Elodea Canadensis shoots planted per mesocosm) crossed with three malathion exposure scenarios  on aquatic communities containing zooplankton, phytoplankton, periphyton, two snail species, and larval amphibians. In the absence of macrophytes, single malathion pulses caused short-term declines in cladoceran abundance followed by their rapid recovery, which precluded any indirect effects (i.e. trophic cascades). However, repeated malathion pulses caused cladoceran extinctions, resulting in persistent phytoplankton blooms and reduced abundance of one snail species. In contrast, with macrophytes present, even at low density, malathion had no effect on any taxa. We also discovered novel effects of macrophytes on the benthic food web. In the two highest macrophyte treatments, we observed trends of reduced periphyton biomass, decreased abundance of one snail species, and decreased amphibian time to and mass at metamorphosis. To our knowledge, this is the first evidence of negative submerged macrophyte effects on amphibians, a taxa of global conservation concern. Our findings suggest that facilitating macrophytes could be an important strategy for buffering freshwater communities from insecticides, though consideration of their impacts on animal species is necessary.Understanding how ecological interactions mitigate the impacts of perturbations such as pesticides in biological communities is an important basic and applied question for ecologists. In aquatic ecosystems, new evidence from microcosm experiments suggests that submerged macrophytes can buffer cladocerans from pulse exposures to the widely used insecticide malathion, and that mitigation increases with macrophyte density. However, whether these results scale up to more complex aquatic communities where ecological interactions such as competition can alter toxicity is unknown. Further, macrophyte abilities to mitigate different insecticide exposure scenarios (i.e. single versus repeated pulses) have never been tested. To address these gaps, we performed a factorial mesocosm experiment examining the influence of four macrophyte treatments (0, 10, 50, or 100  A contemporary challenge facing ecologists and ecotoxicologists is to elucidate factors that can mitigate the effects of anthropogenic contaminants in aquatic ecosystems. Traditionally, the ecological effects of contaminants, such as insecticides, are based on laboratory toxicity studies using a small number of test species and then extrapolated to entire communities . HoweverOne common cause of discrepancy between predicted and actual effects of insecticides is the influence of ecological interactions. For example, in freshwater communities, natural stressors such as competition and predation can exacerbate direct insecticide toxicity –10. FurtElodea canadensis), caused up to nine-fold reductions in the toxicity of the insecticide malathion to the cladoceran Daphnia magna in small (0.95-L) outdoor jars. Moreover, each increase in macrophyte density caused greater mitigation. We also understand the mechanism of this mitigation. As submerged macrophytes photosynthesize, they increase water pH by taking up CO2, which decreases carbonic acid concentration and shifts the bicarbonate buffer system towards the more alkaline bicarbonate and carbonate [Growing evidence suggests that submerged macrophytes can mitigate insecticide effects in aquatic ecosystems. For example, Brogan & Relyea  demonstrarbonate . This hiarbonate ,16. HoweIn addition to mitigating insecticide direct effects, submerged macrophytes may also dampen the indirect effects of insecticides in freshwater communities. For example, macrophytes can suppress phytoplankton growth via allelopathy  and aqueWhen examining the influence of macrophytes on insecticide effects in aquatic communities, there is also a need to consider different insecticide-exposure scenarios. For example, depending on weather patterns and application frequencies, insecticide exposure in aquatic communities can occur as single or repeated pulse perturbation events –27. Howewww.ncfap.org/database/national.php). Despite malathion’s popularity, few studies have examined its ecological effects in non-target communities. We hypothesized that the magnitude of malathion’s direct and indirect effects would increase with the number of insecticide exposure events (control < single pulse < repeated pulses) and that these effects would decrease with increasing submerged macrophyte density.To address these gaps in our understanding, we examined the mitigating role of a range of natural macrophyte densities in freshwater communities containing phytoplankton, periphyton and 22 species of animals  during several realistic insecticide-exposure scenarios. We used the organophosphate insecticide malathion (Diethyl 2-dimethoxyphosphorothioylsulfanylbutanedioate) because it is one of the most commonly used active ingredients in the U.S. , with 10E. canadensis shoots initially planted per mesocosm) with three malathion exposure scenarios . The 12 treatment combinations were replicated four times for a total of 48 experimental units. This study was approved by the University of Pittsburgh's Institutional Animal Care and Use Committee (IACUC) under Protocol #09–04536. None of the species used in this study are protected or endangered.The experiment was conducted in Summer 2009 at University of Pittsburgh’s Pymatuning Laboratory of Ecology. We used a completely randomized, factorial design crossing four macrophyte treatments  shoots throughout each mesocosm, attempting to evenly spacing the shoots. Though we haphazardly selected Elodea shoots for planting, we attempted to stock each mesocosm with shoots spanning a similar range of masses. We simulated planting in the 0-macrophyte treatment to standardize sediment disturbance. The Elodea shoots used in this experiment were collected and mixed from three local state-owned wetlands with approval and permits from the Pennsylvania Fish and Boat Commission. Prior to adding the Elodea shoots to the mesocosms, we placed the collected plants in 200-L wading pools containing well water and sediment for 2 wks to allow any attached invertebrate eggs to hatch.The experimental units were outdoor 1,200-L mesocosms containing 850 L of well water. On 2 May, we added 95 L of sediment to each mesocosm and on 28 to 31 May, we haphazardly planted the appropriate number of Elodea. We also used a zooplankton tow (250 μm mesh) to collect zooplankton. We combined all water and zooplankton samples, removed all predatory invertebrates, and then added 200-mL aliquots of this water to each mesocosm. On 26 May, we added five unglazed, vertically oriented clay tiles (10 x 10 cm) to the north side of each mesocosm to serve as periphyton samplers.On 21 May, we established microbial, algal and zooplankton communities in each mesocosm. To do this, we directly collected