Magnetic resonance imaging (MRI) is widely used for the evaluation of moyamoya disease (MMD). In this paper, we describe the features of time-of-flight magnetic resonance angiography (TOF-MRA) and susceptibility-weighted imaging (SWI) at 7 T in a series of MMD patients. In this prospective pilot study, 7 patients  with MMD and no contraindications for MRI underwent T2-weighted, SWI, and TOF-MRA sequences using a research 7 T head-only scanner. We show that such sequences at ultrahigh field (UHF) represent new and valuable approaches to unravel and characterize MMD. While SWI reveals more remarkable imaging signs related to an improved magnitude and phase contrast imaging, the collateral network pathways in MMD could be excellently delineated using 7 T TOF-MRA. In particular, using SWI and MRA fusion images in UHF MRI helps to improve the detection of bleeding points in hemorrhagic MMD. Our findings indicate that ultrahigh field MRI is very promising to access the severity of the disease and may facilitate revascularization surgery of MMD patients. Moyamoya disease (MMD) is a rare cerebrovascular pathology with a progressive steno-occlusion of the major trunks of the intracerebral arteries, accompanied with the development of collaterals called the moyamoya vessels . Due to Susceptibility-weighted imaging (SWI) has been proven to have a higher lesion contrast and sensitivity, which leads to an improved detection of the cerebral hemorrhages compared with the conventional and magnitude-based techniques and/or CT –10. SWI In the past few years, the 3.0 Tesla (T) MRI has played an increasing role in the clinical practice and has been known to be an ideal tool for the comprehensive evaluation of MMD patients –15. CompIn this study, we preliminarily evaluated patients with moyamoya disease using 7 T MRI and attempted to identify some imaging features of the disease.7 individuals  who presented with moyamoya disease from October 2019 to December 2019 underwent both 7 T MRI and digital subtraction angiography (DSA) for the diagnostic confirmation were included in this study. The study was approved by the Research Ethics Board of our institution, and signed informed consents were collected from all the participants.The acquisition protocol comprised four sequences, among which those of TOF-MRA, SWI, and T2 will be discussed in this paper. We obtained TOF-MRA, SWI, and T2 -weighted image volumes using the 7 T scanner . All patients underwent DSA , such that standard intra-arterial DSA was performed with femoral catheterization with 5-F catheters using a biplane DSA unit after the induction of local analgesia or general anesthesia in uncooperative patients. The standard injection rates and volumes were as follows: 4 to 5 ml/s for 8 to 10 ml for the internal carotid artery and 3 to 4 ml/s for 7 to 9 ml for the vertebral artery.The image processing consists of the standardized axial, coronal, and sagittal MIP images. All the postprocessed images were used by the MRI readers in their interpretation of the examination. Kendall's coefficient of concordance was calculated to determine agreement between readings (IBM SPSS Statistics 15.0).The clinical and MR imaging features of the 7 cases included in this study are shown in An independent analysis was performed by the 2 reviewing neuroradiologists and 2 reviewing neurosurgeons. Kendall's coefficient of concordance on the imaging features of the four evaluators were presented in The details of the cases are as follows: case 1: 47-year-old male with asymptomatic intracranial hemorrhage ; case 2:This case series of moyamoya disease patients with diverse symptoms suggests that the TOF and SWI sequences optimized for UHF are new and valuable approaches to better identify and characterize moyamoya disease.In MRI, the signal-to-noise ratio (SNR) increased proportionally with the magnetic field strength and represented the most important factor to decide on the resolution. The clinical applications of TOF angiography have been somewhat limited due to the low spatial resolution obtained at 1.5 T and 3.0 T . TherefoThe elevated concentration of deoxyhemoglobin in the ischemic brain tissue can be detected on SWI due to the increased blood-oxygen-level-dependent (BOLD) effects, which makes the SWI technique a good candidate to reveal the increased oxygen extraction fraction. This phenomenon may appear as hypointensity of the cortical vessels, deep white matter vessel (brush sign), and parenchyma (ischemic tissue sign).In this case series, with a higher spatial resolution, ACVS was frequently discovered on the SWI sequence . Recently, Qian and colleagues  observedCerebral microbleeds (CMBs) were also detected in one case (case 7), which were reported to represent a predictor for hemorrhage in MMD. CMBs are first and foremost a radiological construct describing small foci of blood degradation products in normal  brain tissue after extravasation of blood . DependiMiyakoshi and his colleagues  were theSeveral limitations of this study should be addressed. First, both ACVS and BS are subjective evaluations that are challenging to quantify. Second, the dynamic follow-up of these imaging features was not conducted in this study, and further longitudinal studies are needed to determine whether these features progress along with the disease and disappear after the surgical intervention.This case series showed that the UHF SWI sequence improved the characterization of already known lesions, which emphasizes the delicate intricacy of cortical and vascular anatomy at the subcentimetric level and represents a promising approach to further increase the sensitivity to MMD. In conclusion, MRI at UHF may be promising for the evaluating of MMD especially the risk of hemorrhage.


Social aggression, such as domestic violence, has been associated with a reduced ability to take on others’ perspectives. In this naturalistic imaging study, we investigated whether training human participants to take on a first-person embodied perspective during the experience of domestic violence enhances the identification with the victim and elicits brain activity associated with the monitoring of the body and surrounding space and the experience of threat. We combined fMRI measurements with preceding virtual reality exposure from either first-person perspective (1PP) or third-person perspective (3PP) to manipulate whether the domestic abuse stimulus was perceived as directed to oneself or another. We found that 1PP exposure increased body ownership and identification with the virtual victim. Furthermore, when the stimulus was perceived as directed toward oneself, the brain network that encodes the bodily self and its surrounding space was more strongly synchronized across participants and connectivity increased from premotor cortex (PM) and intraparietal sulcus towards superior parietal lobe. Additionally, when the stimulus came near the body, brain activity in the amygdala (AMG) strongly synchronized across participants. Exposure to 3PP reduced synchronization of brain activity in the personal space network, increased modulation of visual areas and strengthened functional connectivity between PM, supramarginal gyrus and primary visual cortex. In conclusion, our results suggest that 1PP embodiment training enhances experience from the viewpoint of the virtual victim, which is accompanied by synchronization in the fronto-parietal network to predict actions toward the body and in the AMG to signal the proximity of the stimulus. Using a combination of virtual reality and fMRI, our work reveals how first-person perspective (1PP) embodiment increases identification with the virtual victim during the experience of domestic abuse. We showed that when participants are embodied in the virtual victim the fronto-parietal brain network responsible for the representation of the bodily self and its surrounding space showed highly synchronized activity across participants when experiencing domestic abuse. Moreover, in this condition proximity of the aggressor strongly correlated with neural synchronization of the amygdala. We conclude that 1PP embodiment allows participants to identify with the virtual victim through changes in this fronto-parietal network.Perspective taking enhances the ability to understand another person’s actions, thoughts and emotions. In cases where it is more difficult to visualize the other’s viewpoint specific training can be used to support perspective taking. In the virtual body ownership illusion, multisensory feedback, often combined with a first-person perspective (1PP), is used to create the illusion that a virtual body is part of the own body . 1PP andA vast body of literature has documented animal and human threat processing networks in the brain, which include subcortical structures, such as the amygdala (AMG), and the visuo-motor cortex for sensory detection and preparatory responses . For fasTwenty healthy volunteers participated in this study. Half of the participants were male  and half were female . All participants had normal or corrected-to-normal vision and gave their informed consent. Exclusion criteria were the institute’s MRI safety criteria. Because of the nature of the stimuli, we also excluded volunteers who had a criminal record, or a history of physical or emotional abuse. The study was approved by the local ethical committee.The stimuli consisted of a VR scenario, two auditory stimuli containing instructions, and one 3D split-screen video. The VR scenario displayed a female avatar in the hallway of a house , left. TThe experiment consisted of two different sessions, which were one week apart. In the first session, participants were informed about the study and signed the informed consent form. Afterwards, the participants were familiarized with the MRI environment. Subsequently, outside of the scanner room, they put on the Oculus Rift and followed auditory instructions to perform several visuomotor exercises. They saw the VR scenario from either the 1PP or the 3PP . In the 1PP session they looked into a full-length mirror and saw the female avatar performing head movements that were consistent with the participants’ own movements. The synchrony between the female avatars’ movements and the participants’ own movements contributes to the illusion of body ownership , right. After a week, participants came back to the laboratory and followed the same procedure as during the first session, but during this second session they performed the VR exercises from the other perspective . All other aspects of the session were identical. They also filled out the VR questionnaire again at the end of the session and were debriefed about the contents and meaning of the study. Again, the emotional state of the participants was assessed and they were asked to contact the experimenter if they had any reoccurring thoughts or feelings, or were otherwise affected by