Previous Enhanced Recovery After Surgery (ERAS®) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes.A causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes , early actual discharge) and secondary outcomes  are considered along with their multiple dimensions.Concerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes.The multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions. The ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative care pathway intended to improve and shorten recovery after major surgery through the application of a bundle of interventions , 2. HoweAny study on this topic exploited the incomplete compliance with ERAS items, which variably accompany ERAS databases and provides the necessary variability for addressing the question of the benefit of a single item or of ERAS as a whole. Nevertheless, previous analysis did not adequately consider that non-compliance is scarcely ever independent from other important variables. This raises at least three major methodological issues that have been poorly addressed in previous studies. First, ERAS outcomes and ERAS interventions themselves are affected by several confounding variables. For example, the American Society of Anesthesia score (ASA) status can affect both the outcome and the early postoperative mobilization. Second, ERAS items are themselves inter-related. For example, conservative intraoperative fluid administration is conceivably more applicable in patients who did not receive preoperative bowel preparation. Third, when dealing with ERAS, the outcome measures are composite. For example, the principal outcome measures in ERAS studies, postoperative length of hospital stay and complications, cannot be considered separately since they measure a similar trait.We retrospectively studied a prospectively collected data of patients undergoing elective colorectal surgery between 2014 and 2018 with an ERAS protocol in 20 Italian hospitals affiliated with the PeriOperative Italian Society (POIS). The aim of our study is to analyze the effects of a number of ERAS items with a statistical model that considers the aforementioned methodological issues, namely a multivariate Latent Class Two-Parameter Logistic (LC-2PL) model  formulatTwenty Italian hospitals affiliated with POIS collaborated in collecting data. All centers treated their patients within an ERAS pathway, which was defined with active contribution from the ERAS Society. Before the start of the study, all hospitals had been involved in a pathway implementation program led by POIS consisting in education and audit meetings every six months for a two-year period.All data were collected prospectively through a standardized electronic spreadsheet, which was used to record 90 variables per patient , laparotomy (vs laparoscopy), and surgical stoma (coded as binary variables). We also consider the following external variables that directly affect the outcomes: type of surgery , malignancy of the underlying disease, blood derivatives transfusion.The main advantage of the proposed causal latent class model is that we jointly account for several outcomes that are distinguished as primary and secondary according to their relative clinical importance in the ERAS framework. The primary outcomes are the following: occurrence of any complication, occurrence of surgical site infection (SSI), occurrence of medical complications unrelated to the surgical site, such as cardiovascular, pulmonary, thromboembolic, or urinary complications, ready for discharge after POD 5, and actual discharge from hospital after POD 6 . Within The secondary outcomes that we account jointly are the following: bowel function recovery after POD 1, need for IV fluid resumption after suspension, need for nasogastric tube (NGT) replacement after removal, occurrence of postoperative nausea and vomiting (PONV), surgical re-intervention, hospital re-admission, death within POD 30. In the multivariate model presented below we assume they represent two distinct dimensions: the first made by bowel function, need for IV fluid resumption, need for nasogastric tube, nausea and vomiting and the second made by surgical re-intervention, hospital re-admission and death.We highlight a proposal for the estimation of multiple treatments within observational studies, since we are interested to disentangle the effects of the ERAS items on primary and secondary outcomes. The treatment is confounded with the patient’s characteristics and to address this problem we follow the potential outcome approach to causal inference as proposed by , 12 and , the variable under the non-treated and treaded status, respectively. An underlying latent variable Differently from previous proposals we suppose the counterfactual outcomes as latent variables denoted as mentclass2pt{minimIn what follows, first we describe the estimation of the probability of treatment exposure given the pre-treatment covariates and each block of ERAS items  conditional exchangeability meaning that the latent potential outcomes are independent on the treatment given the covariates, ii) positivity (ignorable treatment assignment) meaning that there is a positive probability for every patient of receiving any type of treatment, iii) consistency implying that the latent potential variables are well-defined and as a result any observed outcome is the potential variable corresponding to the observed treatment sequence.Let ollowing , 28 we eollowing  to estimLet mentclass2pt{minimiability .The dependence of the potential latent variables is modelled through the following multinomial logit modelAnother set of parameters is referred to the conditional distribution of the observed outcomes and it is defined asThe model is estimated through a weighted log-likelihood function by considering a sample of lgorithm . The latk latent classes, #n is the sample size. The model is estimated for an increasing number of latent classes and the best model is selected as that before the BIC starts to increase. Once the suitable number of latent classes is selected every patient is allocated to a latent class according the highest posterior probability. Standard errors for the estimated parameters are obtained as the square root of the diagonal elements of the inverse of the observed or expected information matrix computed through numerical methods.In order to choose the best number of latent classes and to discover meaningful groups of patients in the population we apply a model selection strategy. The resulting subpopulations should be internally cohesive and well separated from one another. We rely on the BIC index  that is https://github.com/penful/Eras. The complete results are available from the authors upon request.The available observations are related to 1261 patients operated between 2014 and 2018. Table The multivariate causal LC-2PL model is estimated for a number of latent classes ranging from 1 to 5. According to the lowest value of the BIC index we select the model with three latent classes. Table By looking at the estimated ATETs defined with respect to the first LC chosen as reference due to the fact that it collects patients with the best outcomes, we evaluate the efficacy of each intervention. Table The estimated regression coefficients in the bottom part of the table indicate that preoperative hospital stay, malignant lesion, and blood transfusion significantly favor being in the group of intermediate performing patient (2nd LC) with respect to best performing (1st LC).Table The estimated regression coefficients in the bottom part of the table indicate that postoperative fluids, preoperative hospital stay, PONV prophylaxis, premedication, and blood transfusion significantly favor being in the group of worst performing patients (3rd LC) rather than stay in the intermediate group of patients (2nd LC).The multivariate causal LC-2PL model for the secondary outcomes is estimated as the previous model for a number of latent classes ranging from 1 to 5. According to the lowest value of the BIC index we select the model with two latent classes. The estimates of the model parameters for the secondary outcomes are reported in Tables Table The estimated ATETs in the bottom part of the table indicate that blood transfusion, preoperative glucidic drink, and prokinetics significantly favor being in the group of the worst performing patient (2nd LC) with respect to best performing (1st LC).With respect to our primary outcomes, the model points out three classes of patients. The first one has a high probability of good outcome and represents the majority of our patients. The second class exhibits possibly prolonged TRD and discharge notwithstanding the absence of complications. The third class presents high probability of both complications and prolonged TRD and discharge. Five variables positively affect the outcomes . Two variables negatively affect the outcomes .With respect to our secondary outcomes, three of them could not contribute to discrimination between classes of patients, since their probability was uniformly either low  or high (bowel function recovery after POD 1). The model points out two classes of patients: a first class with high probability of good outcome (including the majority of our patients), and a second one with high probability of IV fluid resumption, NGT replacement, PONV occurrence, and surgical re-intervention. Six variables positively affect the secondary outcomes and four of them do the same for the primary outcomes . Four variables negatively affect the secondary outcomes and one of them does the same for the primary outcomes (blood transfusion).Our results contribute to the ongoing debate about the existence of ERAS “core-items”. In fact, although it is recognized that the complete ERAS protocol is the best way to improve postoperative outcome, the number and relative combination of the ERAS items implemented in previous works varied across studies without substantial differences in postoperative short-term outcomes , 32. IndIn addressing these issues no previous study adequately considered the dependency of multivariate outcomes from confounding variables and non-compliance to ERAS items, the inter-relation between ERAS items themselves, and the composite nature of the primary and secondary outcomes at stake.The estimation of treatment effects in observational studies when the treatment assignment depends on the sequence of previous assignments and on time-varying confounders is still a matter of debate. The main advantage over the standard simple multinomial logit model is that our counterfactual framework assesses causal associations, corrects for pre-treatment confounders and for multiple treatment conditions in order to reduce the bias due to confounding. Another advantage is that it is a multivariate model-based clustering method and allows us to properly account for suitable groups able to disentangle the heterogeneous population of patients. Moreover, it yields a classification that uses the maximum a-posteriori estimates of the model parameters.The results of the application provide evidence that waiving bowel preparation increases the probability of good outcome. Recent ERAS guidelines on colonic surgery and a large meta-analysis of more than 21,000 patients agree that mechanical bowel preparation is not associated to any reduction in postoperative complications, mortality, and length of hospital stay when compared with no preparation , 41. ActRecent studies demonstrate how a balanced intraoperative goal directed therapy reduces mortality, overall morbidity, and the time to first flatus and to oral feeding . The ERAThe results suggest that epidural analgesia exerts a favorable effect on outcome and therefore they confirm the findings of other studies according to which epidural analgesia after laparotomy provides optimal pain control and reduces the inflammatory stress response. This reduces the incidence of pulmonary and cardiovascular complications, in particular in frail patient , 47. NevThe negative effect of a prolonged preoperative hospital stay, which we observed, deserves attention. Serious comorbidities requiring longer preoperative hospitalization can make it difficult to optimize patients’ conditions and preserve functional capacity before surgery. It has been recently demonstrated that a decline in preoperative functional capacity, determined by the Duke score activity index, is associated to increased myocardial infarction and death 30 days and one year after major non-cardiac surgery . PrehabiA possible limitation of our study is related to conceivable differences between the participating hospitals and through the time span of the data collection, both in the degree of ERAS pathway implementation and in the baseline standard of care. A potential selection bias could be at stake, despite all centers have been invited to submit consecutive elective patients. Nevertheless, the wide mix of ages and comorbidities included indicates a small likelihood of selection bias among patients.The major strength of our proposal resides in the features of the proposed statistical method. Moreover, we accessed a dedicated ERAS database from which we derived the data used for the analyses and we used a validated indicator of short-term recovery such as the TRD .We analyze a colonic surgery ERAS database by proposing a multivariate causal latent class two-parameter logistic model. This modern statistical method overcomes several drawbacks of traditional methods to estimate average treatment effects on the treated. Since we are dealing with observational studies we employ a propensity score method. We propose to use a maximum likelihood approach by employing weights estimated through the inverse-probability of receiving the treatments. In this way, we avoid rough comparisons of patients thus producing a valid inference and reducing the possibility of biased treatment effects. As noted by  generallAccording to the results early postoperative ambulation and IV fluid stop, epidural anesthesia, and waiving any surgical drainage exert a favorable effect on primary outcomes , while prolonged preoperative hospital stay and blood transfusion act unfavorably.