water using buckets from each same pond where we had collected Hyla versicolor) and placed them into individual containers to oviposit under a permit from the Pennsylvania Fish and Boat Commission and collection permission from the University of Pittsburgh. We then mixed the resulting eggs and moved them to 200-L wading pools containing aged well water. Once hatched, we fed the tadpoles ad libitum until reaching an appropriate handling size (~10 mg). On 16 June (defined as day 0 of the experiment), we added 20 gray treefrog tadpoles to each mesocosm. The densities of 10 tadpoles/species/m2 are well within natural densities [Next, we collected and added larval amphibians to our mesocosms. From 28 to 29 May we collected 30 pairs of breeding gray treefrogs  and weiPhysa acuta and P. gyrina, which can only be differentiated by dissecting their internal genitalia) and rams horn snails (Helisoma trivolvis) from local ponds. To prevent adult snail endoparasites from being introduced to the mesocosms, the snails used in the experiment were hatched from eggs of the snails collected from local ponds with the permits and collection permission from the Pennsylvania Fish and Boat Commission. We cultured the snails in clean well water in 200-L wading pools. On 17 June (day 1), we sorted all hatched pond snails into small (< 10 mg), medium (10 to 20 mg), and large (> 20 mg) size classes. We added five pond snails from each size class to each mesocosm. On 24 June (day 8), we sorted rams horn snails into small (< 100 mg) and large (> 100 mg) size classes (range = 17 to 211 mg) and added 4 small and 3 large rams horn snails to each mesocosm. While these snail densities are considerably lower than what can occur in wetlands in western Pennsylvania, , we added the maximum number possible to each mesocosm given the lower-than-expected number of hatchlings produced during culturing. We also assessed the 24-h survival of pond snails and rams horn snail following handling; we found 100% survival for each taxa.To represent grazer communities commonly found in wetlands, we also added freshwater snails to the mesocosms. On 5 May, we collected pond snails  and applied this concentration to the appropriate mesocosms on 17 July (day 37).Once all animals were added, we did not disturb the mesocosms for 10 d. On 3 July (day 19), we applied the insecticide treatments using technical grade malathion . Our original target concentration was 18 μg/L, which is well within the US Environmental Protection Agency’s estimated environmental concentration (EEC) for surface waters  in 25 mL of ethanol to make a stock solution of (0.042 g/mL). We then added 0.71 mL of this stock solution to each appropriate mesocosm (average volume = 850 L). We elected not to apply an ethanol control because the concentrations we used have had no effect on any taxa in similar, previous experiments ,13,38. A at pH 8 ), each aWe collected water samples within 1 hr of application and sent the water samples to an independent testing laboratory for concentration analysis. However, we received unreliable results from this lab and were therefore not able to verify the actual concentrations we applied. Despite these unreliable results, malathion’s effects on the cladoceran community were highly consistent with previous studies using similar nominal concentrations and application regimes .a), and periphyton mass several times throughout the experiment. We quantified water temperature and dissolved oxygen using a calibrated digital water meter  and pH using a calibrated Oakton pH 5 Acorn series sensor . Water quality was measured by placing the meters at approximately half water depth in the center of each mesocosm. We sampled light decay rate and biotic variables using approaches described in [Throughout the experiment we sampled abiotic water quality , light decay rate, temperature) and biotic variables including the density of each major zooplankton group , phytoplankton abundance , we felt that it maximized our ability to give each snail an equal opportunity of being sampled across all of our treatments. We also quantified gray treefrog survival, time to metamorphosis, and mass at metamorphosis  with rocks in separate locations on the bottom of each mesocosm so that each cup faced upwards. We placed a single pellet of alfalfa into each cup to attract the snails. After 24 h, we removed the cups from each tank, sorted the snails by species and then counted and weighed the snails. We used this approach to sample snails because mechanically collecting snails by netting within a stovepipe sampler or on the edges of the mesocosm walls would have been confounded by the substantially higher surface area present in mesocosms with osis see . The firElodea density from 0 (no macrophytes) to 10 (most macrophytes). On day 320 (just before we took down the experiment), we quantitatively determined Elodea biomass density (g/m2) by sub-sampling macrophytes from the middle of each tank using a stovepipe sampler . We rinsed the sub-sampled macrophytes to remove any attached algae and invertebrates and then dried the macrophytes for 24 hrs at 60°C. We then weighed the plants to determine their dry mass in order to calculate Elodea biomass density by dividing the mass by the volume inside of the stovepipe.Finally, we used two different approaches to determine how different our macrophyte treatments were in the middle and at the end of the experiment. On day 47, we used a qualitative approach in which nine independent observers visited each mesocosm and visually ranked total Elodea treatment and insecticide treatment, we performed separate univariate ANOVAs on visually ranked macrophyte density at day 47 and on measured macrophyte biomass at day 320. To analyze the effects of the treatments on abiotic response variables over time, we performed a two-way repeated-measures multivariate analysis of variance (rm-MANOVA) on pH, DO, temperature and light decay. To analyze treatment effects on biotic response variables over time, we performed a two-way rm-MANOVA on cladoceran, copepod, and rotifer density, phytoplankton abundance (chlorophyll a), and periphyton biomass. When we found significant multivariate effects, we explored the univariate effects on each response variable using two-way rm-ANOVAs. When significant univariate time-by-treatment interactions were detected, we examined treatment effects within each time point using two-way ANOVAs. Where appropriate, we used Tukey’s test for post-hoc comparisons. This hierarchical approach allowed us to control overall experiment-wise error when performing multiple rm-ANOVAs and subsequent ANOVAs. When necessary, we log (+1) transformed our data to meet the assumptions of GLM.We used general linear models (GLM) to analyze the data from this experiment. To analyze the effects of Elodea and insecticide treatments on snail abundance and average