participating in this experiment. No participant reported to be distressed by the experiment or have persisting thoughts or feelings about the experiment.The order of the VR exposure perspective (1PP vs 3PP) between sessions was counterbalanced across participants, so that half of the males and half of the females had the session order 1PP-3PP and the other halves had the opposite order. The 3D video that was watched during fMRI measurements was identical in both sessions and was preceded and followed by 3 s of fixation. The two experimental conditions were the perception of the 3D video preceded by 1PP VR exposure (1PP session) and the perception of the 3D video preceded by 3PP VR exposure (3PP session). The 3D stimulus was shown once in each session, similar to other naturalistic research .A 3T Siemens MR scanner  with a 64-channel head/neck coil was used for imaging. Functional scans were acquired with a multiband gradient echo echo-planar imaging sequence with a repetition time (TR) of 1500 ms and an echo time (TE) of 30 ms. The functional run consisted of 90 volumes comprising 57 slices . After the functional run, high-resolution T1-weighted structural images of the whole brain were acquired with an MPRAGE with a TR of 2250 ms and a TE of 2.21 ms, 192 slices .The VR questionnaire contained questions relating to the subjective experience of the 3D domestic violence scenario. The scores on the VR questionnaire were compared between sessions (1PP vs 3PP exposure) by conducting an Wilcoxon signed-rank test (two-tailed) on all items, corrected for multiple comparisons using a false discovery rate (FDR) of 0.05 . All sigThe fMRI data were pre-processed and visualized using fMRI analysis and visualization software BrainVoyager QX version 2.8.4 (Brain Innovation B.V.). Functional data were corrected for head motion , corrected for slice scan time differences and temporally filtered . For the ISC analyses, it is recommended to spatially smooth the functional data with a Gaussian smoothing kernel of slightly larger than double the original voxel size . Therefot test, corrected for multiple comparisons using a FDR of 0.05, to ensure that head motion did not differ between sessions. We found no differences in FWD between conditions at any time point (FDR > 0.8). Out of all runs of the 1PP session (20 participants × one session) 90% of runs had 98.9% of time points with a FWD under 0.5 mm (t test. We found no difference between sessions for the mean FWD (t(19) = −0.1212, p = 0.9048). For all participants and sessions, the mean FWD was below 0.5 mm (maximum = 0.2 mm). The grand mean FWD (mean across participants and time points) was 0.0962 for the 1PP session and 0.0958 for the 3PP session.Head motion was below 1.1 mm for every participant (voxel size = 2 mm). We calculated the frame-wise displacement FWD;  for everr 0.5 mm . Out of For the connectivity analyses and the second set of ISC analyses (see below), we defined anatomic regions of interest (ROIs), which included regions relevant for perspective taking, embodiment, peripersonal space, and emotion processing, as well as the superior parietal lobe (SPL), primary auditory cortex (PAC), the primary visual cortex (PVC) and middle temporal area (MT/V5) . Statistx-axis to set the data to radiological format, and rotated the data −90° in the x-axis and +90° in the y-axis to get a sagittal orientation. Subsequently, we transformed the Colin27 anatomic data to Talairach space (Each voxel in a probabilistic region reflects the cytoarchitectonic probability (10–100%) of belonging to that region. We followed a procedure to obtain maximum probability maps as described in ch space  and applN (N – 1)/2). The group-level ISC is the sum of these correlation coefficients divided by the number of subject pairs. The ISC maps for each condition were corrected using an FDR of 0.001. The ISC difference maps between the sessions were calculated as described in The ISC toolbox for fMRI in MATLAB  and in-hz scores using a Fisher z transformation and the mean across all subject pairs was calculated by summing the transformed correlation coefficients and dividing by the number of subject pairs . The first two volumes of the time courses were excluded and the remaining 88 volumes were separated in eight time windows of 10 volumes, which were each separate by 1 volume. Although short time windows could result in less reliable estimates, the minimal window length depends on the stimulus and sample size. Windows of 10 samples have been used previously with 16 participants . Our appct pairs . The corN = 20), i.e., each region served as a reference region. These dGCM maps are maps with an influence difference term for each voxel that has a positive value where influence from the reference region dominates and a negative value where influence to the reference region dominates  plugin of BrainVoyager QX 2.8 and in-house MATLAB scripts to calculate effective connectivity between brain regions. GCM  uses vecominates . The indominates  with an  regions , we compN = 20), i.e., each region served as a reference region. For each reference region the 40 individual, instantaneous GCM maps  were subsequently used in a second level RFX group analysis to calculate differences in functional connectivity between conditions. For the group analysis, a RFX ANOVA, with condition (1PP vs 3PP) as a within-subjects factor, was calculated for each reference region. The resulting whole-brain F-maps were corrected for multiple comparisons using the cluster level statistical threshold estimator plugin of BrainVoyager QX 2.8 . Functional connectivity between two time-series X and Y exists when the values of time-series X enhance predictions of contemporaneous values of the time-series Y, taking into account other sources of influence  to 7 (completely) Likert scale. The differences in answer scores between 1PP and 3PP conditions were analyzed using Wilcoxon signed-rank test, corrected for multiple comparisons at FDR = 0.05 . Our main questions of interest related to differences in perceived body ownership, identification and plausibility. We found that participants reported higher body ownership and identification during the VR threat scenario in the MRI scanner  when theIdentification was assessed with question 1: “To what extent did you feel identified with the female body during the experience?”. The results of the Wilcoxon signed-rank test showed a significant difference between conditions (FDR = 0.03), with higher scores of identification in the 1PP session  showed that 1PP exposure induced higher ISC than 3PP exposure in left dorsal and ventral PM, in bilateral IPS, left SMG, bilateral SPL, right PSC and bilateral PVC during perception of the 3D video . We found that during threat perception preceded by 1PP exposure directed connections from PM, IPS, SMG, and MT toward SPL were stronger , while it did not in the 3PP session . For the ACC and the aINS, the ISC time courses did not correlate significantly with threat distance in the 1PP session  and the 3PP session . These results indicate that when the participants were embodied in the virtual victim after 1PP exposure, the increased intersubject synchronization of the AMG signaled the proximity of the aggressor, while this was not the case after 3PP exposure.Finally, we investigated whether activity in emotion-related structures, such as AMG, is more strongly synchronized across participants when the participants had 1PP embodied exposure than 3PP exposure before the experience of nearby threat. Although we found no evidence for explicit experience of increased threat in the 1PP session in the questionnaire data, the trend (FDR = 0.05) for higher scores after 1PP exposure found on question 12.3: “To what extent did you find the following behaviors of the male avatar threatening – when he invades your peripersonal space and moves his hands?”, suggests that the intrusion into the personal space after 1PP exposure may have had an effect on the consciously or subconsciously perceived threat. We calculated the time course of ISC in the ROIs of three emotion-related structures  using eight non-overlapping time windows of 10 volumes . Subsequently, we correlated the time course of the ROI with a predictor that coded for threat proximity. We found  that durOur first hypothesis was that synchronization of brain activity across participants in the fronto-parietal network will be stronger when a threat is perceived to be in our own space (1PP embodied exposure) than in another’s space (3PP exposure). The results of the ISC analyses indicated a clear effect of 1PP versus 3PP exposure on the neural synchronization in this network. After 1PP exposure we found that all regions related to body ownership and nearby space representation, including PM, IPS, SMG, SPL, and PSC, were more synchronized across participants. This was not the case when participants were exposed to 3PP. We expected that during threat perception in the 1PP session sensory information from PVC, PAC, and PSC would converge via the IPS in the PM, as the PM should initiate the defensive responses. We based this hypothesis on the fact that electrical stimulation of F4 and VIP in monkeys  produces movements similar to defensive movements followed by air puffs , 2004 anAfter 3PP exposure, we observed that brain activity in this fronto-parietal network was not synchronized consistently across participants. We hypothesize that this may indicate that after first-person embodiment the body and nearby space representation is aligned with the virtual body and intrusion of this space synchronizes activity across participants in the fronto-parietal network, while after 3PP exposure this does not occur. Indeed, our ISC findings suggest that exposure to a 3PP does not synchronize the personal space network and this aspect of the results did not provide support for a shared peripersonal space that is independent of perspective. However, the effective connectivity results did show 3PP specific modulations in the fronto-parietal network. We found an increase in connectivity from IPS to PM and an increase of top-down connectivity from the peripersonal space network nodes  toward the PVC and MT. The former results indicate that although information was sent from IPS to PM in line with peripersonal space encoding models and existing anatomic connections , the ISCPrevious research has shown that the temporoparietal cortex [including the temporoparietal junction (TPJ) and SMG] is implicated in perspective taking , interocOur second hypothesis focused on synchronized brain activity in emotion-processing regions during 1PP experience of nearby threat. Threat monitoring and defensive responses are especially enhanced when the threat is near, as shown by a series of experiments with virtual characters  and threIn addition, we found modulations of connectivity toward the emotion processing regions during the perception of the scenario, both after 1PP and 3PP exposure. The connectivity analyses revealed that in the 1PP session PAC and IPS sent information to right ACC and from the right ACC information was forwarded to right AMG and left ACC. The ACC has a general role in decision-making and social and emotional processing  and has Our study provides a clear example of how establishing body ownership in VR outside of the MRI environment, in combination with a 3D video during fMRI measurements, greatly extends the opportunities for adopting more naturalistic methodologies in social and affective neuro-imaging experiments. The scarcity of human neuroscience studies using dynamic threatening stimuli contrasts with the relevance of personal space intrusion in the perception of threat, both for the victims  and for


