, these variants, together with the MYCAN lineage, are referred to here as the Myotis North American (MYNA) clade. Several viruses identified as originating from Myotis bat species in Colorado (three) and Arizona (four) clustered with big brown bat variants while four Arizona samples and three California samples clustered closely with the variants believed to be harboured by P. hesperus. These viruses may either represent spill-over infections from their reservoir hosts or instances of incorrect host species assignment.Taken together, analysis of the RAMP1 and RAMP2 datasets identified several United States specimens that clustered within the MYCAN lineage , S1 Fig.Desmodus rotundus [The perpetuation of rabies in bat populations has serious consequences for public and animal health due to the potential for spill-over infections. In Latin America, due to successful campaigns to control dog rabies, the majority of reported rabies cases in both domestic animals and humans are now due to exposure to wildlife rabies, especially to the variants that circulate in the vampire bat, rotundus ,29. In trotundus . Moreoverotundus . Such evMyotis bats as rabies reservoirs. First, despite the frequency with which specimens of this genus are submitted for rabies diagnosis, only small numbers are found to be rabid. Clearly, the prevalence of rabies in Myotis bats is very low despite the tendency of passive surveillance methods to be biased towards collection of sick bats with human contact. Consequently, studies of bat rabies in the Americas have usually included only small numbers of bats of this genus and this has confounded efforts to study the role individual Myotis species play in RABV maintenance. The 127 cases identified in this report, collected in Canada over 25 years, represent by far the largest study of Myotis-associated RABV variants ever undertaken in this country.This study has overcome two main challenges to a better understanding of the importance of Myotis-associated viruses was identified did not clearly attribute these variants to particular species of this genus. Instead, the authors refer to two groups of Myotis species, the M. lucifugus complex, comprising M. lucifugus, M. keenii, M. evotis and M. thysanodes and the M. californicus complex that includes this species as well as M. ciliolabrum and M. lebeii. Indeed, in this study use of the BOLD for identification of species within the M. lucifugus complex was problematic and probably indicative of several challenges including: submission to the database of barcodes incorrectly assigned to species, recent recognition that the taxonomy of North American Myotis bats may be flawed by either over or under splitting of the genus or that the mitochondrial genome exhibits incomplete lineage sorting, thereby confounding use of this approach for some members of the genus. Certain species within the Myotis genus are paraphyletic by COI barcoding and their accurate discrimination is problematic [Myotis species, many of which have quite restricted ranges [M. californicus complex, identifying them as the eastern small-footed bat given that other members of this complex are restricted in their range to western Canada. By a similar process, specimens within the M. lucifugus complex were assigned to particular species consistent with their biogeography and predicted phylogeny [Myotis taxonomy may impact some of the conclusions drawn here about the role of certain reservoir species.The other challenge addressed in this study is the identification of bat specimens to species, particularly for rabies diagnostic submissions, since these specimens are often physically damaged upon collection and are sometimes incomplete (eg. head only). While genetic methods of species identification, especially those targeting genes of mitochondrial origin, have gained significant following in recent years , challenblematic ,32. In Cd ranges ,33. Two hylogeny . Most ofMyotis genus, but in addition 15 bats (10 big brown bats and five silver-haired bats) were erroneously identified as little brown bats. The latter observation brings into question a previous conclusion [Myotis bats clustered within clades representative of variants of other bat species [Myotis bats or be the result of host species misidentification. Such findings reinforce the need for improved species identification to reliably infer the RABV reservoir role of many bat species in the Americas and routine genetic characterisation of rabid bat submissions targeting the COI gene or potentially other loci would significantly improve knowledge in this area.The high level of species misidentification (56 of 149) when comparing specimens by barcoding versus morphological traits was due primarily to challenges in differentiating between members of the nclusion  that the species ,35. ThesMyotis species across North America. The MYCAN lineage that evolved from the MYNA group can be differentiated further into several distinct variants that currently circulate regionally in parts of Canada and the UnitedStates over ranges that, to some extent, reflect the geographical distribution of their respective host species.This study has shown that a single progenitor RABV was responsible for the emergence of the majority of viruses (MYNA group) that now circulate in Both the little brown bat and the northern long-eared bat range across most of the southern areas of all 10 Canadian provinces  but theyDespite their extensive overlap in range, little brown and northern long-eared bats do differ in their foraging and roosting preferences . NortherThe reservoir species for the outlying branches of the MYO-II clade  are less clear due to limited numbers of specimens in each of these clades, but species restricted to