mass at day 68, we performed a two-way MANOVA on Physa spp. and H. trivolvis log + 1 abundance and average mass. We performed a separate two-way MANOVA on gray treefrog survival (arcsine-transformed), time to metamorphosis, and mass at metamorphosis. We examined all significant multivariate treatment main effects and interactions using subsequent two-way ANOVAs and Tukey’s mean comparison tests.To analyze the effects of the Elodea density increased in all mesocosms containing macrophytes and the effects of our Elodea treatments depended on the sample date. On day 47 , we found no treatment effects on visually estimated Elodea density ranks  and on the abiotic environment in our mesocosms. At the end of the experiment, the 10- and 50-Elodea treatments still did not differ in biomass density, but both contained about 50% less biomass than the 100-Elodea treatment. In regard to the abiotic effects, the presence of Elodea generally had no effect on temperature, increased DO, and maintained lower light decay rates relative to mesocosms containing no Elodea (see Elodea biomass density and abiotic variables). Because pH is the primary mechanism by which plants mitigate malathion’s toxicity [Over the course of the experiment, ty ranks , suggesttoxicity , we discElodea interaction on pH . At each sample date, Elodea treatment had an effect on pH . At day 26, pH in the 10-Elodea treatment was 0.76 pH units greater than the 0-Elodea treatment (p = 0.001), but at least 0.82 pH units less than the 50- and 100-Elodea treatments , which did not differ from each other . On each subsequent sample date, pH in the 10-, 50- and 100-Elodea treatments was at least 1.17 pH units higher than the 0-Elodea treatment  and did not differ from each other . Because pH is proportional to the log hydrogen ion concentration, treatments differing by 1 pH unit actually differ 10-fold in hydrogen ion concentration.We also observed an effect of the time-by-Elodea, insecticides, time, and all interactions  but not Elodea  or the Elodea-by-insecticide interaction . Because there appeared to be a pattern of different cladoceran responses to insecticide treatment within different Elodea treatments . As noted in the methods, the lack of a malathion treatment effect in the absence of Elodea led to our decision to increase the malathion concentration from 18 to 36 μg/L.Cladoceran density was influenced by ith time . On day eatments , we condElodea treatment . In the 0-Elodea treatment, the single malathion exposure caused a marginally significant decline (76%) in cladocerans, relative to controls, on day 47 (p = 0.053). However, cladocerans returned to control levels by day 68 and remained equal to controls through day 100 . In the repeated-pulse treatment, cladoceran densities were less than 3% of control densities on days 47, 68, and 100 (P ≤ 0.009). However, in treatments that contained 10, 50, or 100 Elodea shoots, cladoceran density in the single- and repeated-pulse treatments never differed from the controls on any sample date .On sample days 47, 68, and 100 , we found that the effect of insecticide treatment on cladoceran density depended on the Elodea interaction and the three-way interaction with malathion , but not insecticides  or their interaction . On day 26, the Elodea effect was driven by a 13-fold higher copepod density in the 10-Elodea treatment than the 100-Elodea treatment (p = 0.035). On day 68, however, the Elodea effect was driven by a 2-fold higher copepod density in the 0-Elodea treatment compared to the 100-Elodea treatment (p = 0.031). In between these two dates (day 47), there were no effects of Elodea , insecticides , or their interaction .Copepod density was affected by time, the time-by-alathion . Two-wayElodea-by-insecticide interaction  driven by an effect of insecticides on copepod density in the 10-Elodea treatment  but not in the other Elodea treatments . With 10 Elodea shoots, we observed 12 to 15 times higher copepod densities in the single- and repeated-pulse insecticide treatments compared to the controls (p ≤ 0.016); the single- and repeated-pulse treatments did not differ from each other (p = 0.993).On day 100, we observed a Elodea, time, and the time-by-Elodea interaction; however, the insecticide had no effect . On day 26, the 50- and 100-Elodea treatments had five times higher rotifer densities than the 0-Elodea treatment (p ≤ 0.004); the 10- and 0-Elodea treatments did not differ (p = 0.993). On all subsequent sampling dates, rotifer densities in the 10-, 50- and 100-Elodea treatments were 2 to 13 times higher than in the 0-Elodea treatment .Rotifer density was affected by o effect . UnivariElodea, the Elodea-by-insecticide interaction, time, and several interactions with time , but not insecticides  or their interaction . On day 26, phytoplankton abundance in the 0- and 10-Elodea treatments was over five and two times higher, respectively, than in the 100-Elodea treatment (p ≤ 0.049); abundance in the 50-Elodea treatment was intermediate . On day 47, phytoplankton abundance in the 0-Elodea treatment was more than three times higher than the 10-, 50-, and 100-Elodea treatments , which did not differ from one another . On day 68, phytoplankton abundance in the 0-Elodea treatment was over five times higher than in the 10- and 50-Elodea treatments ; the 100-Elodea treatment did not differ from any of the other treatments .Phytoplankton abundance was affected by ith time . As a reElodea treatment . This interaction occurred because insecticides had an effect on phytoplankton when Elodea were absent  but no effect when Elodea were present at any density . In the 0-Elodea treatment, the insecticide effect was caused by a nearly 12-fold increase in phytoplankton abundance (i.e. a phytoplankton bloom) in the repeated-pulse insecticide treatment compared to the control and single-pulse treatments , which did not differ from one another (p = 0.457).On day 100, we found an effect of insecticides on phytoplankton abundance, but the effect depended on Elodea interaction, but not by insecticides , but not on day 68 . On day 26, Tukey’s test revealed a trend of higher periphyton biomass in the 0- and 10-Elodea treatments than in the 100-Elodea treatment (p ≤ 0.09), though no treatments differed from the 50-Elodea treatment . On day 47, we again observed a trend of higher periphyton biomass in the 10-Elodea treatment than in the 50- and 100-Elodea treatments , though biomass in the 0-Elodea treatment did not differ from any of these treatments . Finally, on day 100, periphyton abundance in the 50-Elodea treatment was three times greater than in the 0-Elodea treatment (p = 0.004); the 10- and 100-Elodea treatments did not differ from the 0- or 50-Elodea treatments .Periphyton biomass was affected by time and the time-by-ides see . We deteElodea  and moderately significant effects of the Elodea-by-insecticide