To determine the association between mammographic density (MD) and the risk of breast cancer (BC) in Chinese women and to investigate the role of fertility risk factors in regulating the relationship between MD and BC.We used Quantra software and the BI-RADS classification to assess MD in 466 patients and 932 controls. Conditional matched logistic multiple regression analysis was used to determine the relationship between MD and BC, and risk was evaluated with the odds ratio (OR) and 95% confidence interval (CI).The ORs for category 4 versus category 2 were 1.95 ) and 1.76 (95% CI (1.28∼2.42)) for the BI-RADS and Quantra classifications, respectively. The ORs for category 5 volumetric breast density (VBD) versus category 2 VBD and 5 fibroglandular tissue volume (FGV) versus category 2 FGV were 1.63 (95% CI (1.20∼2.23)) and 1.92 (95% CI (1.40∼2.63)), respectively. Females with category 5 VBD whose age at menarche was ≤13 years had the highest risk of BC ), and females with category 5 FGV whose age at menarche was = 15 years had the lowest risk of BC ). Females with categories 3–5 VBD and categories 3–5 FGV had reduced risks of BC with increasing number of births. Females with category 5 VBD had an increased risk of BC with increasing age at first childbirth (the OR increased from 1.49 to 1.95). Those with category 5 VBD had a reduced risk of BC with increasing breastfeeding duration (the OR decreased from 2.08 to 1.55). Females with category 5 FGV had a reduced risk of BC with increasing breastfeeding duration (the OR decreased from 4.12 to 1.62).Both the BI-RADS density classification and Quantra measures indicated that MD is positively associated with the risk of BC in Chinese women and that associations between MD and BC risk differ by age at menarche, parity, age at first childbirth and breastfeeding duration. Currently, BC is the cancer with the highest incidence among Chinese females (between 30 and 59 years old) and is the sixth most common cause of cancer death . Compared to the incidences of BC among European and American females, the incidence of BC in Chinese females is low, but the rate of increase in the incidence is more than 2 times that of Caucasian females and is especially prominent in urban areas. The reasons may be due to the unique birth policy in China, the delayed birth of the first child, a reduced breastfeeding time and a Western lifestyle. However, compared with women in Europe and the United States, women in China are usually diagnosed with late-stage BC, and thus, the mortality rate is high.As the most common malignant tumor, breast cancer (BC) has a mortality rate second only to that of lung cancer and seriously affects the health of women. According to global cancer statistics released by GLOBCAN in 2018, it was estimated that there would be 209 million new cases of and 630,000 deaths from BC worldwide in 2018, accounting for 24.2% and 15.0% of all new cancer cases and deaths, respectively.,5 However, studies of the risk association between dense breast tissue and BC have mainly been conducted with Caucasian females.–9 The incidence of BC among Chinese females is relatively low, and as a result, less attention has been given to MD in this population. However, in recent years, the incidence of BC in Chinese women has been increasing yearly,,11 and the ratio of individuals with dense breast tissue is higher among Chinese women than among Caucasian women.The BI-RADS classification is a well-accepted method used by radiologists to assess mammographic density (MD). The studies on MD and BC risk showed that compared to that in females with low breast density (<5%), the risk of BC in females with extremely dense breast tissue (>75%) is increased by approximately 3–5 times.–14 As full-field digital mammography (FFDM) is currently the primary means of BC screening in women, fully automated volume density measurement software such as Volpara, developed in the Netherlands, and Quantra, developed by Hologic, Inc., in the United States, have proven to be effective MD measurement tools, and most studies have shown that there is good correlation and agreement between the fully automated volume density measurement software and the BI-RADS classification.,16 In recent years, several studies have analyzed the risk association between MD and BC using fully automated density software.–19 However, the relationship between MD and BC in Chinese women has not been established. Therefore, the objective of this study was to evaluate the risk relationship between MD and BC in women in Shanxi, China, using Quantra volume density software and the 5th edition of the BI-RADS density classification.The accuracy of the MD measurement affects the relationship between MD and BC. Previously, the most widely used methods were the BI-RADS classification and computer-assisted area measurement using Cumulus software; however, both techniques produce variable results and lack inter- and intra-evaluator reliability, which affects the accuracy of the risk assessment between the 2 factors.22.1This study included a retrospective case-control study nested with large breast screening programs at Shanxi Provincial People's Hospital, which is the largest center for breast disease diagnosis and treatment in the area. From March 2013 to May 2017, 45,369 Han Chinese women underwent an FFDM examination at Shanxi Provincial People's Hospital, which served as the underlying cohort. Incident BCs (n = 466) were eligible during the study period. All patients were diagnosed with BC by surgical pathology or biopsy.The control group derived from healthy females who had a breast screening during the same period of time. Inclusion criteria included:(a) a negative mammographic and ultrasound report (BI-RADS 1-2 category);(b) a negative mammographic and ultrasound report 2 years later. Exclusion criteria included: (a) a history of BC ever;(b) BI-RADS 3 category or greater in mammography or ultrasound reports;(c) a history of breast implants or surgery. A total of 932 individuals  were randomly selected from the 1901 eligible individuals based on age (±3 years) and the FFDM examination date. The age range of the case group was 26∼81 years, and the median age was 50.86 years. The age range of the control group was 26∼81 years, and the median age was 50.06 years.Questionnaires were used to obtain general information, including height, body weight, educational level, occupation, marital status and birthplace; fertility factors, including age at menarche, age at first birth, menstrual status, age at menopause, history of breastfeeding and history of oral contraceptives; and other factors, including history of oral estrogen, history of smoking, history of drinking and family history of BC in immediate family members. For variables with missing data , we plugged in data using the average value for the variable among controls in the same age group. This study was approved by the Ethics Committee of Shanxi Provincial People's Hospital, and all individuals participated in the study voluntarily. All participants were required to sign an informed consent form and to complete research-related questionnaires.2.2The Hologic Selenia Mammography System and Quantra  volumetric density measurement software were used. Each participant underwent examination of both breasts at the standard cranial-caudal and mediolateral-oblique positions. The images of all participants were first evaluated independently by 2 radiologists with more than 10 years of experience, using a double-blind method for the BI-RADS density classification according to the fifth edition of the BI-RADS classification standard. A third senior physician assessed the images of participants whose classifications were not consistent between the 2 radiologists so that a consensus classification was reached among the 3 physicians. The raw imaging data of all participants who underwent mammography were transferred to the breast workstation and the density software processing platform (Cenova DICOM server) for raw data processing. Finally, the Quantra density software automatically generated the bilateral breast Fibroglandular tissue volume (FGV), breast volume and volumetric breast density (VBD) percentage and provided a BI-RADS-like category of the volume density.2.3χ2 test was used for categorical variables. In the analysis of the association between the quintile classification of breast FGV, the quintile classification of the breast VBD percentage among the 1901 normal subjects and the risk factors for BC, continuous variables were analyzed for linear trends using 1-way ANOVA, and categorical variables were analyzed for linear trends using the χ2 test.A conditional logistic regression model was used to analyze the BI-RADS density classification, Quantra density classification, breast FGV quintile classification, VBD percentage quintile classification and the risk of BC between the case and control groups. Finally, using a conditional logistic regression model, we analyzed the risk association of the FGV quintile classification and VBD percentage quintile classification with BC after stratification by fertility factors in the case and control groups. The age at menarche , number of births , age at first childbirth (≤25 years or >26 years), breastfeeding time (1–12 months or >12 months), OR value and 95% confidence interval (CI) were used to describe the risk relationship. Values were considered statistically significant when P was < .05. All statistical analyses were carried out using SPSS version 22.0 software.In the analysis of the general characteristics of all 1398 subjects in the case-control groups, the paired t-test was used for continuous variables, and the 3As shown in Table As shown in Table P values for the within-group trend analysis for both classification methods were <.0001.As shown in Table P values for the within-group trend analysis for both VBD percentage and FGV classifications were <.0001.As shown in Table P = .007), and only females with category 5 VBD (age of menarche ≤13 years) had a significantly increased risk of BC ). Females