Purpose: Congenital retinal macrovessels (CRM) are large aberrant blood vessels that cross the horizontal raphe. Visual acuity may be negatively affected in cases afflicted with CRM due to macular serous detachment, hemorrhage, exudation, foveolar cyst formation and retinal artery occlusion. Even the presence of an anomalous vessel itself running through the foveal avascular zone may compromise the visual acuity. In this case report, we discuss the multimodal imaging characteristics of a case of symptomatic unilateral CRM-related cystoid macular edema and serous macular detachment in a 13-year-old boy.Observations: Optical coherence tomography angiography (OCTA) imaging of the superficial retina revealed the aberrant vessel and anomalous arteriovenous communication between the aberrant vessel and the retinal artery. The foveal avascular zone also appeared partly distorted.Conclusions: The present case reports the second-youngest patient afflicted with unilateral CRM and associated macular edema. There was spontaneous resolution of macular edema within six weeks. In light of the observations in this case and the literature review, the need to refrain from rapid therapeutic intervention in the eyes of patients affected with CRM and macular edema must be emphasized. Congenital retinal macrovessel (CRM) is a term coined by Brown et al. , implyinWe hereby highlight the multimodal imaging features of a case of unilateral macular macrovessel associated with cystoid macular edema and serous macular detachment in a 13-year-old boy that resolved spontaneously.A 13-year-old otherwise healthy boy with a history of visual decline in his right eye of one-week duration was examined. He had an unremarkable past medical history and no history of ocular trauma or ocular surgery. On examination, best-corrected visual acuity (BCVA) was 20/100 in the right eye and 20/20 in the left eye. Anterior segment of either eye was unremarkable. Fundus examination of the right eye revealed a normal optic disc with an aberrant retinal venous macrovessel crossing the horizontal raphe and draining into the inferotemporal major vascular arcade vein. There appeared to be a suspicious anomalous arteriovenous communication with a retinal artery  imaging of the superficial vascular plexus in the right fundus revealed the presence of an aberrant vessel, an anomalous arteriovenous communication of the aberrant vessel with the retinal artery, and a distorted foveal avascular zone . The diagnosed cases displayed an increase in vascular flow compared to the surrounding normal veins %. The di describeChawla et al.  reportedA brain MRI was also performed in order to rule out any cerebral vascular abnormality as pointed out by Pichi et al . Of 49 pMacular edema related to CRM is generally a benign entity, and resolution of edema may occur spontaneously. This case of unilateral CRM with macular edema is that of the second-youngest patient reported in the literature. OCTA can yield additional information in cases of CRM. In the light of the observations of this case and the literature review, the need to refrain from a rapid therapeutic intervention in the eyes of patients with CRM, and macular edema must be emphasized, underscoring the importance of thorough investigations.The authors declare that they have no competing interests.Informed consent has been obtained from the patient’s legal guardian for the publication of this case report.


Coronaviridae are ubiquitous in nature due to their existence in a wide spectrum of mammals and avian species. The coronaviruses, as RNA viruses, exist as quasispecies because of their high rate of mutations. This review elaborates on the pathogenesis and the developed vaccines of most of the ubiquitous coronavirus' diseases, mainly bovine, dromedary camel, porcine, feline, canine, and avian coronaviruses. The review emphasizes the significant setbacks in the full exploitation of most of the pathogenesis of the coronavirus' diseases, raising the prospect of effective vaccines for these diseases. The therapeutical trials for the treatment of SARS-CoV2 and the setbacks of these trials are also addressed. The review draws attention to the lessons accumulated from the large number of studies of the pathogenesis of animals and birds' coronaviruses and their vaccines, particularly the bovine, feline, and avian coronaviruses. The lessons drawn from the studies will have an immense influence on how the human coronaviruses pathogenesis and vaccine development will proceed. In addition, the extensive efforts to designate suitable animal models to study the lately emerged human coronaviruses are one of the invaluable contributions carried out by veterinarian scientists. Finally, factors and determinants that contribute to the possibility of emerging new coronavirus zoonotic disease are elaborated on and a call goes out to urge transdisciplinary collaboration in the implementation of the “One Health” concept.The viruses of the family  Coronavirinae in the family Coronaviridae and Nidovirales. The most distinctive feature of Coronaviridae is the genomic size, having as they do the largest genomes among all RNA viruses (26.4–31.7 kb in length) with a G+C content varying from 32 to 43% (Coronaviruses (CoVs) are a family of enveloped single-stranded RNA viruses of medical and veterinary importance that infect mammals and birds, causing respiratory or enteric diseases . CoVs ar2 to 43% . It was 2 to 43% , 9. The 2 to 43% , with a 2 to 43% . The 2012 to 43% , is a neIt is strongly believed that HCoVs have a zoonotic origin from bats, mice, or domestic animals , 14. Indcorona in Latin) on its outer surface, visible when viewed through an electron microscope. In the current taxonomy of viruses, the order, family, genus, and species are universally used to organize all diversity of viruses within a hierarchical system , which broke out in China's Wuhan seafood market in December 2019 . EpithelViral entry into the host cells is facilitated by the binding of the spike (S) protein to the cell surface receptors , 28. In Recently, it was shown that SARS-CoV2 uses angiotensin-converting enzyme-2 (ACE2) as a port of entry, an important finding to understand SARS-CoV2 transmissibility and pathogenicity , 31. In Many betacoronaviruses utilize aminopeptidase N (APN) as the entry receptors, but CoVs are also able to utilize other different receptors, such as, for example, MERS-CoV, which binds to dipeptidyl-peptidase 4 (DPP4) to gain entry into human cells , 35. DPPin vivo . The exact function of HE is not fully disclosed, but it has been speculated that HE aids in viral entry and/or pathogenesis in vivo .Feline Enteric Coronavirus (FECV) is a virulent biotype of FCoV in domestic cats, and it is the hypervirulent biotype precursor of FIPV that causes fatal diseases in cats. FIPV is classified into two forms, wet and dry sarcoidosis . FIPV inCCoV is genetically related to CoVs of pigs and cats. CCoV is divided into two genotypes, CCoV type-I (CCoV-I) and type-II (CCoV-II) . The maiPorcine Respiratory Virus (PRCoV) is a variant of TGEV that binds to epithelial cells of the lungs, causing antigen aggregation in pneumocytes and alveolar macrophages, which result in interstitial pneumonia . On the BCoV infection leads to financial losses in the cattle industry and infection could be extended to camel herds. BCoV infects the respiratory and gastrointestinal tracts, leading to severe diarrhea in calves, with or without respiratory disease. High mortality rates are due to the bloody diarrhea that results from the destruction of the small and large intestinal villi , suggestGroup 3 of CoVs contains viruses that infect a wide range of fowl species . IBV is MERS-CoV causes mild symptoms in dromedary camels in natural or experimental infection . ExperimMHV causes respiratory, enteric, hepatic, and neurologic infections in mice .Prior to the emergence of SARS-CoV, the two prototypes of human CoVs—OC43 and 229E CoV—were primarily associated with the common cold . The humMERS-CoV was recognized as a newly emerged zoonotic disease developed in dromedary camels as an intermediate host . A surve+, CD4+, and CD8+ T-lymphocytes  is speculated as the harbor of the ancestor of SARS-CoV2. RNA sequence analysis advocates these speculations due to the close homology between the SARS-CoV2 sequence and that isolated from the horseshoe bat . EvidencInnate immunity is crucial for hindering the CoVs replication and is an essential step in the development of the adaptive immune responses. The responses are initiated by the capability of the pattern recognition receptors (PRRs), molecules on the cell surface and in the cytoplasm to sense certain sequences of the viral genome and particular proteins, known as pathogen-associated molecular patterns (PAMPs) , 49. The+, T-cytotoxic lymphocyte and CD4+, T-helper lymphocyte . Feline vaccination encountered the dilemma of generating protective immunity without causing immune-mediated disease. However, cats with preexisting high levels of antibodies against FCoV develop effusive FIP rapidly on challenge. On the other hand, administering antiserum to FCoV before challenge may also enhance the risk of peritonitis. FIP is highly prevalent in young cats between 6 months and 3 years of age . In the Vaccines against BCoV protects against enteric and respiratory disease in young calves. Inactivated vaccines are mainly applied to initiate maternal immunity in pregnant cows , 57. BCoHigh losses in poultry production inflicted by IBV infection is mainly due to the combination of high morbidity and loss of growth performance, accompanied by secondary bacterial infections , 53. IBVE. coli. Experimental vaccines include novel DNA vaccines, vectored vaccines, and recombinant vaccines. For example, the porcine adenovirus was used to deliver the TGEV spike protein  Species: the species that are capable of depicting the pathophysiology of the disease close to that reflected in humans are more suitable candidates.(2) Complexity: it is highly important for the model to reveal the complexity of disease in the utmost detail.(3) Disease simulation: the simulation of the disease could be subjected to several pathways and principles. Hence, the model should exploit the complexity of the disease through collective pathways and consequences.(4) Predictivity: a criterion that is mainly applied for assessing the effect of the drug on the final outcome of the disease.(5) Face validity: this criterion defines the extent of the model in reflecting a symptom or set of symptoms.Animal models are classified in groups according to their biological, genetic, and pathophysiological requirements . They ar(1) Induced  models: certain impairments experimentally induced to allow their study.(2) Spontaneous  models: naturally existing genetic variants that allow the study of the side effects of mutation.