treatment interaction , but not insecticides . Rams horn snail abundance was not affected by Elodea , but was affected by insecticides  and the Elodea-by-insecticide treatment interaction . In the 0-Elodea treatment, we observed a 10-fold decrease in abundance in the repeated-pulse treatment compared to the control, although this effect was marginally significant (p = 0.064); abundance in the single-pulse treatment did not differ from either the repeated-pulse or control treatments . In the 10-Elodea treatment, insecticides had no effect on rams horn snail abundance . In the 50- and 100-Elodea treatments, we detected effects of insecticides ; rams horn snail abundance was 75% lower in single-pulse than in repeated-pulse treatments (p = 0.039). Controls did not differ from the single- and repeated-pulse treatments . Rams horn snail average mass was marginally affected by Elodea treatment ; where average mass was over 1.8 times larger in the 50- and 100-Elodea treatments than in the 10-Elodea treatment (p ≤ 0.026), though there were no other differences between Elodea treatments (p ≥ 0.178).The two-way MANOVA on snail abundance and mass, assessed on day 68, revealed effects of Elodea , marginally significantly affected by insecticides , and not affected by their interaction . The Elodea effect was caused by a 2.5-fold higher abundance in the 0- and 10-Elodea treatments than in the 50- and 100-Elodea treatments (p ≤ 0.008). The insecticide effect occurred because pond snail abundance in the repeated-pulse malathion treatment was more than twice as high as in the single-pulse treatment (p = 0.05), though neither treatment differed from the control . Average pond snail mass was also only affected by Elodea treatment  and appeared to be inversely related to pond snail abundance. Pond snails in the 50- and 100-Elodea treatment were > 2.6 times larger than in the 10-Elodea treatment (p ≤ 0.02). Additionally, pond snails in the 100-Elodea treatment were 2 times larger than the 0-Elodea treatment (p = 0.031), though mass did not differ between any other Elodea treatments (p ≥ 0.110).Pond snail abundance was affected by Elodea  but no effect of insecticides  or their interaction . Subsequent ANOVAs revealed that survival was high across all treatments  and unaffected by Elodea . However, Elodea treatment affected mass at metamorphosis  and time to metamorphosis . Compared to the 0-Elodea treatment, time to metamorphosis did not differ in the 10-Elodea treatment (p = 0.621) but took 5 d longer in the 50- and 100-Elodea treatments (p ≤ 0.02). For mass at metamorphosis, gray treefrog raised with 0-Elodea were similar in mass to those raised with 10 Elodea shoots , but mass in the 50- and 100-Elodea treatments was approximately 25% lower (p ≤ 0.007).The MANOVA on gray treefrog life history traits revealed an effect of Elodea canadensis would mitigate the direct and indirect effects of several realistic insecticide exposure scenarios in aquatic communities. Overall, we found that whenever Elodea was present, malathion’s direct effects were strongly mitigated. This mitigating effect occurred regardless of whether insecticide exposure occurred as single or repeated pulses. By buffering cladocerans from malathion’s direct lethal effects, Elodea also dampened the insecticide’s cascading effects on the rest of the community. Further, we discovered that 50- and 100-Elodea treatments suppressed the biomass of periphyton, resulting in reduced snail abundance and tadpole growth compared to treatments initially planted with 0 or 10 Elodea shoots.We tested the general hypothesis that the submerged macrophyte Elodea but this effect would be mitigated in the presence of Elodea in a density-dependent manner. Indeed, we discovered that without Elodea, both single and repeated malathion applications of 36 μg/L reduced cladoceran densities relative to insecticide-free controls. Although cladocerans recovered to control levels within 3 wks after the single pulse exposure, the repeated pulse exposures maintained low cladoceran densities for the duration of the experiment. This result is consistent with reported cladoceran sensitivities to malathion in laboratory experiments . Other studies conducted in mesocosms have demonstrated similarly toxic effects of comparable malathion concentrations on cladoceran populations [An important prediction in our experiment was that malathion would decimate sensitive cladocerans in the absence of < 5 μg/L , PAN Pesulations ,13.Elodea, the single- and repeated-pulse malathion treatments had no effect on cladocerans in any Elodea treatment containing plants. Using microcosm experiments, Brogan & Relyea [E. canadensis biomass densities to those achieved in our study  reduced species  because  species . While w species , pH leve species ,44, part species ,46. It s species  and needElodea often result in the increased abundance of copepods and rotifers due to competitive release [Elodea treatment, where malathion treatment had no effect on cladoceran density at any earlier sample dates.Compared with cladocerans, rotifers are highly resistant to malathion . Previou release ,13,49. HElodea treatment on these taxa. Copepods were generally less abundant in the 100-Elodea treatment than in the 0- and 10-Elodea treatments throughout the experiment, though this relationship depended on the sample date. It is possible that copepod density in the 10- and 50-Elodea treatments differed at certain time points  due to lag effects of early differences in Elodea treatments (i.e. before day 47), including differences in phytoplankton species composition. However, we did not design our experiment to test such species-level interactions. To our knowledge, no studies have examined mechanisms by which submerged macrophytes might suppress copepod populations. In contrast, rotifers were generally more abundant whenever macrophytes were present. This is likely the result of macrophytes providing rotifers with an important refuge from predators, such as cyclopoid copepods [Although malathion had only minor effects on copepods and rotifers, we observed effects of Elodea treatment, likely because the insecticide caused only ephemeral (< 3 wk) cladoceran declines. In the repeated-pulse treatment, however, consistently low cladoceran densities occurred when Elodea was absent and these caused phytoplankton blooms that developed by day 68 and persisted through day 100. However, these blooms did not occur whenever the macrophyte was present due to the mitigating effects of Elodea on cladocerans. Thus, we found support for our hypothesis that Elodea would not only mitigate the direct effects of malathion on cladocerans, the macrophyte would also mitigate the subsequent indirect effects on phytoplankton.We also predicted that cladoceran declines following malathion exposure would initiate phytoplankton blooms. When we examined