western Canada may be important. In both Canada and the United States, the California bat was the host for three of five isolates of MY-WEST1, and for four of seven isolates of MY-WEST3 in the state of California, while the western long-eared bat was the host for both MY-WEST2 isolates.Myotis species [The situation in western Canada, and specifically in British Columbia, is complicated, because of the province’s highly diverse climate and physiography, which results in a much greater diversity of native bat species. British Columbia is divided into ten ecologically distinct areas or ecoprovinces ranging from wet forested pacific coastal regions and mountainous terrain to the arid interior plateau of the Okanagan valley and northern boreal regions. These diverse foraging and roosting opportunities support nine native  species . HoweverM.c. caurinus ranges throughout coastal regions of southern Alaska and British Columbia, in areas where the CLa viral subtype was prominent; indeed, the 9 specimens of CLa (bt of 93) originated exclusively from Vancouver Island. In contrast, M. c. californicus inhabits the mainland interior, including the southeastern corner of mainland British Columbia, where the three specimens of the CLc subtype (bt of 100) originated. These viral variants may have evolved as a result of limited contact between these sub-species. The five CLb variant specimens (bt of 99) were recovered exclusively from the southwestern part of the mainland, and this variant was responsible for the only human case, sample 03N1069HU, [Myotis–associated RABVs to humans has on occasion been reported in the United States [The California bat, which harbours the CL viral clade, also ranges over several parts of the western United States, but in Canada it is restricted to the southern parts of the British Columbia mainland and most of the pacific coastal region. The apparent emergence of several distinct local CL RABV variants may reflect the distribution of two sub-species of this bat as detailed by Nagorsen and Brigham . M.c. caN1069HU,  to be inN1069HU, . Spill-od States ,38, but The Yuma bat has a range in British Columbia rather similar to that of the California bat and the YU variant viruses associated with this species could also be sub-divided according to geographical location. The YUa  and YUb  clades comprise samples recovered from different parts of the British Columbia mainland; YUa was recovered from a region east of Vancouver while two of the YUb samples were from the southern interior of the province. The YUc subtype  comprised samples from both the mainland and island areas of the coastal (Northeast Pacific) region and the YUd subgroup , comprised of six samples from Vancouver Island and one from a close neighbouring island together with the group outlier (15BC0560YUB) also from Vancouver Island are distributed throughout the region referred to as the Georgia Depression. Seven specimens infected with the YU variant were identified as little brown bats and the role of this latter species as a reservoir for some of these variants could be further investigated with future additional isolates. The YU variant identified in British Columbia and in one isolate from California is quite distinct from the variant previously identified in Yuma bats in other parts of the US (YU-US) and indicates independent emergence of RABV lineages in this species on at least two occasions.The Keen’s bat, which has a very restricted range in the Pacific coastal forest region and is known to range primarily in British Columbia and parts of Washington state , is propMyotis species into the central regions of the province, rabid specimens are recorded from southern areas only. It is unknown if this is an artifact of passive surveillance, due to limited submissions from more northern areas where human populations are relatively sparse, or if it reflects the true range of these viral variants in these bat populations. Modelling studies suggest that maintenance of RABV in temperate zone bat populations relies upon a complex dynamic involving virus incubation times, host hibernation and the annual bat birth pulse [All of the rabies cases identified for inclusion in this study originated from southern areas of the country and did not fully respect the complete known range of many of these bat species. This was certainly the case in BC where despite the recorded range of many th pulse . At the Myotis genus have occurred and, in some cases, have resulted in long term perpetuation in these new hosts. Consistent with previous observations [Myotis-associated RABVs in North and South America.The age of the American bat RABV lineage has been estimated previously using different segments of the genome. Using Bayesian methods applied to complete N gene sequences, Hughes et al.  estimatervations , this stM. chiloensis and M. nigricans, belong to the neotropical Myotis subclade and are phylogenetically distinct from most members of the nearctic subclade that inhabit North America. The geographical separation of these two groups of Myotis bats explains the independent introduction and circulation of distinct RABV variants in these two populations. The spill-over of RABV variants from the Lasiurus and Eptesicus genera and from silver haired bats into Myotis bats observed in this study is consistent with previous suggestions that these reservoirs form important sources of RABV transmission into Myotis bats and that on occasion such events can result in fixation of new virus-host associations [Myotis species south of the Canadian border Click here for additional data file.S1 Table(XLS)Click here for additional data file.S2 Table(XLS)Click here for additional data file.S3 Table(XLS)Click here for additional data file.