(3) Genetically modified models: modification induced by genetic engineering and embryo manipulation.(4) Negative models: species or breeds that are naturally resistant to certain infectious diseases.(5) Orphan models: nonhuman species that suffer from certain natural functional disorder(s).The susceptibility of several domestic and laboratory animals was tested for the expression of the pathoimmunogenicity of SARS-CoV and SARS-CoV2. The following is a list of the most commonly tested animals.The susceptibility of cats to SARS-CoV2 has been the subject of extensive trials for the study of the infection . The SARCat susceptibility to SARS-CoV has also been addressed . RT-PCR The viral RNA was detected in the nasal washes and rectal swabs of intranasally inoculated ferrets. The histological lesions of the low respiratory tract revealed an increase in type II pneumocytes, macrophages, and neutrophils .SARS-CoV2 expressed efficient replication in the ferret digestive tract. The overall clinical signs, viral replication, and the pathological manifestation in ferrets' lower respiratory tract clearly indicated a high susceptibility to SARS-CoV2 . Ferret Although the viral replication in the respiratory tissue and the manifestation of certain clinical signs indicated that cats are permissive to SARS-CoV infection, the picture of the disease in cats was milder than in ferrets . It was A recent study, however, has attributed the variations in the level of the permissiveness to the SARS-CoV2 infection in humans to the affinity of the intermolecular interaction of ACE2 with the viral binding site of S protein . Using hThe susceptibility of dogs to SARS-CoV2 has also been addressed . AlthougCynomolgus and rhesus macaques were inoculated with SARS-CoV to see if they were susceptible to its infection . RNA wasThe susceptibility of cynomolgus macaques to SARS-CoV2 has been evaluated . Two groThe overall assessment of experimental infection of cynomolgus macaques with SARS-CoV2 clearly reveals that this nonhuman primate is susceptible to SARS-CoV2 infection . The patMice are of low susceptibility to SARS-CoV and SARS-CoV2 infection due to the low binding properties to its ACE2 receptor in the respiratory system . HoweverSARS-CoV replication in the respiratory tract of Syrian hamsters led to pulmonary lesions. The hamsters indicated moderate support for viral replication in the respiratory tract, albeit with rapid clearance. Hamsters could be more suitable than mice as a model for SARS-CoV infection .The susceptibility of pigs, chickens, and ducks to supporting SARS-CoV2 replication is very low .The overall assessment of the experimental trials on different animals and birds denotes that animal models that were permissive to SARS-CoV and SARS-CoV2 infections were ferrets, cats, and nonhuman primates. Viral replication in the lower respiratory system of ferrets and cats was very mild . HoweverThe emergence of new zoonosis is highly influenced by different factors and determinants. The factors and determinants that initiate new zoonotic disease that might end in spillover are of ecological, epidemiological, pathological, and cultural nature . The majThe main way to understand the factors that initiate zoonosis that leads to spillover is to conceptualize the research in quantitative and qualitative relations between these factors . For ins(1) The dynamic of the disease in reservoir species(2) The extent of the pathogen exposure(3) The human susceptibility to infection.The accumulated evidence emphasizes that the newly emerged zoonosis in recent decades is mainly due to vast anthropogenic changes. The vulnerability of these changes has been exacerbated by behavioral determinants, nutritional and cultural factors related to foodborne zoonotic diseases and pathogen dynamic transmission . The exaExtensive studies and analysis of the factors that have been referred to as prime inducers of the emergence of new zoonosis are of great importance in developing postulating approaches to predict the possible hotspots for the emergence of new zoonotic diseases . The hot−4 substitution per year per site . The discontinuous RNA transcription mechanism is not fully elaborated. The nsp14 ExoN performs the fidelity by continuous association and dissociation from the negative full-length RNA by recognizing conserved sequences called transcription regulatory sequences (TRS) .Hence, the genotypes expansion and continuous evolution of CoVs are generated through a set of continuous mutations in the viral nonstructural enzymes and recombination with homologous subgenomic RNA templates. Mutation or attenuation in TRS sequences have a major effect on viral transcription and viral replication. However, mutation in nsp14 ExoN, which has a vital role in fostering RNA fidelity during replication and transcription, could drastically cripple the virus . The nspIn sum, generating new CoV variants is maintained by continuous diversity and evolution through the following mechanisms:(1) The replication rate is often associated with mutation and recombination due to flexibility in the fidelity mechanism.(2) Despite the large size of CoV RNA genome in comparison with other single stranded RNA, it is characterized by extra plasticity that enables the virus further modification by mutations and recombination.(3) The tendency of CoVs to switch templates during RNA replication by a mechanism known as discontinuous RNA transcription with high homologous templates in mixed infections provides an opportunity for possible recombination .There is as yet no efficient prophylaxis or treatment for SARS-CoV2 infection. Knowledge of SARS-CoV2 virology is growing rapidly and offers large numbers of potential drug targets. Potential or repurposed medications to treat SARS-CoV2 have previously been used to treat SARS-CoV and MERS-CoV outbreaks with variable efficacy , 89. TheChloroquine and hydroxychloroquine have been used since the 1930s to prevent and treat malaria and to treat chronic inflammatory diseases, including rheumatoid arthritis and systemic lupus erythematosus . They boin vitro activity against other novel coronaviruses through 3-chymotrypsin-like protease inhibition  could be ameliorated by corticosteroids. Tocilizumab, a monoclonal antibodies agent, is also applied to lessen the side effects of ARDS . IntraveIn summary, all the therapeutical trials with all of the above drugs were of partial effect against SARS-CoV2 . NeverthThe scientific community has invested significant effort in the campaign against the SARS-CoV2 pandemic. Despite all the overwhelming knowledge that has been accumulated since the start of the disease, control of this disease or developing an effective cure remains beyond current possible expectations. Lessons should be comprehended from the continuous failure to unravel the wide range of the pathogenicity and epidemiology of animals and bird CoVs.CoVs are ubiquitous viruses that circulate in a wide range of mammals, bird species, and human. The diseases inflicted by these viruses range from very mild to severe with high morbidity and/or mortality rates and high losses to the economy. CoVs' most peculiar feature is their mechanism of replication and transcription, which allow generation of variants capable of interspecies and intraspecies infection. TGEV, for instance, which infects dogs, gives rise to a PRCOV variant that circulates in pig herds. The feline CoVs FECV and FCoV are also examples of intraspecies variants.+ cytotoxic cells. Nevertheless, viral evasion strategies inflict a noticeable setback by initiation of apoptosis. However, ample evidence advocates a long-lasting memory. Animals and bird vaccines for CoVs have been applied extensively in the field, but their efficacy remains questionable, especially FCoVs and IBV vaccines.Despite the elicitation of innate responses that lead to the priming of interferon stimulated genes, the evasion mechanism of CoVs is capable of rendering the innate responses flawed. Cellular immune responses, on the other hand, were shown to be elicited effectively by CoV infection, particularly the CD8The pursuit to designate the susceptible animal models to study the SARS-CoV and SARS-CoV2 pathogenicity continues. Although the infections are restricted to the upper respiratory tract, experimental infection of ferrets and cats indicate advanced clinical signs. Experimental infection of macaques, on the other hand, revealed mild symptoms in the upper and lower respiratory tract. Overall, designating susceptible animal models for SARS-CoV and SARS-CoV2 requires further efforts. Prospects for success could lie in developing genetically modified animal models (induced models). The failure of the therapeutic trials of several drugs to treat SARS-CoV2 in humans emphasizes the need for intensive research in this aspect.The high recombination and mutation dynamic of CoVs make in-depth research into the factors and determinants that give rise to new emerging zoonotic variants urgent. Extensive investigation into the anthropogenic factors is vital to anticipate the spillover hotspots and to design measures that prevent or encounter the newly emergent zoonosis.The overwhelming experiences in tackling CoV infection in animals and research in vaccination failure urge close collaboration by interdisciplinary experts by implementation of the One Health concept.All authors listed have made a substantial, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Dear Readers,1 One major reason for this trend is that patients undergoing CIED implantation now are predominantly older and have more comorbidities as compared with those being implanted 10 years ago.Cardiovascular implantable electronic device (CIED) infection is a serious adverse event that can occur following device placement. To date, the number of CIED-related infections has been increasing, with the rate of escalation having already surpassed the rate of growth of cardiac device implantation.Infected hardware often contains vegetations that can be detected by echocardiogram prior to or during the procedure. Surgical extraction has been the preferable management option in the presence of large vegetations; however, surgical extraction is associated with increased morbidity and cost versus percutaneous extraction.4 In the current issue of The Journal of Innovations in Cardiac Rhythm Management, the authors of an original article titled “AngioVac Debulking in Endocarditis Patients with Large, Device-related Vegetations”5 describe a series of five cases of vacuum-assisted removal of lead-related vegetations and CIED extraction. The debridement of the vegetations was performed either prior to or along with percutaneous lead extraction and all extractions were successful despite the larger size of the vegetations .Vacuum-assisted thrombectomy has been used in the field of interventional cardiology for some time. More recently, the same devices have been introduced to the field of cardiac electrophysiology, with small feasibility studies having demonstrated their value in debulking vegetations prior to or in conjunction with percutaneous lead extraction.Vacuum-assisted debulking of infected CIED leads represents an elegant adaption of an existing technology to fulfill an unmet need in cardiac electrophysiology. However, experience using this technology in combination with CIED extraction remains limited. Larger studies are needed to confirm the benefits suggested in the existing literature.The Journal of Innovations in Cardiac Rhythm Management.Best wishes for a relaxing rest of the summer and I hope that you enjoy reading this issue of Sincerely,MD, FHRS, FACCMoussa Mansour, Editor in ChiefThe Journal of Innovations in Cardiac Rhythm ManagementMMansour@InnovationsInCRM.comDirector, Atrial Fibrillation ProgramJeremy Ruskin and Dan Starks Endowed Chair in CardiologyMassachusetts General HospitalBoston, MA 02114