in all menarche groups had an increased risk of BC with increasing FGV classification , and only those with an age at menarche ≤13 years with category 4 FGV had a significantly increased risk of BC ); females with an age at menarche ≥15 years with category 5 FGV had the lowest risk of BC ).As shown in Table P = .000), and no risk of BC was identified in the group with multiple births. Similarly, in the FGV classification, females with a number of births equaling 1 or 2 had increased risks of BC with increasing FGV classification (both P≤.024), and those in FGV categories 3–5 had a gradually reduced risk of BC with the increase in the number of births. In the risk analysis for age at first childbirth, both age groups had an increased risk of BC with increasing VBD percentage classification (both P ≤.025), and females with category 5 VBD had an increased risk of BC with increasing age at first childbirth (OR increased from 1.49 to 1.95). All age at first childbirth groups had an increased risk of BC with increasing FGV classification (both P ≤.026), and those with categories 4 and 5 FGV had an increased risk of BC with increasing age at first childbirth.In the analysis of the number-of-births risk stratification, only those with a number of births = 1 had an increased risk of BC with increasing VBD percentage classification (P ≤ .028), and those with category 5 VBD had a reduced risk of BC with increasing breastfeeding duration (the OR decreased from 2.08 to 1.55). Females in all breastfeeding duration groups had an increased risk of BC with increasing FGV classification (both P ≤ .013), and those with categories 4 and 5 FGV had reduced risks of BC with increasing breastfeeding duration.In the stratification of breastfeeding duration among those who had given birth, females in all breastfeeding duration groups had an increased risk of BC with increasing VBD percentage classification . Compared to females with category 2 VBD percentages, females in categories 4 and 5 had increased risks of BC . Similarly, compared to females identified as being in FGV category 2, females in category 5 had an increased risk of BC (OR = 1.52). For the BI-RADS-like category of the Quantra software, our results showed decreased risk values for the association between MD and BC compared with the results from the study by Brandt. We further assessed the risk association between the VBD percentage, the FGV quintile classification and the risk of BC in the case and control groups. We found that compared to females in VBD percentage category 2, females in category 5 had an increased risk of BC (OR = 1.63) and that compared to females with category 2 FGV, females identified as having categories 4 and 5 FGV had increased risks of BC . These findings were consistent with those in the study by Brandt et al. A case-control study by Eng et al. also assessed the correlation between the VBD quintile classification using Quantra software and the risk of BC and showed that compared with females in category 1, females in categories 4 and 5 had increased risks of BC , while there was no significant association between FGV quintile classification and the risk of BC.A case-control study by Brandt et al. assessed the association between the BI-RADS-like category of the Quantra software, the quintile classifications of VBD percentage and FGV, and the risk of BC.–23 Our study showed that the proportion of females in category 3, as determined by both density assessment methods, was highest. The conventional BI-RADS density classification method relies on the subjective evaluation of radiologists, which produces variable results and lacks inter- and intra-evaluator reliability.,24 Second, this type of evaluation is affected by image characteristics because the images to be evaluated are generated after reconstruction of the raw data. The majority of studies show moderate or good agreement in the weighted Kappa analysis between the 5th edition of the BI-RADS classification and the Quantra software.–28 Compared to the BI-RADS classification, the MD classification acquired through analysis of the raw data using Quantra volumetric density measurement software has better stability and repeatability. A study by Wang et al. showed that the Quantra density measurements had a good correlation with MRI breast density measurements and could realistically reflect the mammographic dense tissue volume. Therefore, Quantra volumetric density measurement software can more accurately reflect the risk association between MD and BC.Compared to that of Caucasian females, the percentage of Chinese females with BI-RADS category 3-4 density, which is especially prominent among premenopausal females, is higher.,32 and breastfeeding for longer times could reduce the risks of hormone receptor-positive and triple-negative BC. Some studies used the semiautomated area measurement method in Cumulus software to assess the relationship between female fertility factors and MD. The studies showed that the number of births and age at first childbirth were negatively correlated with MD and that breastfeeding time was positively associated with the percentage of dense fibrous breast tissue and dense fibrous area.,36 However, the mechanism of the influence of fertility factors on MD is not yet clear. Two previous studies in a large-scale survey from Chinese females of Han ethnicity analyzed the risk association between fertility factors among the healthy population and MD using BI-RADS density classification and found that the relationship between fertility factors and MD distribution was consistent with the distribution relationship for Caucasian females.,22 Our study investigated the relationship between VBD percentage and FGV quintile classification and the risk factors for BC among 1901 healthy individuals. We found that age and menstrual status had a linear negative association with breast VBD percentage classification and FGV classification and that BMI had a linear negative association with breast VBD percentage classification and a linear positive association with breast FGV classification, which was consistent with a previous study. We also found that menarche and number of births had a linear negative association with VBD percentage classification and FGV classification and that age at first childbirth had a linear positive association with VBD percentage classification and FGV classification, and these findings were consistent with those of previous studies.,35 Finally, we found that breastfeeding time had a linear negative association with VBD percentage classification and a weak linear negative association with FGV classification, which was not consistent with the previous study. Therefore, further studies are required to determine the relationship between breastfeeding time and VBD percentage and FGV classifications.Earlier studies suggested that there was a risk relationship between fertility factors and BC. More births and earlier age at first childbirth could reduce the risk of hormone receptor-positive BC in females, A study by Yaghjyan showed that among females with high MD, compared to those who had given birth to 1 child, those who had multiple births (2 or ≥3) had a lower risk of BC. Our results also showed that among females with a high VBD percentage and high FGV classification, compared to those who had given birth to 1 child, females who had given birth to multiple children had a lower risk of BC, which is consistent with previous studies. Our results showed that with a delay in age at menarche, females with a high VBD percentage and high FGV classifications had a lower risk of BC and that with an increase in age at first childbirth, females with a high VBD percentage had an increased risk of BC; however, females with high FGV classifications had a lower risk of BC, which is consistent with a previous study. Among the population of women who had breastfed previously, compared to females with short durations of breastfeeding (1–11 months), longer breastfeeding durations (≥12 months) resulted in a reduced risk of BC in females with high VBD percentage classifications and high FGV classifications.Fertility factors not only are associated with the risk of BC but also affect only the VBD percentage and FGV distribution of MD among the healthy population, and a higher MD is positively associated with the risk of BC. It is not clear whether fertility factors regulate the risk relationship between MD and BC. Two previous case-control studies assessed the relationships among fertility factors, MD and BC. The study by Woolcott et al. found that among females with high MD, those who had given birth had a lower risk of BC than those who had never given birth.Our study analyzed the association between MD and the risk of BC using the BI-RADS classification and Quantra software to assess MD in case and control groups and confirmed that females of Han ethnicity in Shanxi, China with high MD had an increased risk of BC. The relationship shown in this study between MD and the risk factors for BC among the healthy population is consistent with that found in previous studies, which further confirms the correlation between the distribution of MD among healthy females of Han ethnicity and fertility factors. Finally, we further investigated whether fertility factors could regulate the risk relationship between MD and BC and confirmed this regulation by fertility factors, which could provide a basis for the prevention and treatment of BC.This study has some limitations. We used only Quantra software to assess MD; other software that measures MD should be used to further confirm the association between MD and BC risk in women of Han ethnicity. Moreover, the reference population for establishing the Quantra BI-RADS-like category mainly comprised Caucasian women, and the exact cut-off point thresholds are not specified. Indeed, the use of Quantra density software is still in the preliminary stage. Additionally, this case-control study had a limited sample size; a study with a larger sample size is needed to further confirm our findings.In summary, by assessing the MD of Han Chinese women in Shanxi, China, using the BI-RADS and Quantra methods in a case-control study, we found that women with higher MD classifications had an increased risk of BC and that fertility factors regulated this risk relationship. Further studies are required to confirm this regulation.This study was supported by the Department of Breast Surgery and Pathology at Shanxi Provincial People's Hospital.H.G. Zhao designed the experiments; F.Y. Wang and T.T. Liu administered all questionnaires; and J.M. Wang analyzed all data and wrote the manuscript.Conceptualization: Hong Guang Zhao.Data curation: Tong Tong Liu, Fei Yang Wang.Funding acquisition: Jian Ming Wang.Project administration: Jian Ming Wang.Writing – original draft: Jian Ming Wang.Writing – review & editing: Jian Ming Wang.