phytoplankton abundance in the malathion single-pulse treatment, we found no effects of Elodea-free aquatic communities are becoming well established. For example, Relyea & Diecks [The cascading effects that insecticides have in & Diecks  document& Diecks ,28,51. W& Diecks . Thus, tElodea, repeated-pulse malathion treatment in this study, we did not find support for our prediction that the phytoplankton blooms would reduce periphyton mass via competition for light and nutrients. Instead, we found no effects of malathion on periphyton, regardless of Elodea treatment. However, we would expect this result if, across malathion treatments, grazing pressure was consistently above a threshold level necessary to prevent periphyton mass from increasing beyond a minimum mass. Under such conditions, one would expect that, instead of creating differences in periphyton mass, the phytoplankton blooms would actually manifest as differences in the abundance of grazers in different malathion treatments, possibly driven by changes in periphyton quality or production [Despite the sustained phytoplankton blooms in the 0-oduction .Elodea appeared to negatively affect rams horn snail abundance. Without Elodea, the repeated-pulse malathion treatment tended to decrease rams horn snail abundance relative to controls. Given that rams horn snails  exhibit low sensitivity to malathion  it is uElodea on malathion’s community-level effects, we also discovered important and novel effects of the macrophyte on community structure. For example, during the first two sampling dates (days 26 and 47), periphyton biomass was generally higher in tanks with 0 or 10 macrophytes than 50 or 100 macrophytes. This pattern makes sense as macrophytes and periphyton overlap spatially and compete for light and nutrients in the benthos [While a major focus of the present study was on the influence of  benthos . Because benthos ,55.Elodea had pronounced effects on grazer community structure. For example, pond snail abundance was closely related to periphyton biomass early in the experiment, with the highest abundances occurring in the 0- and 10-Elodea treatments and lower abundances occurring in the 50- and 100-Elodea treatments. While this response may be related to food availability or some other ecological interaction, it is also possible that the snail’s chemosensory ability to detect the alfalfa pellets used in our passive sampling traps was inhibited by the elevated pH in the 50- and 100-Elodea treatments [Elodea’s effects on snail abundance, we also observed that pond snails and rams horn snails generally had larger average masses in the higher Elodea treatments  than in the lower Elodea treatments . The trend of greater average snail mass at higher Elodea densities is likely the result of the lower numbers of grazers in these treatments and, thus, higher per capita resource availability. Although it is possible that snails grew to larger sizes in the higher Elodea treatments because they were eating the plants, freshwater snails primarily graze algae and are not considered to be important herbivores on living macrophyte tissues [Indeed, we found that eatments . Consist tissues ,58.Elodea treatments also had adverse effects on amphibians, causing gray treefrogs to emerge later and at a smaller mass. As in the case of pond snails, this is likely a result of increased competition for resources driven by the negative effects of higher Elodea biomass densities on periphyton biomass. An additional possibility is that periphyton quality decreased as Elodea biomass density increased, but the few experiments addressing this question have found no effect of macrophytes on periphyton quality [Higher  quality ,60. Rega quality ,62. More quality –65.The present study demonstrates the clear ability of submerged macrophytes to mitigate the toxicity of the widely used insecticide malathion in complex communities and under various realistic exposure scenarios. While the mitigating influence of submerged macrophytes on malathion’s toxicity is now well established, several important questions remain. For example, one important next step is to test whether our results scale up to field, where more complex ecological interactions and environmental conditions are present. Further, the relative strength of submerged plant effects on the toxicity of different commonly applied insecticides needs to be examined to determine if there are particular insecticide properties that lead to differential mitigation success. The results of such studies could help improve best management practices to mitigate surface runoff containing pesticides. Finally, given our finding that macrophytes suppressed the growth and abundance of several benthic species, more studies are needed to examine the costs and benefits of different submerged macrophyte densities on aquatic communities, both in the presence and absence of contaminants such as pesticides. This will help aquatic resources managers determine ideal macrophyte densities for maximizing biodiversity and ecosystem function in potentially contaminated environments.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.


Since the scale-up for prevention of mother-to-child transmission (PMTCT) services, rates of HIV infection among exposed infants have significantly declined. However, current achievements fell short of achieving the target sets. We investigated mother-to-child transmission (MTCT) of HIV infection and its determinants among HIV-exposed infants on care at Dilchora Referral Hospital in Dire Dawa City Administration. A retrospective institutional cohort study was conducted by reviewing follow-up records of HIV-exposed infants who were enrolled into care. Infants' HIV serostatus was the outcome measure of the study. Bivariate and multivariate logistic regressions were employed to identify significant determinants. Of the 382 HIV-exposed infants enrolled into care, 60 (15.7%) became HIV positive. Rural residence , home delivery , infant not receiving ARV prophylaxis at birth , mixed feeding practices , and mother-child pairs neither receiving ARV  were significant independent determinants of MTCT of HIV infection. Our findings suggest additional efforts to intensify scale-up of PMTCT services in rural setting and improve institutional delivery and postnatal care for HIV positive mothers and proper follow-up for HIV-exposed infants. In 2011, there were approximately 330,000 children newly infected with Human Immunodeficiency Virus (HIV); most of the infections being occurring in sub-Saharan African countries [Since the Ethiopian Ministry of Health launched the national program for prevention of mother-to-child transmission (PMTCT) of HIV infection in 2001, the number of facilities with PMTCT service has reached 1,445 providing ARV prophylaxis for 10,302 HIV positive pregnant women and 4,945 exposed infants in 2011 [In