Proper strategies to minimise the risk of infection in individuals handling the bodies of deceased persons infected with 2019 novel coronavirus (2019-nCoV) are urgently needed. The objective of this study was to systematically review the literature to scope and assess the effects of specific strategies for the management of the bodies.We searched five general, three Chinese and four coronavirus disease (COVID-19)–specific electronic databases. We searched registries of clinical trials, websites of governmental and other relevant organisations, reference lists of the included papers and relevant systematic reviews, and Epistemonikos for relevant systematic reviews. We included guidance documents providing practical advice on the handling of bodies of deceased persons with suspected or confirmed COVID-19. Then, we sought primary evidence of any study design reporting on the efficacy and safety of the identified strategies in coronaviruses. We included evidence relevant to contextual factors . A single reviewer extracted data using a pilot-tested form and graded the certainty of the evidence using the GRADE approach. A second reviewer verified the data and assessments.We identified one study proposing an uncommon strategy for autopsies for patients with severe acute respiratory syndrome. The study provided very low-certainty evidence that it reduced the risk of transmission. We identified 23 guidance documents providing practical advice on the steps of handling the bodies: preparation, packing, and others and advice related to both the handling of the dead bodies and the use of personal protective equipment by individuals handling them. We did not identify COVID-19 evidence relevant to any of these steps.While a substantive number of guidance documents propose specific strategies, we identified no study providing direct evidence for the effects of any of those strategies. While this review highlights major research gaps, it allows interested entities to build their own guidance. There is scarce evidence on the transmission of coronavirus disease 2019 (COVID-19) and other coronaviruses from the dead bodies of confirmed or suspected cases.There are uncertainties about how to handle the bodies of deceased persons with confirmed or suspected COVID-19.The main findings of this review are based on guidance documents as opposed to primary studies.We identified one eligible study that evaluated a biosafety level 3 laboratory for autopsies of patients with SARS.We summarised the steps from 23 guidance documents providing practical advice on the steps of handling the bodies and the use of personal protective equipment by individuals handling them.WHO will use the findings of this study to inform its response to the COVID-19 pandemic.The interpretation of the findings needs to consider that the included guidance are not supported by direct evidence.There are additional research questions on the modes of transmission of COVID-19 from dead bodies to individuals, the desirable and undesirable effects of each management strategy, and contextual factors that require evidence.On 11 March, WHO characterised the 2019 novel coronavirus (2019-nCoV) outbreak as a pandemic. On 20 April 2020, the pandemic had affected more than 2 400 000 individuals worldwide. Over the same time period, it has claimed the lives of 165 000 individuals.et al reported that 27.8% of healthcare workers in contact with deceased cases of severe acute respiratory syndrome (SARS) contracted the coronavirus.The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), has been characterised as highly contagious, with a relatively high case fatality rate, compared with other viral respiratory infections. This has created anxiety about the preparation and the burial of the bodies of deceased persons with suspected or confirmed COVID-19. There appears to be scarce evidence on the transmission of COVID-19 and other coronaviruses from the dead bodies of confirmed or suspected cases. In one study, Liu Individuals at risk include healthcare workers, morgue staff, transport staff, family members, crematories staff, burial staff and religious staff. It is also a cultural challenge, as some cultural aspects and religious practices may influence how the bodies are handled and the associated risk of transmission. Moreover, the acceptability of different management strategies might vary across cultural and religious groups.The objective of this study was to systematically review the literature to first scope, and then assess the effects of, specific strategies for the management of the bodies of deceased persons with suspected or confirmed COVID-19. We conducted a rapid systematic review, commissioned by WHO, to be able to inform their response to COVID-19 pandemic.https://osf.io/j3nft).The protocol was submitted to PROSPERO; however, it was not accepted because of the scoping component. We have registered the protocol in Open Science Framework . Two information specialists peer reviewed the search strategy. Other members of the team, particularly the content experts, provided feedback to the search strategy. An additional search strategy was developed to identify indirect evidence from systematic reviews on SARS and MERS. We searched the following general electronic databases: Medline (using OVID platform), PubMed, EMBASE, CINAHL (using OVID platform) and the Cochrane Library. We also searched COVID-19-specific electronic databases such as COVID-19 Open Research Dataset (CORD-19), COVID-19 Research Database maintained by WHO (including its daily updates), Epistemonikos COVID-19 L·OVE platform and EPPI Centre living systematic map of the evidence. In addition, we searched Chinese databases such as WHO Chinese database, CNKI and China Biomedical Literature Service. 10.1136/bmjgh-2020-002650.supp1Supplementary dataAdditional searches included searching for registered clinical trials in both the U.S. National Library of Medicine Register of Clinical Trials  and the WHO International Clinical Trials Registry Platform, searching for relevant documents on the websites of governmental and other relevant organisations, screening reference lists of the included papers and relevant systematic reviews, and searching Epistemonikos for relevant systematic reviews addressing SARS and MERS.We included studies meeting specific criteria for the population, interventions, comparisons and outcomes of interest. Our populations of interest included the bodies of deceased persons with suspected or confirmed COVID-19, and the individuals handling those bodies, including nursing and medical personnel, morgue staff, transport staff, family members, crematories staff, burial staff and religious staff. In addition, and as a source of indirect evidence for primary studies, we considered primary studies and systematic reviews about the bodies of deceased persons with suspected or confirmed infections with either SARS virus or the MERS virus, as well as the individuals handling those bodies. The interventions of interest included any strategy to manage bodies of deceased persons, during the different phases of the process. These strategies would address either the bodies themselves or the individuals handling them. The outcomes of interest included risk of COVID-19 transmission to the individuals handling the bodies and to members of the community, morbidity and mortality associated with COVID-19, unintended harms of the management strategies, acceptability by different stakeholders , and surrogate outcomes such as contact or droplet transmission. Also eligible were studies providing evidence relevant to contextual factors such as acceptability, feasibility, impact on equity and resources considerations related to the interventions of interest.We included any study design including randomised controlled trials, non-randomised studies  and qualitative studies. In addition, we included guidance documents on the handling of bodies of deceased persons with suspected or confirmed COVID-19 identified from the websites of relevant organisations and national authorities by content experts and peer-reviewed literature.We exported the literature search results to EndNote X9 for de-duplication, then to Covidence software. All reviewers pilot-tested a standardised title and abstract screening form using the same 30 citations. Once the form was calibrated, the reviewers screened in duplicate and independently all titles and abstracts using above listed eligibility criteria. We obtained the full texts for citations judged as potentially eligible by either reviewer.All reviewers pilot-tested a full-text screening form using the same five full-text articles. Once the form was calibrated, the reviewers screened the full texts independently and in duplicate and resolved any conflicts by discussion, or with the help of a third reviewer. We recorded the primary reason for exclusion at the full-text screening stage.We developed and piloted with all reviewers a standardised data abstraction form in Excel.Two independent reviewers extracted data using that form. We extracted data about the following: study identifier; study design; setting; population characteristics; intervention and comparator characteristics; outcomes (quantitative if possible); source of funding and reported conflicts of interests; ethical approval; study limitations or other important comments. For the identified guidance documents, a single reviewer extracted data and a second reviewer verified the extracted data. We extracted data about the publishing organisation and country, whether the documents were dedicated to COVID-19 dead bodies management, as well as specific guidance under each step of the process. We also extracted