Thanks to the collaborative efforts of scientists across the world,2 Sanger sequencing eventually produced a reference human genome, courtesy of the US$2.7-billion (United States dollar) Human Genome Project completed in 2003.3The year 1977 is quite remarkable in the history of genomics. It was the first time that the complete genome of an organism (phage φX174) would be sequenced – the advent of the first generation of sequencing technologies. Of the two sequencing methods published that year, Fred Sanger’s ‘chain-termination’ method would become the mainstay of sequencing technology for the next three decades. Because of its better usability compared to the Maxam-Gilbert method, it was widely preferred and became commercialised4The launch of pyrosequencing by 454 Life Sciences in 2005 marked the beginning of the second generation of sequencing. Massively parallel or next-generation sequencing (NGS) technologies eliminated the need for multiple personnel working on a genome by automating DNA cleavage, amplification and parallel short-read sequencing on a single instrument, thereby lowering costs and increasing throughput.6Pyrosequencing relies on the release of pyrophosphates when nucleotides are washed over fixed DNA clones in a DNA polymerase-mediated reaction . Pyropho1SOLiD™ and Ion Torrent have been in the NGS market since 2007 and 2010, whereas Roche announced the phaseout of 454 Pyrosequencing in 2013 after facing stiff competition in the market. The reversible terminator sequencing currently sold by Illumina is the predominant NGS platform: a sequencing-by-synthesis approach that uses bridge amplification and fluorescent signals from the addition of deoxynucleoside triphosphate (dNTP) to a growing complementary strand . The sig7Next-generation sequencing technologies have made sequencing much easier, faster and cheaper than Sanger sequencing. The August 2019 report from the National Human Genome Research Institute put the cost of sequencing a complete human genome at $942.00 United States dollars (USD). Thanks to NGS, the reduction in cost of genome sequencing has beaten Moore’s Law prediction , more ev3Illumina, introduced in 2006, is the most robust of all NGS technologies. It quickly gained traction among scientists, because of its high throughput and affordability compared to 454 Pyrosequencing, SOLiD™ and Ion Torrent. In fact, Illumina was the first company to fulfil the ‘$1000 genome’ promise with its HiSeq X Ten sequencer in 2014. Sequencing a genome now costs below $1000.00 USD with ongoing efforts to reach the $100.00 USD target.2 Aside from the fact that polymerase chain reaction – a necessary step in SRS – causes preferential amplification of repetitive DNA, SRS fails to generate sufficient overlap sequence from the DNA fragments. This constitutes a major challenge for de novo sequencing of a highly complex and repetitive genome like the human genome.2 The detection of large sequence changes is another area of difficulty that is encountered using SRS – a major barrier to studying structural variations.8All second-generation sequencing technologies have a common limitation – the inability to sequence long stretches of DNA. To sequence a large genome like human DNA using NGS, the DNA has to be fragmented and amplified in clones of between 75 base pairs and 400 base pairs, hence the term ‘short-read sequencing’ (SRS). Computer programs are then used to assemble the random clones into a contiguous sequence.9 Long-read sequencing methods sequence a single molecule – thus abolishing amplification bias – and generate a reasonable length of overlap sequence for better sequence assembly.1Third-generation sequencing technologies which are otherwise called long-read sequencing (LRS) technologies address the shortcomings of NGS. Whereas the Sanger and SRS approaches cannot exceed read lengths of 1 kilobase pair, third-generation sequencing technologies read lengths are between 5 kilobase pairs and 30 kilobase pairs. The longest read length ever generated by a third-generation sequencing technology is 2 gigabase pairs.10 Single-molecule real-time sequencing was commercially released in 2011 by Pacific Biosciences (PacBio). A SMRT genome sequencer consists of millions of zero-mode waveguides – microscopic wells with DNA polymerase fixed at the bottom. Within each zero-mode waveguide, two hairpin adaptors are ligated to both ends of the molecule to form a circular single-stranded DNA. With the aid of a primer complementary to the adaptors, DNA polymerase is used to sequence a complementary strand. When a fluorescent nucleotide is added to the strand, a fluorescence of wavelength corresponding to the added nucleotide is given off. This signal is captured in real time by a coupled charge device camera and interpreted by a computer program.1There are two prominent LRS technologies namely, nanopore sequencing and the single-molecule real-time (SMRT) sequencing.1Nanopore sequencing, released by Oxford Nanopore Technologies in 2014, works by a different principle: threading the DNA molecule through a 1.5 nm wide bioengineered channel embedded in a biological membrane. Electrical current across the channel depends on which nucleotide is traversing the channel at the time. This variation is used to determine the base sequence of the nucleic acid.de novo sequencing, resolution of repeat sequences , detection of structural variations, epigenetics and transcriptome sequencing, among others. However, the accuracy per read and the throughput of LRS is poor compared to SRS.10 Moreover, there are challenges in the adaptability of LRS for sequencing different genome lengths, as LRS data processing takes longer for organisms with large genomes than for viral genomes.10Single-molecule real-time and nanopore sequencing check all of the boxes in terms of suitability for 3 Nanopore sequencing has improved over the years, although it is still not as accurate as NGS.The high error rates of nanopore sequencing are attributed to the poor sensitivity of the nanopore and the inability to control the speed of DNA translocation through the pore. Whereas the errors in nanopore sequencing are systematic, SMRT base-calling errors are random and can be reduced using circular consensus sequencing (CCS), a method that allows the DNA to have multiple passes through the zero-mode waveguides. Increasing the accuracy of SMRT via CCS comes at a higher cost than using NGS.3 The MinION sequencer is much more affordable when compared with Illumina and SMRT considering the cost of instruments and consumables.9 Considering its portability, affordability and its ability to generate ultra-long reads, the possibility of using MinION to accurately determine larger genome sequences is of immense value to researchers and clinicians. It holds the answer to affordable genome sequencing in low-resource settings and at the point of care. With improving nanopore technology aimed at decreasing MinION’s high error rates, these promises may not be far-fetched.MinION, a small-sized nanopore sequencing device similar to a universal serial bus flash drive, was used to sequence the Ebola virus during the 2014-2016 outbreak in West Africa in 60 min.3 Less accurate long reads from the PromethION flow cell can be obtained at about the same price.5 Error rates for LRS used to be 12% – 15%5 but have now fallen to less than 1% for SMRT and less than 5% for nanopore sequencers10 compared to an error rate of approximately 0.1% in NGS.5The Sequel II 8M SMRT cell, which was launched in 2019 by PacBio, has a CCS read accuracy of 99% and above. PromethION, also released in 2019 by Oxford Nanopore Technologies, generates ultra-long reads, although with less accuracy than SMRT. In their efforts to beef up quality, both companies update their products regularly. The latest -double-sensored nanopore cell R10 and linear consensus sequencing (a similar method to SMRT CCS) are expected to improve the accuracy of Oxford Nanopore Technologies products. Interestingly, LRS technologies are approaching SRS in terms of cost and accuracy. Using the Sequel II 8M SMRT cell that was released, CCS reads can now be obtained for about $1500.00 – an eight-fold reduction in costs.10Notwithstanding SRS market dominance, LRS has broadened its range of applications in recent years as a result of significant improvements in accuracy and throughput. For instance, there has been an increase in the use of MinION in metagenomics studies. LRS technologies are increasingly being used in epigenetics and transcriptomics as well.de novo assembly of short reads for large complex genomes will likely persist for the foreseeable future. The question then becomes whether LRS technologies will improve on their own shortcomings to take over the market.The technical difficulties associated with A paradigm shift in the prevailing technology is likely to occur if there is a major scientific breakthrough, such as the discovery of a DNA polymerase with a longer lifespan for higher throughput and accuracy in SMRT base calling, or a drastic improvement in the sensitivity and DNA translocation speed in nanopore sequencing that matches the accuracy of SRS technologies. However, such improvements are more likely to take place gradually rather than suddenly; I