resource-limited countries with high prevalence of MTCT of HIV infection, where PMTCT is not widespread and early infant diagnosis (EID) is still a challenge, assessing the risk factors for MTCT will help to decrease child morbidity and mortality and strengthen PMTCT programs . With thThis study was conducted at Dil Chora Referral Hospital, in Dire Dawa City Administration. Dire Dawa is located 515 Km to the east of the capital city, Addis Ababa. The city has one referral hospital; four private hospitals; fifteen  health centers; four private higher clinics; and one specialized STI and HIV care clinic. The referral hospital provides comprehensive HIV treatment and care as well as PMTCT service. At the time of the study there were 419 infants at the HIV-exposed infants clinic.Retrospective institution based follow-up study design was used to investigate factors associated with HIV transmission among infants born to HIV positive mothers who were on follow-up at the HIV-exposed infant care clinic. A total of 382 HIV-exposed infants who received care and support between July 2005 and July 2013 at the exposed infant follow-up clinic were included in the study. The independent variables were maternal factors  and infant factors . The study's outcome measure was HIV serostatus at the end of the follow-up.The source population was all infants on follow-up in the HIV-exposed infant care clinic at Dil Chora Referral Hospital. The study population was comprised of exposed infants who were on follow-up care between July 2005 and July 2013 at the clinic and for which a confirmatory HIV test was done. Exposed infants <6 weeks of age, lost to follow-up, transferred out, or dead without confirmatory test were excluded from the study. Minimum sample size determination was made by considering a vertical HIV transmission rate of 10% among exposed infants on care from a previous study . Study pA structured data collection tool was developed to compile the required information by adopting the national HIV-exposed infant follow-up form. The data were collected by reviewing mothers' PMTCT and exposed infants' care follow-up records at the antenatal care (ANC) clinic and exposed infant follow-up clinics, respectively.The data were collected by two experienced nurses (one from ANC and one from exposed infant clinic) trained on comprehensive HIV care, PMTCT, and exposed infant care and who are working at the respective clinics in Dil Chora Referral Hospital. The data collectors were trained on the data collection procedures for one day. A pretest of the data collection tool and data collection process was made at Sabiyan Health Center found in the city. The investigator oversaw the overall process. All completed data collection forms were examined for completeness, consistency, and clarity during data management, storage, and analysis.According to the national HIV-exposed infant care guideline, HIV diagnosis of exposed infants is made by a positive virological test using Deoxyribonucleic Acid-Polymerase Chain Reaction (DNA-PCR) test at 6 weeks or as early as possible thereafter, or if she/he displays any severe classifications possibly due to HIV or has positive antibody test under 18 months and 2 or more of the following: oral thrush, severe pneumonia, or severe sepsis. The child will be referred to ART care clinic after positive HIV diagnosis . ARV proP ≤ 0.2 in the bivariate model were included in the final multivariate logistic regression model and their adjusted odds ratios were calculated. Variables significant at P < 0.05 in the final model were considered as independent determinant factors for infant HIV serostatus. And crosstabs were done to show the rate of each variable with the outcome. All analyses were conducted using SPSS version 16.0 for Windows .Exploration of data was made to check for any inconsistencies, coding error, out of range, and missing values and appropriate corrections were made. Descriptive analyses of sociodemographic information, infant prophylaxis, and infant follow-up information, maternal PMTCT interventions, and infant final HIV serostatus were carried out. Bivariate logistic regression model was used to assess associations of independent variables with the outcome variable and calculate their crude odds ratios. Finally, all variables significant at A total of 382 HIV-exposed infants on care were included in the study. One hundred ninety-three (50.5%) were females and majority 341 (89.3%) were from urban areas. Regarding place of delivery, 344 (90.1%) of the HIV-exposed infants were delivered at a health institution.Of the total infants born to HIV positive mothers, 298 (78.0%) took ARV prophylaxis at birth and 217 (56.8%) received Cotrimoxazole prophylactic treatment. During the follow-up, 276 (69.9%) infants were on exclusive breastfeeding while the 35 (9.2%) were on mixed feeding. From the infants on care, 40 (10.5%) of them had history of growth failure and two of them had red flag in the developmental staging.At the start of exposed infant care, 379 (99.2%) mothers were alive and 283 (74.1%) were enrolled into care. Among the HIV positive mothers, 253 (66.2%) of them were receiving PMTCT intervention during pregnancy and at child birth, of which 100 (26.2%) were already on ART. Almost all, 378 (99.0%) mothers had normal breast condition during the follow-up .During the follow-up, there was maternal to child HIV transmission in 60 (15.7%) of HIV tested infants; most of them 55 (91.7%) were confirmed by DNA-PCR. The transmission was higher in females than in males (17.6% versus 13.8%). Fifty percent of infants delivered at home were HIV positive compared to 11.9% among infants delivered at health institutions. The transmission rate was higher among infants who did not receive ARV prophylaxis at birth (45.2%) compared to those who received (7.4%) .In the bivariate logistic regression analysis, mother's place of residence, infant's place of delivery, infant ARV prophylaxis at birth, feeding practice, infant age at enrollment, maternal enrollment into care, and PMTCT mother-child pairs were all associated with mother-to-child HIV transmission.In the multivariate logistic regression analysis, being rural resident , delivery at home , infant not receiving ARV prophylaxis at birth , mixed feeding practice , and mother-child pairs not on PMTCT were found to be the most important significant determinants of mother-to-child HIV transmission .In this institutional retrospective study of exposed infants, 60 became HIV positive during the follow-up. The determinant factors of mother-to-child HIV transmission were rural residency, delivery at home, infant not receiving ARV prophylaxis at birth, and mixed feeding.The prevalence rate HIV infection among exposed infants in this study was 15.7%, which was comparable to national prevalence rate of 17%  and to rIn this study, infants born to HIV positive