information on personal protective equipment (PPE).One reviewer was to perform the risk of bias assessment and a second reviewer would verify all assessments. We planned to use the Newcastle-Ottawa scale for non-randomised studies.www.gradepro.org) software.We synthesised the data in both narrative and tabular formats. A single reviewer graded the certainty of the evidence using the GRADE approach and a second reviewer verified all assessments.We report the evidence profile in We identified 23 guidance documents providing practical advice on handling suspected or confirmed cases of COVID-19 corpses throughout the different phases. We have summarised the content of these documents in three tables in The majority of the documents were published in English . Eight of the 23 documents (35%) were entirely dedicated to handling of COVID-19 dead bodies. Most of the documents specified that bodies were for suspected or confirmed COVID-19 corpses . Settings most commonly addressed in those documents were the hospitals , healthcare facilities  and communities .et al to set up the autopsy laboratory reduced the risk of transmission to the personnel handing dead bodies.In summary, we did not identify any direct evidence relating to the effects of specific strategies for the management of the bodies of deceased persons with suspected or confirmed COVID-19. Even when expanding to consider indirect evidence, we found scarce literature relating to SARS and MERS infections. The one study we identified provides very low certainty evidence that the specific approach used by Li This review has a number of strengths. First, we searched for indirect evidence relating to two other coronaviruses that are similarly dangerous to COVID-19, that is, SARS and MERS. Second, we used a very comprehensive search of both the indexed and grey literatures, with no restrictions to specific languages or study design. Third, and despite the short timeline for conducting the review (7 days), we were able to use a standard systematic review methodology for the primary studies, that is, without any shortcuts sometimes used in rapid reviews. We were able to achieve this through the involvement of a large and experienced systematic review team. One limitation of our study is that we did not use a duplicate approach for data extraction and synthesis for the guidance documents.The primary evidence was limited only to management of autopsies and does not cover the main steps of handling of dead bodies. Also, the availability of BSL-3 laboratories and autopsy rooms may be a barrier in many settings, especially for low-resources settings.The guidance documents proved to be very useful in identifying discrete steps in the management of bodies of deceased persons with suspected or confirmed COVID-19. We noted some variability in the strategies adopted for the different steps across these documents. One limitation of the guidance documents is the lack of consideration of cultural practices around death . Still, and given the lack of primary research, these documents can be helpful to governmental or non-governmental entities when developing such guidance.There might be significant harms from the transmission of COVID-19 from the bodies of deceased persons considering the number of deaths currently observed and anticipated in the COVID-19 pandemic. There is one report on a forensic practitioner in Thailand who had contact with biological samples and corpses of COVID-19 and contracted the virus.In the absence of such evidence, the synthesis of guidance documents, provided in While the risk of infection from dead bodies is deemed to be low, a precautionary approach using PPE including gloves, gown, mask and goggles would be reasonable where direct contact with dead bodies or fluid spray from dead bodies is possible. Only two guidance documents recommended the use of N95 respirators for the handling of dead bodies.There are three types of related questions that require research evidence. First, there is a need for evidence on the modes of transmission of COVID-19 from bodies of deceased persons to the different types of individuals handling those bodies. Such evidence is essential to propose potentially effective management strategies. Second, there is a need for evidence on the desirable and undesirable health effects and other consequences of proposed management strategies. Third, there is a need for contextual evidence in relation to these proposed management strategies . Such evidence is extremely important given the cultural and religious dimensions of the handling of bodies of deceased patients.


Over the past decade, there has been a growing awareness of the vital role of the microbiome in the function of the immune system. Recently, several studies have demonstrated a relationship between the composition of the microbiome and the vaccine-specific immune response. As a result of these findings, the administration of probiotics has been proposed as a means of boosting vaccine-specific immunity. Early results have so far been highly inconsistent, with little evidence of sustained benefit. To date, a precise determination of the aspects of the microbiome that impact immunity is still lacking, and the mechanisms of action are also unknown. Further investigations into these questions are necessary to effectively manipulate the microbiome for the purpose of boosting immunity and enhancing vaccine-specific responses in infants. In this review, we summarize recent studies aimed at altering the neonatal gut microbiome to enhance vaccine responses and highlight gaps in knowledge and understanding. We also discuss research strategies aimed at filling these gaps and developing potential therapeutic interventions. Following the relative sterility of the intrauterine environment, the microbiome is seeded from the earliest postnatal microbial exposures. The early life maturation of the microbiome also coincides with the period when the immune system is undergoing rapid development and is most susceptible to perturbations in the microbial environment. This early period of microbial and immunological maturation coincides with the timing of the primary series of immunizations. Thus, these early influences have the potential to have significant long-term effects on the development of vaccine-specific immunity.Bacterial diversity increases over the first year of life  and by 2in utero environment is sterile has been challenged in recent years by studies reporting evidence of prenatal microbial colonization resulting from exposure to microbial communities of the placenta and amniotic fluid  and extracellular vehicles (EV) found in breast milk also influences the development of the infant microbiome. HMO are soluble complex carbohydrates which are indigestible to the infant. They function as a prebiotic, binding pathogenic bacteria, and modulating the intestinal immune response to promote beneficial bacteria , such ascrobiome .The definition of environmental effects on the infant microbiome covers a broad category that involves both intrauterine exposures , and the postnatal environment ; these have been previously reviewed in references , 27. AltBacteroides and Bifidobacteria  cell 2 response . In germfragilis . Colonizfragilis . Additiofragilis , 52. Thefragilis , 52.Furthermore, although the majority of studies conducted thus far have investigated the effect of the microbiome on the immune system, there is also evidence demonstrating that the immune system facilitates the maintenance of factors essential to the host-microbe relationship . The lacLactobacillus acidophilus for the first 6 months of life demonstrated reduced IL-10 responses to tetanus toxoid (TT) vaccine  can shift the balance toward a Th1 response   . Antibiocolitis) . Additiocolitis) . In contcolitis)  and did colitis) . These fFinally, impaired vaccine responsiveness has been reported in low-income settings compared to wealthier regions –77. ThesGiven that the intestinal microbiome of infants is still developing and is characterized by low diversity and rapid change , it has Bifidobacteria displayed an enhanced polio-specific response following vaccination and a positive correlation was observed between total Bifidobacteria as a percentage of intestinal flora and titres of anti-poliovirus IgA (Lactobacillus rhamnosus GG (LGG) had an increased rate of rotavirus IgA seroconversion (Lactobacillus paracasei F19 (LF19), from 4 to 13 months of age, demonstrated an increase in immune responses to diphtheria following vaccination, with no difference in Hib or tetanus-specific IgG levels  was associated with a reduction in infant antibody responses to tetanus, Hib, and pneumococcus vaccines , (3) a standardized approach to evaluate the microbiome in order to allow comparisons among different cohorts   longitudinal prospective cohort studies in infants across a broad geographical and socioeconomic spectrum to define the ontogeny of the microbiome ontogeny, (2) utilization of both olomics) , 95, andWe believe the above strategies will not only improve the gaps in understanding the microbiome-immune system-vaccine interplay but could also help decrease mortality and morbidity in the pediatric population by developing potential therapeutic interventions and enhancing immunogenicity.CR, OO, and KS conceived the manuscript, co-wrote and reviewed the content. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To devise a simple, fast, and low-cost method for glaucoma assessment using digital image analysis of the angle and optic nerve in human subjects.  Images from glaucoma and fundus assessment were used in this study, including color fundus photographs, standard optic nerve optical coherence tomography (OCT), and digital slit-lamp images of the angle/gonioscopy. Digital image conversion and analysis of the angle using ImageJ  and adaptive histogram equalization contrast-limited AHE (CLAHE) to prevent noise amplification were implemented. Angle and optic nerve images were analyzed separately in the red, green, and blue (RGB) channels followed by 3D volumetric analysis of the degrees of angle depth and cup volume of the optic nerve. Horizontal tomogram reconstitution and nerve fiber detection methods were developed and compared to standard OCT images. B-scan of the cup, respectively. RGB channel splitting and image subtraction produced a map closely resembling that of the retinal nerve fiber layer (RNFL) thickness map on OCT.  