do not see that occurring in the next 10 years.7 Even a major scientific breakthrough in sequencing technologies could still take about 2–3 years before finding its footing in the market for wide acceptability.History suggests a difficult transition from short-read to long-read technologies. When 454 pyrosequencing was introduced in 2005, it had a clear advantage over Sanger sequencing in terms of throughput and cost. However, funding agencies and scientists were not immediately receptive to the new technology. Many of the researchers had got used to Sanger sequencing, whereas investors were mindful of their stakes. Thus, it took 3 years before NGS gained wide acceptance in the scientific community.3 It is the biggest company on the genomic sequencing market with a worth of $43.6 billion USD. The company’s large and increasing customer base makes it difficult to change sides by motivating customers to buy their stocks.11 Currently, no technology compares to Illumina in terms of cost, throughput and accuracy. Even if one were to arise today, it would still have a hard time replacing Illumina, considering the niche that Illumina has carved for itself in the market.As of 2014, Illumina controlled about 70% of the market for DNA sequencers and accounted for 90% of global DNA data.12The potential of LRS, particularly SMRT, is not unnoticed by market giant Illumina, who entered talks in 2018 on a $1.2 billion USD merger with PacBio. Both parties, however, terminated the deal owing to concerns from the United Kingdom Competition and Markets Authority and the United States Federal Trade Commission about an emerging monopoly.10 and can produce reference genomes for most organisms.3One is left to imagine why Illumina wanted a merger. Sheer desire for monopoly or the prospect of a robust hybrid technology? Anyway, the synergy of both generations of sequencing technology is worth considering. Hybrid sequencing combines the throughput and accuracy of SRS with the long read length of LRS. It is highly effective for genome polishing5 have yet to attain their full potential. In this decade, I expect that LRS technologies will gain more recognition and acceptance as they are adapted for sequencing a variety of organisms. In the absence of an innovation in LRS technology that can significantly increase accuracy and throughput and reduce costs far beyond what SRS technologies offer, I would argue that it is unlikely that LRS technologies completely replace SRS technologies in the next 10 years. Meanwhile, in the middle of these improvements in SRS and LRS technologies, I expect to see increased efforts towards making hybrid sequencing more scalable.While it may be difficult to predict with certainty major breakthroughs capable of altering the narrative in genomic sequencing, it is apparent that LRS holds the key to many unanswered questions in genomics. Long-read sequencing technologies, although constantly improving and gradually closing the gap on NGS in terms of accuracy and costs,


Are universal hepatitis C virus (HCV) screening for all US adults aged 18 years or older and targeted HCV screening among people who inject drugs cost-effective for limiting HCV infection?In this economic evaluation study, HCV screening for people who inject drugs in the US increased quality-adjusted life-years (QALYs) by 0.23 , with an incremental cost-effectiveness ratio of $45 465 per QALY. Universal HCV screening increased QALY overall by 0.01, with an incremental cost-effectiveness ratio of $291 277 per QALY.The findings of this study suggest that HCV screening for people who inject drugs may be a cost-effective intervention to combat HCV infection, which would decrease the risk of untreated HCV infection and liver-related mortality. This economic evaluation analyzes the cost-effectiveness of 2 hepatitis C screening programs, a program targeting people who inject drugs and a universal program for US adults, and compares outcomes with the status quo in a Monte Carlo microsimulation. Between 2 and 3.5 million people live with chronic hepatitis C virus (HCV) infection in the US, most of whom (approximately 75%) are not aware of their disease. Despite the availability of effective HCV treatment in the early stages of infection, HCV will result in thousands of deaths in the next decade in the US.To investigate the cost-effectiveness of universal screening for all US adults aged 18 years or older for HCV in the US and of targeted screening of people who inject drugs.This simulated economic evaluation used cohort analyses in a Markov model to perform a 10 000-participant Monte Carlo microsimulation trail to evaluate the cost-effectiveness of HCV screening programs, and compared screening programs targeting people who inject drugs with universal screening of US adults age 18 years or older. Data were analyzed in December 2019.Cost per quality-adjusted life-year (QALY).Cost per QALY gained.In a 10 000 Monte Carlo microsimulation trail that compared a baseline of individuals aged 40 years (men and women) and people who inject drugs in the US, screening and treatment for HCV were estimated to increase total costs by $10 457 per person and increase QALYs by 0.23 (approximately 3 months), providing an incremental cost-effectiveness ratio of $45 465 per QALY. Also, universal screening and treatment for HCV are estimated to increase total costs by $2845 per person and increase QALYs by 0.01, providing an incremental cost-effectiveness ratio of $291 277 per QALY.The findings of this study suggest that HCV screening for people who inject drugs may be a cost-effective intervention to combat HCV infection in the US, which could potentially decrease the risk of untreated HCV infection and liver-related mortality. Furthermore, the cost of new drugs is relatively lower than older drugs; prices for HCV treatments have decreased by approximately half. In the absence of such knowledge, the cost-effectiveness of universal and targeted screening for HCV remains uncertain.HCV treatment can be very effective, especially if HCV is diagnosed in the early stages of the infection.The primary aim of this study was to assess and compare the cost-effectiveness of targeted screening for people who inject drugs with a universal HCV screening program for US adults aged 18 years or older, considering the most effective and recent medical treatments for HCV.CHEERS) guideline.36 CHEERS was followed in study assumptions and for reporting the cost-effectiveness analysis of universal HCV screening and targeted screening for PWID. The Common Rule exempts this study from institutional board review because no human participants were involved.This study was conducted based on structured reporting of economic evaluations of health interventions according to Consolidated Health Economic Evaluation Reporting Standards  to F4 (cirrhosis). Health states were categorized in 2 main phases of disease progression: fibrosis progression stages F0 to F4, and nonfibrosis progression after stage F4. Health states included healthy (no HCV), no fibrosis (F0), portal fibrosis with no septa (F1), portal fibrosis with few septa (F2), numerous septa without cirrhosis (F3), compensated cirrhosis (F4), decompensated cirrhosis, hepatocellular carcinoma, post–hepatocellular carcinoma, liver transplantation, and post–liver transplantation.42 Without treatment, patients in the F0 state might experience spontaneous clearance of the HCV and return to a no HCV state in state F0. Otherwise, patients may progress to the next severity state of the disease  as the general population during and after successful treatment and, if reinfected,44 will begin fibrosis progression from the F0 state. The initial fibrosis state distribution was based on existing literature.45 The fibrosis transition rates .The treatment regimen included in this analysis was a combination of glecaprevir and pibrentasvir, used to treat chronic HCV genotypes 1, 2, 3, 4, 5, or 6 without cirrhosis or with compensated cirrhosis. The treatment protocol is 3 tablets (100 mg glecaprevir and 40 mg pibrentasvir) taken daily for 8 weeks. The treatment is highly effective, with a success rate of 98%.47 Health state medical costs, which are the cost of treatment based on the severity and progress of the disease, were obtained from the published literature on an annual timeframe.50 Costs considered included visits (inpatient and outpatient), diagnostic and laboratory testing, physician services, emergency department place of service, and pharmacy.48 The total cost for liver transplantation was obtained from US organ and tissue transplantation cost estimates provided by a prior study.49 The cost of an HCV screening test was assumed to be $140 based on the existing literature.50 Finally, the cost of no HCV was assumed to be $0. Costs were inflation-adjusted to 2019 US dollars using the US Consumer Price Index, when necessary.51Direct medical costs related to HCV included in the study are listed in 53 Life tables from the US Centers for Disease Control and Prevention (CDC) were used for natural mortality rates for the US population.43 This study was conducted in 2019, and data were analyzed in December 2019. The baseline of analysis was a 40-year old individual in the United States. Cost-effectiveness