Increased gyrification in diverse cortical areas has been reported in patients with schizophrenia, which is considered to reflect deviations in early neurodevelopment. Schizotypal personality disorder (SPD) is thought to be a prototypic disorder within the schizophrenia spectrum, which shares biological and psychological commonalities with schizophrenia as a neurobiological basis for vulnerability factors. However, to the best of our knowledge, no magnetic resonance imaging (MRI) studies have investigated the gyrification pattern in SPD.T1-weighted structural MRI scans were obtained by 1.5-T scanner from 101 patients with schizophrenia, 46 patients with SPD, and 77 age- and gender- matched healthy control subjects. Using FreeSurfer software (version 5.3.), the local gyrification indices (LGIs) of entire cortex were obtained with the method of Schaer and colleagues. Clinical symptoms of the patients were rated with the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS) at the time of scanning. A general linear model controlling for age, gender, medication dose, and duration of medication was used to compare the LGIs across the groups and to conduct vertex-by-vertex whole brain LGI correlation analyses with clinical variables. This study was approved by the Committee on the Medical Ethics of Toyama University based on the declaration of Helsinki. After a complete description of the study was provided, written informed consent was obtained from all subjects.Compared with the controls, the patients with schizophrenia showed significantly higher LGI in widespread cortical areas including the bilateral frontal, parietal, and occipital regions. The patients with SPD demonstrated significantly higher LGI in the bilateral frontal and left parietal regions compared with the controls. Compared with the patients with SPD, the patients with schizophrenia showed significantly higher LGI in the left occipital and right frontal regions. Both SAPS and SANS total scores were positively correlated with LGI in the bilateral temporal regions in patients with schizophrenia, and were negatively correlated with LGI in the bilateral occipital regions in patients with SPD.Increased LGI in the bilateral frontal regions may be the common morphological substrates for the schizophrenia spectrum, possibly representing vulnerability to schizophrenia. In addition, increased LGI in the left occipital and right frontal regions preferentially observed in schizophrenia may have a critical role in manifestation of florid psychotic symptoms.


To compare the quality of four OCT-angiography(OCT-A) modules.The retina of nineteen healthy volunteers were scanned with four OCT-devices . The device-software generated en-face OCT-A images of the superficial (SCP) and deep capillary plexuses (DCP) were evaluated and scored by 3 independent retinal imaging experts. The SCP vessel density was assessed using Angiotool-software. After the inter-grader reliability assessment, a consensus grading was performed and the modules were ranked based on their scoring.There was no significant difference in the vessel density among the modules . The numbers of discernible vessel-bifurcations differed significantly on each module . The ranking of each module differed depending on the evaluated parameter. In the overall ranking, the Zeiss module was superior and in 90% better than the median . Optovue was better than the median in 60%, Topcon in 40% and Heidelberg module in 10%, however these differences were not statistically significant.Each of the four evaluated OCT-A modules had particular strengths, which differentiated it from their competitors. OCT-angiography (OCT-A) is a new diagnostic tool and heavily promoted as an alternative or an adjunct to classic fluorescein angiography (FA). It is a fast imaging tool, detecting streaming blood, thereby allowing to construct an image of the retinal vasculature; in contrast to “classical” FA it is dye-free, and therefore lacks significant side effects associated with the fluorescein injections such as such as vomiting, hypersensitivity reactions and cardiovascular complications.  This newSeveral OCT manufacturers now offer OCT devices including algorithms enabling the practitioner to obtain regular OCT B-scans as well as volumetric angiographic images. Different techniques such as Doppler shift, speckle variance/decorrelation, phase variance, optical micro-angiography and correlation mapping are employed to differentiate blood vessels by depicting the change in the OCT-signal induced by the moving blood cells. ,4 So farPrevious studies aimed to compare the performance of different OCT-A techniques applied in the above listed OCT-A modules including phase variance, absolute complex difference, speckle variance and absolute intensity difference. It was confirmed that all methods generate excellent flow motion contrast images, with phase variance and absolute complex difference methods requiring more complex analyses than intensity based algorithms such as speckle variance and absolute intensity difference.  