Digital slit-lamp angle images showed similar accuracy as standard anterior OCT measurements. Comparative analysis of RGB channels produced volumetric cup and horizontal tomogram, which closely resembled the 3D OCT appearance and  While OCT imaging is rapidly progressing in the area of optic disc and chamber angle assessment, rising healthcare costs and lack of availability of the technology open a demand for alternative and cost-minimizing forms of image analysis in glaucoma. Volumetric, geometric, and segmentational data obtained through digital image analysis correspond well to those obtained by OCT imaging. The need for improved management of glaucoma seems obvious with the increasing prevalence worldwide. A recent study correctly predicted that a total of 79.6 million people will be affected by glaucoma in 2020, which is indeed the case today. Out of these, bilateral blindness was estimated to occur in 11.2 million . In the Glaucoma is classified as a group of diseases with progressive damage to the optic nerve. It can be divided into primary open angle glaucoma (POAG), primary angle-closure glaucoma (PACG), and secondary glaucoma. The most recognized risk factor for glaucomatous progression is increased intraocular pressure (IOP), which occurs in eyes with an imbalance between aqueous liquor production and drainage through the angle. In this matter, the angle drainage becomes essential, and angle anatomy is doubtlessly an important factor for assessment in glaucoma management. Worldwide, the prevalence of POAG shows variation, which can be attributed to multiple factors including ethnicity. Meta-analysis reveals a prevalence of POAG of 1.4% in Asian, 2.0% in Caucasian, and 4.2% in the African population . In contThe burden of blindness from glaucoma is challenged not only by the increasing number of cases but also by the difficulties to recognize the affected population. Glaucoma is an asymptomatic disease, which only raises suspicion when it becomes advanced. Studies have estimated the prevalence of undetected glaucoma to be 50% in developed countries and up to a striking 98.5% in developing countries –12. On tThe notable number of undetected glaucoma cases and overtreated patients has given rise to multiple evaluations of screening tools to trace unrecognized glaucoma. Yet, the United States Preventive Services Task Force (USPSTF) has indicated a lack of convincing evidence to facilitate regular screening, whereas no screening tool has been shown cost-beneficial to date , 16. TheIn addition to the increasing burden of glaucoma, the imminent shortage of healthcare professionals worldwide strengthens the need for the development of cost-beneficial screening methods , 18. In B-scans, and the provided standard grade for glaucoma.Images from glaucoma and fundus assessment were used in this study, including freely available/online color fundus photographs, standard optic nerve optical coherence tomography (OCT), and additional digital slit-lamp images of the angle obtained by gonioscopy . Applying the diagnostic criteria for glaucoma, a novel method is hereby aimed at showing similarities and possible data correlation between findings, data presented by Standardization of the fundus images was achieved through known methods of image processing by ImageJ . Normalization of the histographic information across each image was achieved as volumetric representation and was derived from image intensity. As image intensity varied according to camera exposures, histogram equalization (HE) was needed to standardize the images. In addition, comparative to HE, contrast-limited adaptive histogram equalization (CLAHE), a tool designed to prevent the over amplification of noise that adaptive HE can give rise to, was used in the study. Splitting of the color fundus images into red, green, and blue (RGB) channels was performed to achieve optimal comparison and dynamic range of the images acquired.After application of CLAHE in the regions of interest (ROI), the images were converted into a 3D representation in ImageJ by adjusting volumetric measurements of the image intensity through a 3D rendering on the screen and an interactive 3D-surface plot function. Splitting of the RGB was carried out consequently, and the optimal channel was selected for further analysis. Images taken from the fundus were imported into ImageJ for further analysis.Images were split into RGB, and then, the differences between the channels were observed, and a spectrum lookup table was applied to allow image intensities to be compared to the gold standard images and data produced by the RNFL analysis given by the spectral domain Topcon 3D-2000 OCT. RGB fundus imaging separates a fundus image into three wavelength components to help visualize the retinal pigment epithelium/choroid (red filter), neural retina (green filter), and nerve fiber layer (blue filter). This allows for better visualization of the retinal tissues .RGB color splitting allowed for a more averaged distribution of the intensity range across the ROI selected by the user . The colParameters in the screen were adjusted to the range as shown in The review of split RGB channels concluded that the green channel harvested better information . HoweverThe images, both by profile and when rendered in 3D, appeared to show a close resemblance to the tomographical images shown in Splitting of the RGB channels in the fundus/optic nerve images  and obtaNormalization of histographic information across angle images obtained from gonioscopy is important to standardize the image intensity across a dynamic range and across the image ROIs. The CLAHE filter can be applied initially to RGB split images to look for the best possible profile in the intensity images. ImageJ splitting of fundus images into red, green, and blue color channels allows a simple way to obtain monochromatic renderings from any full color acquisitions; a disadvantage of doing so is that some loss in resolution can occur as a result of viewing just a single channel. Nevertheless, as exposure often needs to be increased to compensate for light loss when a physical filter is introduced into the light path of the fundus camera, this splitting technique allows for a more comfortable exposure for the patient when taking the image.Green light is typically focused deeper into the retina, while red light is particularly good for visualizing the retinal pigment epithelium and the choroid, and blue light is good for determining the nerve fiber layer. Digital retinal photography is unique in comparison to film-based techniques; it allows for the immediate adjustment of exposure settings and offers easy contrast enhancement. The disadvantage to digital imaging is the linear response and narrow exposure latitude of currently available digital sensors. The problem of dynamic range has been acknowledged by a number of digital single lens reflex (DSLR) manufacturers; so, for example, some cameras have an automatic exposure bracketing mode that is used in conjunction with the high dynamic range imaging software. Some sensors such as the Fujifilm Super CCD combines sensors of different sizes to give increased dynamic range, while other manufacturers use in-camera software to prevent highlight overexposure such as the D-Lighting feature from Nikon.Unlike the traditional single-lens reflect camera, screeners take images on a fundus camera where the exposure settings have been typically predetermined by the software for standardization. The only variable the screener has to mitigate is the limited dynamic range of digital sensors due to small pupil settings or the flash level of the fundus camera. This is especially important to consider when imaging the optic nerve because of the stark contrast between the nerve and the surrounding retina. Images can also suffer from degradation caused by media opacity, and assessability has to be considered before reading such images .It is important to have proper exposure as well; over or under exposure can be detrimental to digital image quality, while the exposure control requires a delicate balance between flash output, sensor gain, and gamma settings. The International Standards Organization (ISO) has a standardized scale for measuring the sensitivity of the film to light. These standards have traditionally been used with film-based fundus cameras .The 3D volumetric measurement of image intensity and analysis of the profile of the cup was made possible by applying CLAHE in the ROI and by conversion of the images into 3D representative images in ImageJ and adjusting the volumetric measurements of the image intensity through a 3D rendering on the screen and an interactive 3D-surface plot function. Splitting of the RGB allowed for selection of optimal channel for further analysis. Using multiple filters in a photo assay style approach, one can provide the examiner with more than one monochromatic interpretation of the fundus, as is the case of epiretinal membranes and macular pigmentary changes detected at 490 nm, 540 nm, and 615 nm wavelengths.Using a modern retinal fundus camera, retinal ganglion axons can also be directly observed. The fine nerve fibers reflect when imaged  and alloMultiple examinations are used in conjunction for diagnosis of glaucoma. The lack of a definitive reference standard limits both their specificity and sensitivity. Furthermore, there is no evidence that any combination of tests is superior in terms of patient outcome or cost-effectiveness . Glaucomo visualization of the drainage structures is the best achieved by gonioscopy, which is still a gold standard in angle grading. To our current knowledge, total internal reflection from the chamber angle cannot be surpassed; otherwise, the need of a contact gonio lens appears to be a major weakness in designing a fast, infection-proof, noncontact, and reliable method suitable for screening. Nevertheless, image analysis of angle anatomy can be useful for future implications. Indeed, by applying the same contrast enhancement and volumetric measurement techniques described above on the temporal corneal periphery in photographs of the anterior segment, we can simulate the examination without the need of an additional light source for the slit beam.When making the diagnosis of glaucoma, physicians fail to properly complete gonioscopy about 50% of the time . The truScreening strategies for glaucoma with early diagnostic and prognostic value may decrease the societal cost in all regions of the world, especially among low-income earners. With the rising availability of less costly retina digital cameras, which cost 80% less to acquire than an OCT equipment itself , 44, a cAltogether, we hereby present an alternative low-cost way to detect and manage glaucoma prospectively by applying a glaucoma assessment method using volumetric, geometric, and segmentational data obtained through digital image analysis, which correspond well to those obtained by high-definition OCT imaging. While the OCT technology is rapidly progressing in the area of optic disc and chamber angle assessment, rising healthcare costs and lack of availability of the technology open a demand for alternative forms of image analysis in glaucoma.