mothers from rural residence were three times at higher risk  of acquiring HIV infection than those born to mothers from urban areas. This finding falls in between figures reported from similar studies , 7. The Infants born at home had a threefold higher risk for HIV infection  compared to those delivered at health institutions. This is comparable to other studies from developing countries , 9, 10. ARV prophylaxis at birth was another determinant factor for MTCT of HIV infection. Infants who did not receive ARV prophylaxis immediately after birth were 5.8 times at higher risk of being infected with HIV than their counterparts . This was similar to finding from other African countries [Infants receiving mixed feeding were 42 times at higher risk of acquiring HIV infection compared to those receiving exclusive breastfeeding . A number of similar studies from resource-limited countries have also reported mixed feeding as an independent predictor of HIV transmission , 10, 11.This study has some limitations. Since the data was secondary, the information gathered was not complete for some infants or mothers. Not all maternal potential factors for vertical transmission were explored by the study. There were changes in PMTCT and HIV-exposed infant care protocols at different times but this research did not assess the difference with each protocol.A higher prevalence of HIV infection was observed among exposed infants on follow-up at the HIV-exposed infant clinic. The risk of HIV transmission was higher among infants from rural areas, indicating scaling up of PMTCT program especially in rural settings. In addition, a higher risk of HIV infection among exposed infants delivered at home, infants who did not receive ARV after birth, and mixed fed infants suggests additional efforts by healthcare providers to intensify community mobilization and provide regular health education to HIV positive mothers, so as to increase PMTCT intervention, institutional delivery, and proper follow-up at the exposed infants care clinic. More prospective studies are needed to understand the influence of additional factors on MTCT, especially in rural settings.


HIV self-testing (HIVST) has been found to be highly effective, but no cost analysis has been undertaken to guide the design of affordable and scalable implementation strategies.ISRCTN02004005) investigating the impact of offering HIVST in addition to facility-based HIV testing and counselling (HTC). Primary costing studies were undertaken of the HIVST service and of health facilities providing HTC to the trial population. Costs were adjusted to 2014 US$ and INT$. Recruited participants were asked about direct non-medical and indirect costs associated with accessing either modality of HIV testing, and additionally their health-related quality of life was measured using the EuroQol EQ-5D.Consecutive HIV self-testers and facility-based testers were recruited from participants in a community cluster-randomised trial  or facility-based HTC (n = 446). The mean societal cost per participant tested through HIVST  was lower than through facility-based HTC . Although the mean health provider cost per participant tested through HIVST (US$8.78) was comparable to facility-based HTC (range: US$7.53-US$10.57), the associated mean direct non-medical and indirect cost was lower . The mean health provider cost per HIV positive participant identified through HIVST was higher (US$97.50) than for health facilities (range: US$25.18-US$76.14), as was the mean cost per HIV positive individual assessed for anti-retroviral treatment (ART) eligibility and the mean cost per HIV positive individual initiated onto ART. In comparison to the facility-testing group, the adjusted mean EQ-5D utility score was 0.046 (95 % CI: 0.022-0.070) higher in the HIVST group.HIVST reduces the economic burden on clients, but is a costlier strategy for the health provider aiming to identify HIV positive individuals for treatment. The provider cost of HIVST could be substantially lower under less restrictive distribution models, or if costs of oral fluid HIV test kits become comparable to finger-prick kits used in health facilities.The online version of this article (doi:10.1186/s12916-016-0577-7) contains supplementary material, which is available to authorized users. Awareness of HIV status is key to ensuring timely access to effective HIV treatment and prevention , 2. Sub-HIV testing and counselling (HTC) continues to be undertaken predominantly in health facilities , despiteHIV self-testing (HIVST) has been found to be highly acceptable, safe and effective at achieving high coverage rates in communities, including amongst hard-to-reach populations of men and adolescents –15. HoweThe study recruited individuals who were participants in a cluster-randomised trial (ISRCTN02004005) investigating the impact of offering HIVST in addition to standard facility-based HTC . We estiThe study area included three high-density urban suburbs of Blantyre, Malawi  with an Routine and confirmatory HIV testing and care services were available at Queen Elizabeth Central Hospital (QECH), and two primary health clinics located in the study area . HIVST was provided for a two-year period, with the service introduced from February to May 2012. From the onset of intervention in seven HIVST clusters, and from January 2013 in all HIVST clusters, participants could also request home-based assessment and initiation of 14 days of HIV care, including ART if eligible [The present study recruited participants from February 2013 to April 2014. Recruitment was restricted to adult residents of the 28 clusters who had just tested for HIV, either at home (HIVST clusters) or in a facility , but had not started ART. A previously validated satellite “Map Book” was used to determine cluster of residence , and conEconomic costing of both the HIVST service and facility HTC services was undertaken to estimate direct health provider costs , 19. CosHIVST community counsellors, programme managers and accounting staff were interviewed to estimate the costs of identified resources and other service delivery, excluding research costs. For facility HTC services, HTC counsellors and administrative staff at the Blantyre District Health Office and the Queen Elizabeth Central Hospital were interviewed. Trial testing registers and Ministry of Health programme output data were used to determine overall numbers of individuals tested and number of HIV positive individuals identified.An interviewer-administered questionnaire was developed that asked all participants recruited into the study about the direct non-medical and indirect costs that they or accompanying family member or carers incurred in accessing HIV testing services. User fees were not charged for either modality of testing. Direct non-medical costs included the cost of transportation, food and drinks whilst