A recentHowever so far no data are available which systematically compare the commercially available OCT-A modules.The aim of this study therefore was to compare the quality of 4 different commercially available OCT-A modules in healthy subjects.Nineteen healthy subjects were evaluated in this cross sectional study. Subjects had a visual acuity of 20/20 or better without a clinical history and without any evidence of an eye disease including retinal disease or glaucoma. Exclusion criteria were also the presence of diabetes or hypertension or any other cardiovascular disease. The retina was scanned using a Zeiss Cirrus 5000 HD-OCT , an Angiovue, RTVue XR Avanti , a Topcon DRI OCT Triton Swept source OCT and a prototype of Spectralis OCT2 . The Topcon DRI Swept source (SS)- OCT used a wavelength of 1050nm, whereas the remaining devices used shorter wavelengths around 800nm . The Zeiss Cirrus HD-OCT Model 5000 with Angioplex uses a so called OCT- microangiography complex algorithm (OMAG) and an A- scan rate of 68Khz. OMAG identifies changes in the phase and intensity information of the OCT scans to quantify motion contrast. The protThe study adhered to the tenets of the Declaration of Helsinki and was approved by the local ethics committee at Inselspital. A weaver of informed consent was granted due to the use of anonymized data (KEK number 2016–02100). The superficial (SCP) as well as deep vascular plexus (DCP) were segmented using the inbuilt software on each device. The location of the segmentation line of the SCP and the DCP of each module can be found in The grading protocol included qualitative as well as quantitative parameters: Motion artefacts , image artefacts , the distinguishability of the foveal avascular zone (FAZ) , and the vessel continuity and discriminability of large and small vessels  were assessed. The number of clearly identifiable bifurcations identifiable on the superficial en-face image was counted on each scan. Therefore a main, large vessel branch at 12 o`clock was chosen and the number of identifiable, subsequent bifurcations towards the terminal capillary end were counted on the respective branch. Additionally, the superficial layer retinal vessel density was assessed using the publicly available software Angiotool.  Vessel dMotion artifacts (or displacement artefacts) were considered as present when there were characteristic white-line artefacts present on OCT-A image with corresponding discontinuity at the en-face image in the B-scan direction or lateral displacement of parts of the image or doubling of retinal vessels. Axial motion artefacts resulting from breathing, tremor or pulsations as well as transverse motion artefacts caused by loss/change and saccades were evaluated.,13 BlinkThe parameter “some artefact” was defined as the presence of at least one artefact of respective category. The presence of 5 or more artefacts of respective category was considered as severe artefacts. Artefacts making reasonable evaluation of the microvasculature impossible were considered as severe artefacts as well. This included also broad artefacts as large as 5% of the image width or length in horizontal and vertical directions, respectively. Some representative examples of artifacts can be found in Figs After concordance analyses and the evaluation of the inter-grader reliability, a consensus grading was performed. The consensus dataset was then used to compare, score and rank the four modules.www.r-project.org). Fleiss kappa coefficient was employed to quantify inter-grader reliability. After the evaluation of the interrater reliability, a consensus grading was performed and a final score ranging from -1/0/+1 was given for each feature for each image. These scores were then summed up and normalized with a maximal and minimal scoring ranging from -100 to +100. Based on the scores the devices were ranked for each evaluated parameter. Differences in ordinal variables such as motion artefacts, FAZ and vessel continuity were analyzed using Chi-squared test and numeric data such as number of counted bifurcations as well as vessel density were evaluated using ANOVA. An overall ranking of the modules was performed using exact binominal testing. Hereby it was evaluated in how many cases the module was better than the median with the set of evaluated parameters serving as the test sample for all features.Statistical analyses were performed with SPSS  software and R . Inter-grader reliability in respect to each OCT-A module can be found in There was no difference in the overall vessel density among the evaluated modules using Angiotool . However although there was no difference in vessel density, the correlation coefficients were rather weak for respective parameter among the modules , The Optovue was in 60%, the Topcon in 30% and the Heidelberg in 10% better than the median. However, differences are not statistically significant.We here present the first comparison of 4 OCT-A modules. Each of the four modules had particular strengths, which differentiated it from their competitors. Overall, however, the Zeiss module seemed to be the most reliable, accurate and precise device in terms of our evaluated variables, followed by the Optovue, the Topcon and the Heidelberg module. Each module employed different technology to quantify the motion contrast and each module had different approaches to minimize motion artefacts and achieve optimal image quality with high resolution. –8,17.Inter-grader agreement also differed in respect to evaluated feature and device. It seems noteworthy that the reliability of the grading was found to be higher in the Zeiss and Optovue module compared to the Topcon and Heidelberg module. This may be explained by the fact that the grader reliability seems