In 2016, the issue of the Environmental Protection Tax Law indicated the enhancement of environmental protection in China. This study examines the market reaction to firms in heavy-polluting industries, and the effects of external legal institutional quality and internal environmental disclosure on firm value around the passage of Environmental Protection Tax Law. Using an event study approach coupled with ordinary least square regressions, the researchers find a significantly negative market reaction to firms in heavy-polluting industries, but this negative reaction varies depending on the expected increase in future regulatory costs. Specifically, the above negative reaction is stronger when the firm reveals that itself or its subsidiary belongs to heavy-polluting industry, however it would be mitigated when a firm is in a region with better quality of legal institutions or discloses environmental improvement activities. Overall, the results are consistent with the market perceiving that the environmental protection tax law enacted would increase regulatory costs for firms in heavy-polluting industries, and also show the higher-quality regional legal institutions and more efforts on environmental protection could relieve the market’s pessimism caused by uncertainty. Public and government attention to the environment are increasing along with the surge in pollution levels in China since 2013 [The literature reveals the effects of regulatory costs on firm value based on predicting the government’s future environmental regulations after environmental disasters or increasing haze levels ,3. LogicThe regional legal quality represents the effectiveness of regulation implementation . The autUsing an event study approach combined with ordinary least square regressions, the authors find a significant, overall negative market reaction to firms in heavy-polluting industries at the time the tax law passed, and this negative reaction varies depended on regional legal quality and firms’ disclosures of their heavy-polluting status and environmental improvement activities. Specifically, the negative market reaction was stronger when the firm admitted that itself or its subsidiary belonged to heavy-polluting industry. However, it could be mitigated by higher-quality regional legal institutions or the disclosure of environmental improvement activities particularly by a narrative language.This study seeks to make three main contributions. First, the authors explore market perceptions of regulatory costs in a unique setting, where the regulations are under transitions and the regional legal institutions are developed unevenly. Second, in the aspect of regulatory costs, this study enriches the research on how macro-level policies influence firm value through examining the market reaction to the passage of the Environmental Protection Tax Law. Third, our research enhances the understanding of the role of environmental information disclosure on firm value. The inconclusive arguments about the role of environmental information disclosure in previous literature is partly because of the potential endogeneity problems . It is oThe outline of this paper is organized as follows: the second section introduces the institutional background in China, followed by the development of research hypotheses based on relevant literature. After that, this paper outlines our sample and empirical methodology with the analyses of empirical results. The final section makes the conclusions.Due to the rapid economic development through industrialization and urbanization, China has become the world’s second-largest economy since 2010 and the biggest energy-consuming country in the world . Along wIn order to mitigate severe environmental problems, the Chinese government has enacted a series of laws and regulations to handle environmental problems. On the one hand, in order to control emissions, a set of environment-related laws has been issued in China, such as the Environmental Protection Tax Law in 2016 by the National People’s Congress . The envthe Bulletin on Disclosure of Corporate Environmental Information announced by the State Administration of Environmental Protection  required firms which discharge pollutants above the levels specified by governments to disclose environmental-related information annually [the Regulation on Environmental Information Disclosure for Listed Firms issued by the Shanghai Stock Exchange enforced corporate environmental information disclosure for listed firms when itself or its subsidiary belongs to heavy-polluting industries recognized by the government, and allowed voluntary disclosure of environmental information for the rest of firms. The Guidelines on Environmental Information Disclosure for Listed Firms issued by SAEP in 2010 not only enhanced the implementation of previous regulation, but also required that firms in the selected industrial sectors go through environmental audits and make their results public if they intend to apply for public listing or refinancing in the stock market. However, those official rules only provided general guidance rather than detailed ones to generate variation in transparency and breadth of environmental information disclosures by firms located in different regions due to the variation in law enforcement by local authorities [In addition, the Chinese government has enacted a set of regulations to enforce and encourage firms to disclose environmental information. In 2003, annually . In 2008horities .Existing literature has investigated whether the change in expected regulatory costs triggers abnormal market reaction for firms in certain industries. Bowen, Castanias, and Daley  and HillDifferent from Li et al.’s focus on the uncertain future regulatory costs related to haze, the change in regulatory costs caused by the passage of the Environmental Protection Tax Law is relatively easy to document . The incTherefore, we propose the following hypothesis:Hypothesis 1.The market reaction to the passage of Environmental Protection Tax Law is negative for firms in heavy-polluting industries.Although China has made significant efforts in establishing a legal system to control pollution, the enforcement of environmental laws remains a problem . In addiThis regional variation in environmental law enforcement is noted in previous literature ,25, whicPrior to the Environmental Protection Tax, the local Environmental Protection Bureau (EPBs) monitored and measured the level of pollutants and was responsible for collecting discharge fees. The local governments directly managed the local EPBs, and sometimes tended to prioritize economic growth over environmental quality ,27. UndeAfter this reform, local EPBs are only responsible to monitor and evaluate pollutant emissions, and local Taxation Bureaus guided by both local government and the higher Taxation Bureau are in charge of environmental tax collection. The change in responsible institutions improves the compliance cost for firms, particularly for firms with worse tax compliance history. Hence, the market is likely to respond more negatively to firms located in regions with lower-quality legal institutions due to the relatively larger increase in expected regulatory costs for those firms. We propose the following hypothesis:Hypothesis 2.Firms in heavy-polluting industries located in a region with higher-quality legal institutions generates a less negative market reaction around the passage of the Environmental Protection Tax Law.According to disclosure requirements by the Shenzhen and Shanghai Stock Exchanges, a firm must state whether it or its subsidiary belongs to heavy-polluting industries in annual financial report and disclose its environmental information if the firm is in the category of heavy-polluting industries. However, not all firms expected in heavy-polluting industries reveal their heavy-polluting status as required. For instance, CSG Holding Co. Ltd. belongs to non-metallic mineral product manufacturing and construction industries which were recognized as heavy-polluting industries in the 2008 and 2010 Guidelines for Environmental Information Disclosure for Listed Firms. However, in its 2015 financial report, the firm stated that it did not belong to heavy-polluting industries. Similarly, many firms should be classified in heavy-polluting industries but had not truly declared their polluting status in financial reports.Unlike a developed capital market dominated by institutional investors, the majority of Chinese investors are individuals with less experience and investment skills ,31. ChinHypothesis 3.Firms in heavy-polluting industries disclosing its heavy-polluting status in annual reports generate a more negative market reaction around the passage of the Environmental Protection Tax Law.The effect of environmental information disclosure on firm performance is, to date, still inconclusive. Based on the stakeholder theory, one strand of literature suggests that environmental information disclosure will enhance corporate environmental image and reduce the market’s prediction of future regulatory costs ,32. On tThe value of environmental information for investors is to make sure firms would not violate regulations and suffer from high violation costs. The environmental information disclosure may reduce the market’s uncertainty about the firm’s future illegal activities. Specifically, the disclosure of detailed environmental improvement activities would reduce investors’ uncertainty about the firm’s increasing tax burden and make them believe firms still experience sustainable development without the influence of increasing environmental protection tax. Based on previous studies ,36, thisSymbolic environmental improvement information enhances a firm’s social legitimacy . OrganizHypothesis 4a.Firms in heavy-polluting industries experience a less negative market reaction around the passage of the Environmental Protection Tax Law if they reveal environmental improvement activities using a narrative language.Hypothesis 4b.Firms in heavy-polluting industries experience a less negative market reaction around the passage of the Environmental Protection Tax Law if they reveal environmental improvement activities using quantitative data.The researchers combine an event study approach with an ordinary least square regression to document the market reaction to the passage of the Environmental Protection Tax Law on December 25th, 2016 and the effect of expected regulatory costs on firm value. The researchers retrieved data from two sources. The stock trading data and firm-level governance and financial information for A-share listed firms were collected from the Chinese Stock Market & Accounting Research (CSMAR) database . CSMAR, In order to examine whether the market responds differently to firms in heavy-polluting and non-heavy-polluting industries, our initial sample consisted of all Chinese A-share firms listed in Shanghai and Shenzhen stock exchanges on December 25, 2016 after excluding firms without qualified stock trading data to implement event study. The legislative day  is chosen rather than the exercise day  because the former day is the formal announcement day for the enforcement of the Environmental Protection Tax Law which could capture the majority of the effect on stock prices . CompareThe researchers selected the sample according to following criteria: (1) excluding firms without enough stock prices information for event study and (2) excluding the special treatment (ST) listed firms.Further, the researchers differentiate heavy-polluting firms from non-heavy-polluting firms. The selection of heavy-polluting firms is based on research by Du et al. ,46. AccoAfter sifting through the data, the number of observations used for event study to calculate the short-term stock-price performance of firms was 2619, including 721 firms in heavy-polluting industries and 1898 firms in non-heavy-polluting industries. Since only firms with it or its subsidiary belonging to heavy-polluting industries are enforced to disclose environmental-related information in reports, this study further explores the effects of regional institutions and environmental information disclosures on firm value within heavy-polluting firms. Hence the researchers excluded observations  in non-heavy-polluting industries and those with missing data for variables included in regression models. The final sample for cross-sectional analysis consisted of 650 firms  in heavy-polluting industries.The researchers used event study to determine whether and how the market responds differently to firms in heavy-polluting industries and non-heavy-polluting industries by calculating the short-term stock-price performance of firms  around the passage of the tax law. The CAR around the passage of the tax law is calculated based on a market model.i at time t, t, i, i for a given day using i. The CAR for each stock i, was calculated by summing up the abnormal returns over the event window in accordance with the following formula:The researchers first calculated normal return of the stock for each firm by estimating the following standard market model:Based