analysis was conducted using a societal perspective to assess and compare the status quo with screening for HCV under 2 scenarios: annual screening of the total population  and targeted screening of PWID. ICERs were calculated by dividing the difference in expected costs of each scenario by the difference in their effectiveness . The targeted screening scenario is based on a probability of 60% HCV infection in the PWID population vs a probability of 1% under the universal screening scenario.54 HCV infection rates for PWID depend on frequency and duration of use and range from 30% to 90%.17The primary outcome of this study was quality-adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were calculated. Costs were discounted by 3% annually based on recommendations from the US Panel on Cost-effectiveness in Health and Medicine.To determine the expected rates of liver-related mortality, HCV infection, and liver transplantation in the 2 screening scenarios, a 10 000 trial Monte Carlo microsimulation was undertaken. A Monte Carlo microsimulation performs repeated random sampling to get results in a process that cannot easily be estimated and performed. The Monte Carlo microsimulation used in this study estimated the effects of screening if the HCV screening program were scaled to 10 000 people. The microsimulation calculated the results 10 000 times, each time using a different set of random values from the model probability functions to calculate overall totals of liver-related mortality, HCV infection, and liver transplantation for a sample of 10 000 people in a 10-year horizon.Sensitivity analyses were conducted to measure and evaluate the uncertainty derived from the model assumption. Sensitivity analyses recalculated outcomes under alternative assumptions and used a range of probabilities and values instead of a specific probability and value to determine the association of a variable  with the outcomes. The TreeAge Pro Healthcare 2019 (TreeAge Software Inc) statistical package was used for all analyses.55 This means that this scenario is cost-effective.54 The cost per QALY of universal screening is $392.70 vs $14.40 for the status quo. Relative to the status quo, HCV infection for the total US population is estimated to increase total costs by $2845 and shows a very small increase in QALYs of 0.01. The ICER for universal screening is estimated to be $291 277 per QALY gained, which is greater than $50 000 per QALY value. This means this scenario is not cost-effective.Results from a 10 000 trial Monte Carlo microsimulation analysis showed that PWID screening vs status quo is estimated to reduce liver-related mortality by 88 deaths and new infections by 8754. In addition, the model estimated that the number of liver transplantations decrease by 18 during a 10-year horizon. Results from a 10 000 trial Monte Carlo microsimulation analysis showed that universal screening vs the status quo is estimated to reduce liver-related mortality by 1 death and new infections by 3053 during a 10-year horizon.Results from the 2-way sensitivity analysis for PWID showed that, based on the assumption that 60% of PWID have HCV infection and the reinfection rate is 1%, the cost of the HCV drug treatment could increase from $26 400 to $29 054 per PWID and ICER would still be less than $50 000 per QALY, meaning HCV screening would still be cost-effective . AdditioUniversal HCV screening could be cost-effective across a range of HCV infection rates and costs of HCV drug treatment. For example, if the cost of the HCV drug treatment decreased from $26 400 to $13 200 per patient and the infection rate increased to 10%, the ICER would be less than $50 000 per QALY and HCV screening would still be cost-effective. Also, if the infection rate increased to 4% and the cost of the HCV drug treatment decreased to $2640 per patient, the ICER would be less than $50 000 per QALY and HCV screening would still be cost-effective.This study examined the cost-effectiveness of universal HCV screening and targeted screening of PWID adult populations for the US using Monte Carlo microsimulation analysis. This analysis used recent data on effectiveness and costs of the pangenotypic regimen of glecaprevir and pibrentasvir as treatment for chronic HCV, which costs approximately half the price of older treatments. Our results showed that HCV screening for PWID is cost-effective with an ICER of $44 815 per QALY. Furthermore, Monte Carlo microsimulation results for a PWID population showed that screening and treatment were associated with prevention of at least 88 HCV-related deaths and reduction in new infections by 8754 cases relative to the status quo. The proposed strategy was associated with avoidance of HCV-related deaths and new infections by 99% and 83%, respectively. In this scenario, screening PWID for HCV was associated in a reduction of the number of liver transplantations by 18. However, universal screening for the total adult US population was not cost-effective in our analysis.56 Previous studies of HCV screening in the US are mixed. HCV screening is reported to be cost-effective when the prevalence of HCV is high in the total population or in primary care settings.32 Some studies did not support widespread screening for HCV for average-risk adults.34 In contrast, other studies suggested that broad screening for the general population can be cost-effective.58 For example, Eckman et al58 reported that 1-time universal screening of adults was cost-effective in increasing quality-adjusted QALYs. However, the treatment cost for the advanced stages of the disease was considerably lower, and the drug regimen examined was different and substantially lower in cost than that of the glecaprevir and pibrentasvir regimen examined in our study. A 2018 study59 from the US Preventive Services Task Force (USPSTF) recommended screening for HCV infection in adults aged 18 to 79 years.13 However, the USPTF recommendation is based on the effectiveness of screening on improving health outcomes and not on a cost-effectiveness analysis.Our study findings for PWID-targeted HCV screening were consistent with results of screening of high-risk populations reported in other countries, including the Netherlands, Canada, Japan, and the United Kingdom.35 Few studies have assessed the cost-effectiveness of HCV screening in the US considering recently introduced effective treatments of HCV.Most prior studies that analyzed the cost-effectiveness of HCV screening used data on specific populations or older pharmaceutical treatment protocols than what are currently available.In our study, a combination of glecaprevir and pibrentasvir was examined as the drug treatment of early stage HCV. It is a highly effective regimen that is low cost relative to older drug protocols, costing $26 400 for an 8-week treatment period. However, despite the lower cost, screening of all US adults was not found to be cost-effective in our analysis, resulting in an ICER of nearly $300 000 per QALY.17 Addressing HCV infection among PWID by diagnosing and treating infection in its early stages can prevent many HCV-related complications and deaths in the US and substantially decrease health care expenditures. Our study did not examine how PWID screening may be best accomplished. For example, routine screening of incarcerated populations may be effective.22 However, ineffective or costly screening programs of PWID will limit the potential cost-effectiveness that we report in our analysis.Our study also analyzed the cost-effectiveness of targeted HCV screening for the PWID population. The prevalence of HCV infection among PWID is very high, having been estimated to be between 30% to 90%.60 Furthermore, our model included only direct medical costs. Indirect costs related to HCV treatment may be significant, such as patient mental health status and caregiver costs. We used wholesale acquisition costs, which are frequently used in economic analysis because they are reasonably transparent and consistent.61 Direct cost estimates were obtained from published sources and may not fully reflect the actual costs of treatment for a particular region or medical system within the US. Finally, our modeling assumes individuals complete the 8-week drug treatment regimen if diagnosed. To the extent that individuals fail to complete the regimen, our analysis may overstate the cost-effectiveness of screening.Our study has limitations. In the Markov model, potential HCV reinfection was assumed to be 1%, which is the probability of infection for the general population. However, HCV reinfection rates are higher among PWID (11%).Drug injection is a key risk behavior for HCV infection, resulting in an infection rate among PWID of 30% to 90%. If untreated, HCV infection may progress to liver cirrhosis and, ultimately, death. New drug protocols have been developed to successfully treat HCV, and this study examines the cost-effectiveness of targeted screening of PWID and universal screening for the US adult population. Results from our analysis, using an ICER of $50 000 per QALY as a cutoff, suggest that HCV screening that is tailored to PWID is cost-effective in averting premature deaths and liver transplantations associated with HCV disease progression.