associated with the quality of the images and evaluated features. Images of higher quality depicting the evaluated feature more accurately will result in a stronger inter-grader agreement than poor images. Taking into account that overall the Zeiss module was ranked best and the Optovue device second best, the differences in the inter-grader reliability seem reasonable.Motion artefacts in the SCP and the DCP were less prominent with the Zeiss Angioplex module, followed by the OCT-A modules of Optovue, Topcon and Heidelberg. However, these findings were not statistically significant. A previous study compared the AngioVue (Optovue) with the Angioplex (Zeiss) and found that the Angioplex required shorter acquisition time and showed a lower number of motion artefacts when compared to the Angiovue. Further In order to prevent motion artefacts manufacturers use different approaches. Zeiss (FastTrack), Heidelberg (TrueTrack) and Topcon (SMARTTRACK) implemented a retinal eye tracking, while the here evaluated Optovue device, used a software based method in which a retinal area is repeatedly scanned horizontally and vertically. This software based approach may account for longer acquisition times compared to the eye tracking as shown in the previous study by De Vities et al.  In our sTo sum up, the presence and severity of motion artefacts did not significantly differ among the evaluated modules and manufacturers are continuously working on better solutions to delimitate respective problems on OCT-A. For instance, some manufacturers now offer motion correction technology in order to overcome respective artefacts.The category of imaging artefacts in our study comprised the presence of segmentation and projection artifacts. Projection artefacts arise from light, which is not directly reflected by the moving blood but passes through and illuminate features posterior to the vessel.  This impA recent study suggested that the usage of the FS-ADA algorithm, which is implemented in the Heidelberg module, would cause less projection artefacts compared to the SSADA algorithm. The SSADBut these explanations only account for the artefacts due to projections in the DCP. For the SCP mainly segmentation errors attribute to the artefacts in the category. Previous studies have shown that segmentation artefacts are rather common. ,21 For lInterestingly the distinguishability of the FAZ borders differed between the SCP and the DCP. While the FAZ borders of the SCP was best visualized by the Zeiss Angioplex followed by the Optovue, Topcon and Heidelberg, the borders of the DCP were harder to distinguish and were best identifiable on the Optovue followed by the Heidelberg, Topcon and Zeiss module. The SSADA algorithm employed on the Optovue uses a four-fold spectrum split, which improves the signal to noise ratio, which may account for the high scoring on the distinguishability of the FAZ border on the SCP and the DCP. ,18 It waVessel continuity on the SCP and DCP were best preserved and discriminable on the Zeiss module, followed by the Topcon, Optovue and Heidelberg. Of course, the severity of motion and imaging artefacts had significant impact on this evaluated parameter as high resolution and the absence of artefacts is key for the continuity and discriminability of vessels. Therefore already above mentioned parameters may account for the superior presentability of the vessels on the Zeiss module. A previous investigation indicated that the vascular network may be better visualized using OCTARA (Topcon) than the SSADA module.  It is fuThe vessel density of all 4 devices was evaluated using the publicly available Angiotool and was comparable among all 4 modules. The measured vessel density of the SCP in our cohort of all devices was also comparable to the normative vessel density previously reported by Coscas et al., which was evaluated with the inbuilt Angiovue software and found to be around 52.58±3.22%.  However This study has definite limitations. First, a prototype was tested against three commercially available modules and it remains to be shown whether the final version of the Heidelberg porotype improves their performance compared to the other so far available modules. Second, the scanned area on the Heidelberg device (4.3x 1.5 mm) differed from the area scanned with the remaining devices (3x3mm). This may have impacted resolution and acquisition time and limits the comparability to the other devices. Usually image quality of healthy subjects outperforms quality of images of diseased eyes. Thus, the evaluation and comparison of respective modules in diseased eyes are warranted as well. Beside the 4 evaluated modules there are other OCT-A systems currently under development which were not tested in this study, including the OCT RS-3000Advance of Nidek and the SOCT Copernicus REVO and REVO NX of Optopol.In conclusion, each device uses different approaches to offer optimal high-resolution images of the vascular network with the minimum possible artefacts. In our study, the approach of Zeiss was in most of the evaluated features superior and better than the median, but all modules had their individual strengths and weaknesses. The current study reflects just the current stage of development, but the OCT-A imaging is still in its early beginnings and is rapidly developing and improving with great strides forward.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.