on the sample of firms in heavy-polluting industries, the paper uses cross-sectional analysis to investigate the effects of external legal institutions and internal environmental information disclosure on firm value in the aspect of the market’s perception of expected future regulatory costs. The researchers use Ordinary Least Square regressions (OLS) and adjust standard errors for heteroscedasticity by applying the Huber-White sandwich estimators ,48. Our In order to control the potential effects of outliers, the researchers winsorized all firm-level continuous variables at the 1st and 99th percentiles. Additionally, to mitigate endogenous problems, all firm-level independent and control variables were lagged by one year. Moreover, given that the market reactions might vary across regions and industries, industry fixed effect and region fixed effect were controlled in this study. Specially, industry effect dummy variables were designed based on two-digit industry codes of firms, while region effect dummy variables were designed based on seven different regions in China .th Session of the Standing Committee of the Twelfth National People’s Congress of the People’s Republic of China held during December 19 to 25, 2016. Since the conference schedule was made public on the first day of the meeting, December 19 (day −5) and the first market trading day December 26 (day 0) after the passage of the law were chosen as the beginning and the end of the event window respectively. The researchers calculated a series of CAR within various event windows, and chose CAR  as our dependent variable in main regressions to carry out cross-sectional analysis following the principle that the event window should be short enough to enhance the power of the analysis and sufficiently long to incorporate the full effect of the event . The EnvRlegal measured by the legal environmental index in 2015 from NERI indices to represent the quality of regional legal institutions. For the disclosure of firm’s heavy-polluting status, we used Heavy-pollutingF, a dummy variable, to measure how a firm in heavy-polluting industries discloses its heavy-polluting status. The variable equals one if a firm discloses itself or its subsidiary belongs to heavy-polluting industries in annual reports, and zero otherwise.To examine the effects of regional legal quality, we used EimprovementA and EimprovementC were incorporated in regressions. EimprovementA equals one if a firm describes environmental improvement activities by a narrative language, and zero otherwise. EimprovementC is equal to one if a firm reported an accurate amount of environmental improvement cost, and zero otherwise.In addition, the researchers tested the effects of the disclosure of environmental improvement activities in the following ways. Yin et al. classified environmental information disclosure into symbolic-style disclosure indicating a firm’s environmental strategy and goals by a narrative language, and substantive-style disclosure reporting quantitative data . FollowiFsize, measured with the logarithmic transformation of the total asset; Fage, measured with the number of years since a firm’s initial public offering (IPO) as the end of 2016; Tobin’s Q, measured with market value of the firm divided by the total asset, which indicates growth opportunities for a firm; ROE, return on equity, measured as net income divided by the total equity; Dratio (the debit ratio), measured with the ratio of the total liability to the total asset, reflecting the influence of resource constraints. (2) corporate governance characteristics: Econcentration, measured with the ownership percentage of the ultimate controlling shareholder reflecting the influence of the controlling shareholder; Idirector, measured with the ratio of the number of independent directors over the total number of the board of directors to reflect the quality of corporate governance; SOE, a dummy variable, equaling to one if the ultimate controlling shareholder of a firm is a government agency or government controlled state-owned enterprises, and zero otherwise. The industry and region fixed effects were controlled in this study as well.Based on prior CSR and environmental information disclosure (EDI) studies ,28, we cHeavy-polluting firms was negatively and significantly related to the market reaction while Rlegal and EimprovementA had a positive and significant effect, suggesting that firms disclosing its heavy-polluting status have inferior market reaction but firms located in regions with higher-quality legal institutions or reporting detailed improvement activities enjoy superior market reaction. Multivariate regressions in the next subsections are used to examine whether these preliminary results continue to hold after accounting for firm-level characteristics.Panel A of Since only firms in heavy-polluting industries are required to report environmental information, this study only include heavy-polluting firms in the following cross-sectional analysis by OLS regressions. Specifically, given the leakage of the information, the researchers used CAR  as the dependent variable in main regressions and test the sensitivity of our findings by using CAR , CAR  and CAR  in the robustness check.Fage, ROE, Dratio and Econcentration were consistently negative and significant at the 5% or 10% level, indicating that the investors responded negatively to firms with a shorter listing period, higher prior performance, more debts and more concentrated ownership structure. The market expected that firms with the above characteristics may suffer from a larger increase in future regulatory costs after the new tax law was enacted, consistent with previous studies. Specifically, the market was concerned the younger firms engaging more in environmental conservation [The coefficients on ervation , the higervation , and firervation .Rlegal was significantly positive at the 1% level, providing a strong support to our Hypothesis 2 that the market has more confidence in heavy-polluting firms located in a province with higher-quality legal institutions. The explanation may be that the rigorous enforcement of pollutant discharge fees policy and other environmental laws in those provinces leads to the higher environmental law compliance for local firms, so that the market predicts the less increase in future regulatory costs for firms located in regions with better legal institutions after the tax law was enacted.Model 2 reports the effect of regional legal quality. The coefficient estimate for Heavy-pollutingF was significantly negative at the 1% level, strongly supporting our Hypothesis 3 that firms disclosing its heavy-polluting status triggered a worse market reaction around the new tax law passed because the market predicts those firms would bear a higher increase in tax burden due to their heavy-polluting character.Model 3 shows whether a firm disclosing its heavy-polluting status influenced the market reaction. The coefficient estimate of EimprovementA was significantly positive at the 1% level, which supports Hypothesis 4a that the detailed symbolic description for environmental improvement would lead to superior market reaction. Consistent with our prediction about the influence of substantive disclosure, the coefficient on EimprovmentC was positive. However, the coefficient was not significant, only partially supporting our Hypotheses 4b that the disclosure of accurate environmental improvement investment would lead to a better market reaction. Our results further provide evidence for Yin et al. (2019)’s argument that the symbolic-style disclosure using a narrative language contributed more to the firm’s profitability than the substantive-style disclosure using quantitative data.Model 4 provides an analysis pertaining whether and how the disclosure of environmental improvement information influenced the firm value. The coefficient on Model 5 includes all variables examined in this study and shows that our results were consistent in the final model. All hypotheses and results are summarized in Although the independent and control variables are lagged by one year and industry and region fixed effects are controlled, the researchers used a Hausman test to further ensure there were no endogeneity problems for independent variables chosen in this study. Based on the results of Hausman tests, all p-values are not significant even at the 10% level so that the endogeneity would not be a serious problem for this study. The results are available in Panel A of Additionally, the researchers conducted robustness tests to verify whether our main results still hold by using CARs within different event windows. In Panel B of As environmental quality becomes ever-more important for the public, the Chinese government implements increasingly strict environmental protection regulations. However, there are few studies to look at how environmental policy change influences firm value. This study examines the value effects from the passage of the Environmental Protection Tax Law on heavy-polluting firms as well as firm- and regional-level influential factors in the aspect of expected future regulatory costs. Consistent with published literature, this study also finds an overall significantly negative market reaction to heavy-polluting firms at the time of the tax law passed and provides evidence on the firm value change resulted from the passage of policies and regulations expected to influence future regulatory costs ,3.Given the unique nature of Chinese institutions, this study further investigated whether external regional legal institutions and internal environmental information disclosure explain the variation in the market value change of heavy-polluting firms caused by the passage of the Environmental Protection Tax Law. Consistent with our predictions depending on the market’s perception of the increase in future regulatory costs, the market reaction was more negative for firms disclosing their heavy-polluting status or disclosing environmental information without detailed improvement activities, but less negative for firms located in regions with higher-quality legal institutions or disclosing detailed environmental improvement information.Considering the mandatory environmental information disclosure requirements in China, the market may have viewed firms revealing their heavy-polluting status or disclosing environmental information in reports as likely to experience a larger increase in regulatory costs to comply with the Environmental Protection Tax Law . HoweverThis study has several implications. First, the findings that expected regulatory costs related to the passage of the Environmental Protection Tax Law can affect the shareholder value in China suggest that market investors should pay attention to social development trends and policy changes so that they can adjust their investment to follow general trends. For instance, they could switch to more environmentally-friendly industries and avoid the uncertainty stemming from the increasingly stringent pollution control by the government. Second, the positive influence of the firm disclosing its environmental protection by subjective description on the firm value suggest that market investors do care about firms’ environmental protection value and strategies described by a narrative language. Therefore, a firm should mitigate the market’s concern with the future regulatory costs resulted from the increasingly stricter environmental regulations by disclosing detailed environmental information, in particular narrative information about environmental law compliance and environmental improvement.The implications of our research should be considered within the confines of the limitations. First, this study only takes firms in heavy-polluting industries as the sample to investigate the role of external regional legal quality and internal environmental information disclosure on the firm value around the passage of Environmental Protection Tax Law. The reason is there are lack of environmental disclosure data for most firms in non-heavy-polluting industries who are not required to report environmental information compulsorily. In view of this, future research can collect environmental information data for non-heavy-polluting firms to understand the influence of voluntary disclosure on firm value. Second, this study does not apply carbon emissions data to group heavy and non-heavy polluting firms due to the missing of verified carbon emissions data and the punishment coverage of environmental protection tax. Further studies can use carbon emissions data at firm level to extend our understanding of the influence of regulatory costs on firm value. In closing, the findings are consistent with the notion that the perception of future regulatory costs will influence the market reaction to environmental events or the enforcement of environmental policies. Moreover, this research also shows the external regional legal institutions and internal environmental informal disclosure could influence the market’s perception of the increase in future regulatory costs around the passage of new laws.