To quantify the change in the risk of food insecurity and maternal mental disorder (MMD) before and during the coronavirus disease 2019 (COVID-19) pandemic.Repeated cross-sectional survey. Between 17 July and 10 September 2020, mother–child pairs who were enrolled in a population-based survey in 2017 were re-contacted by telephone for consent and to complete a telephonic COVID-19 survey. We used the Brazilian Food Insecurity Scale to assess food security and the Self Reporting Questionnaire-20 to assess MMD. McNemar’s test for paired data that also accounted for clustering was used. Logistic regression was used to assess the relationship of unemployment and receipt of government assistance with food insecurity and MMD in 2020.Ceará, Brazil.Five hundred and seventy-seven mother–child pairs completed the 2017 and 2020 surveys. At the time of the 2020 interview, the child cohort was 36–108 months of age.P value < 0·001) during the pandemic in July–August 2020 as compared with November 2017, while the prevalence of MMD was 40·2 % higher during the pandemic . Loss of formal employment was associated with increased risk of food insecurity, but not with the risk of MMD.The proportion of mothers reporting food insecurity was 15·5 % higher (95 % CI 5·9, 25·1, The risk of food insecurity and MMD in Ceará increased during the COVID-19 pandemic. These findings highlight the need for policies and interventions to reduce the impact of the COVID-19 pandemic on maternal and child health, nutrition and well-being in Brazil. Aiming to mitigate COVID-19 transmission, social distancing measures were implemented in many cities in Brazil, which led to isolation, school closures and unemployment, as well as potentially increased the risk of food insecurity and negatively impacted mental health and well-being,3. Social distancing and school closures were implemented in Ceará, following the government lockdown decree on 19 March 2020. The Brazilian government provided COVID-19 assistance starting in April 2020. This assistance was a monthly cash payment of ˜US$120 for self-employed and informal workers over 18 years of age who do not receive any other benefit from the Federal Government , individuals who did not have formal employment and for families with a per capita monthly income (per person) up to half the minimum wage (about US$93) or a total monthly family income of up to three times minimum wage (about US$560).The global pandemic of coronavirus disease 2019 (COVID-19) has surpassed 48 million cases worldwide in November 2020, and Brazil has recorded more than five million confirmed cases,5. A study conducted in Bangladesh found that the percentage of households experiencing food insecurity increased by 52 % during a COVID-19 lockdown as compared with 1–2 years before the pandemic. In the USA, the COVID-19 Impact Survey found that 34·4 % of households with children ≤12 years old were food insecure in April 2020, compared with 15·1 % in 2018. Further, multiple studies have found that the COVID-19 pandemic and lockdowns have negatively affected mental health in diverse contexts and populations,9. Nevertheless, evidence on food insecurity and mental health in LMIC, particularly in Latin America, that compares rates before and during the pandemic is limited. To address this evidence gap, we report the change in the prevalence of food insecurity and maternal mental disorder (MMD) before and during the COVID-19 pandemic in Ceará, Brazil.The COVID-19 pandemic and related lockdowns may significantly increase the risk of food insecurity through multiple pathways including loss of employment and disruption of food supply chainsPesquisa de Saúde Materno Infantil no Ceará - PESMIC), a population-representative repeated cross-sectional survey focused on maternal and child health including children living in the state of Ceará, in northeastern Brazil. Ceará is the sixth poorest state in Brazil, with an average per capita income of US$150, and subsistence agriculture predominates in the rural area of the state. The PESMIC completed a survey round of mothers and children in 2017, and the full details of the methods can be found elsewhere. Briefly, PESMIC 2017 survey round used random cluster based on the Brazilian Institute of Geography and Statistics census tracks. In each census track, twenty houses were randomly selected and households with children <72 months of age were eligible for enrolment. In 2020, eligible participants in the COVID-19 impact study were all 3566 mothers of children who were enrolled in the PESMIC survey round in 2017. Telephone contact number was available for all participants. Between 17 July and 10 September 2020, participants were re-contacted by trained interviewers by telephone for consent and to complete a survey. At the time of the 2020 interview, the child cohort was 36–108 months of age.We analysed data from the Maternal and Child Health Research in Ceará , which is validated in Brazil for food insecurity screening. Both survey rounds used the reduced version of EBIA, which included five question, and food insecurity was defined by the endorsement of any of the five questions. We did not use the full fifteen-question EBIA, and we were therefore not able to assess the severity of food insecurity. The Self Reporting Questionnaire-20 was also administered to assess symptoms of common mental disorders; MMD was defined as a score higher than 8 as per the scoring standard,12. Employment status and receipt of government assistance were assessed by maternal self-report.The study questionnaires in 2017 and 2020 included the Brazilian Food Insecurity Scale  or MMD (n 83) data in 2017 were excluded from the analysis; all participants had complete data for 2020. We also examined the association of maternal employment and receipt of government assistance with food insecurity and MMD within the 2020 survey with logistic regression. We used separate univariate models with food insecurity and MDD as dependent variables and maternal employment and receipt of government assistance as independent variables (both were not included in same model). No participants were missing dependent or independent variables in the 2020 survey. Both survey rounds received approval from the Brazilian research ethics committee.We examined the proportion of participants reporting food insecurity and MMD during 2017 n 2989). Participants who were followed up had relatively similar risk of food insecurity as compared with those not followed up  and had slightly higher monthly income .A total of 577 maternal–child pairs participated in the 2020 survey during the COVID-19 pandemic. The participants who completed the 2020 survey were relatively similar to those who were included in the 2017 PESMIC but were not followed up in 2020  during the pandemic in July–August 2020 as compared with November 2017, while MMD was 40·2 % higher for MMD during the pandemic  . Unemployment and receipt of government assistance were not associated with MMD in 2020  were associated with an increased risk of food insecurity.,7. We found that formal job loss was markedly associated with increased risk of food insecurity. Ceará has been economically stable since 2017; therefore, job losses reported in the 2020 survey were most likely related to the COVID-19 pandemic. In addition to unemployment, the interruption of food supply chains can also contribute to the increased risk of food insecurity; however, in Ceará, there were no major interruptions in the distribution of food reported during the study period.Increased risk of food insecurity during the COVID-19 pandemic is in line with studies in high-income and LMIC settingset al. suggested that COVID-19 and public health actions like social distancing may negatively impact mental health through isolation, loss of income and uncertainty about the future. In this study, MMD significantly increased during the pandemic; however, job loss and the need for government assistance were not associated with increased risk and therefore suggest that the other factors negatively contributed to poorer mental health. Of note, food insecurity is associated with poorer mental health and may be a contributor in our study. Food insecurity and MMD can negatively impact child nutritional status, parenting and child development and represent an unprecedented risk to children’s health and well-being–21.In addition, Pfefferbaum v. telephone) may have led to information bias; however, it is not clear the degree to which participants may over- or underreport food insecurity and MMD by telephone.Our study has several limitations. First, our study may be at risk of attrition bias as not all participants surveyed in 2017 were followed up in 2020; however, we found that participants who were followed up were relatively similar to those not followed up. In addition, the difference in the modality of data collection between survey rounds (in-person Ceará is one of the poorest states of Brazil, and the average monthly per capita income of US$ 150 can be compared with that of many other developing countries. These findings highlight the need for policies and interventions to reduce the impact of the COVID-19 pandemic on food insecurity and maternal mental health in Brazil. A few potential strategies include extending or increasing the government COVID-19 assistance programme, direct provision of food to families in need and expanded access to mental health services.