waiting, and other costs incurred as a consequence of testing. Indirect costs included time off work multiplied by self-reported income . In addiWe used data reported by the World Bank to adjust all costs to account for inflation and differences in purchasing power between countries . All cosParticipants were recruited after they had received their HIV test result, but before starting ART. HIV results and health-related quality of life (HRQoL) were captured at the same interview as economic costs. We used a self-assessed health (SAH) measure to ask individuals to rate their general health on a five-point Likert scale, with responses coded as: very good; good; fair; poor; or very poor. This SAH measure has been found to be a strong predictor of future health outcomes in high-income settings , and has5) health states. Resultant health states can be converted to an EQ-5D utility score using a “tariff set” derived from national surveys of the general population [A translated Chichewa version of the EuroQoL EQ-5D  tool waspulation . As no Mpulation , assuminpulation . The Zimt-test used for EQ-5D utility and VAS scores. Principal component analysis was used to generate wealth quintiles combining socioeconomic variables including nine household assets, and home environment variables [Analysis used Stata version 13.0 . Comparisons of categorical variables used the chi-squared test, with the student’s ariables .Direct health provider cost per individual tested, and the cost per HIV positive individual identified were estimated from total annual provider cost of HTC services divided by number of individuals tested and number testing positive, respectively. For the HIVST, the proportion testing HIV positive was based on overall parent study data . Direct We made comparisons between the mean direct non-medical and indirect costs for HIV self-testers and facility testers, and for facility-testers who resided in control clusters and intervention clusters. As the cost data were skewed, we used non-parametric bootstrap methods, with 1000 bootstrap replications, to derive 95 % confidence intervals (CI) for mean cost differences for relevant cost categories .We undertook multivariate analysis to investigate the independent effect of the mode of HIV testing and HIV test result on the total societal costs associated with HIV testing. Total societal cost summed direct health provider costs, direct non-medical costs and indirect costs. For the HIV self-testers, we estimated the direct health provider cost per individual tested at the counsellor level. This was possible because the HIVST service records the total number of individuals tested by each of the community counsellors. For facility-based HIV testers, we used the estimated direct health provider cost per individual tested for the clinic attended for testing. As all participants incurred a cost, and the cost data were skewed, we used generalized linear models (GLM) for multivariate analyses of cost data . We ran We compared the responses to the SAH and EQ-5D measures between HIVST participants and all facility testers, and between facility-based HIV testers residing in the intervention clusters to those residing in control clusters. For the descriptive component of the EQ-5D, binary responses (no problems or some/severe problems) were used since severe or extreme problems were rarely reported. We undertook multivariate analysis to investigate the independent effect of the mode of HIV testing and HIV test result on the EQ-5D utility score. EQ-5D utility scores were non-normally distributed, negatively skewed and truncated at 1.0. We evaluated four commonly used estimators to analyse these data: ordinary least squares (OLS) regression, Tobit regression, fractional logit regression and censored least absolute deviations (CLAD) regression –34. We cFor all multivariate analyses we ran two alternative models: the first adjusted for modality of HIV testing, HIV test result, age and sex, and the second additionally adjusted for marital status, educational attainment, income and socio-economic position . We accoSensitivity analysis was carried out using the UK York A1 tariff for the EQ-5D , which tEthical approval was obtained from the College of Medicine Ethics Review Committee, University of Malawi, and the University of Warwick Biomedical Research Ethics Committee. All participants provided written (or witnessed thumbprint if illiterate) informed consent.The study recruited 1,241 participants who had either self-tested and were being assessed as part of the QA study (n = 775) or who undertook facility-based HTC (n = 466) during the study period  compared to US$9.23 (95 % CI: US$9.14-US$9.32) for HIVST. In the multivariate analysis  than among facility testers residing in the intervention  or control  clusters. The mean VAS score for HIVST participants was also higher  than for facility-HTC participants residing in the intervention  or control  clusters.In the multivariate analysis, the model diagnostics showed that the OLS estimator performed as well or better than the other estimators Table . In the In the sensitivity analyses, when the UK tariff was used to derive EQ-5D utility scores, the adjusted mean EQ-5D utility score was 0.059 (95 % CI: 0.026-0.093) higher amongst HIVST participants than among facility testers , compared to US$0.69 for standard finger-prick RDT kits used in health facilities, explains much of the variation. In our analysis the cost of oral fluid RDT kits accounted for half of the total cost per individual tested through HIVST, whilst finger-prick RDT kits accounted for only one tenth of the cost of facility-based HIV testing. In 2010 alone, nearly 100 million HIV testing episodes were undertaken in Africa . Given tWe compared both health provider and societal costs of HIVST and facility-based HTC. Health care costing studies and economic evaluations predominantly adopt a health provider perspective as the findings are used to inform how best to allocate finite health care resources. Taking into account the costs at the societal level informs us on the wider impact of healthcare interventions on the economy as a whole, and may explain reasons for sub-optimal uptake by the population served. Previous research highlights that high direct non-medical and indirect costs act as a deterrent to accessing facility-based HTC services , 38, 39.HIV testing and counselling has been provided at health facilities in Africa for over a decade. HIV counsellors at health facilities are experienced in providing HTC, and monitoring and evaluation systems have evolved. In contrast, HIVST is still in its infancy, with concerns remaining  around potential social harms . ConsequWe used the average yield from the HIVST service over the two years in operation to estimate the health provider cost per HIV positive individual identified through HIVST, assuming individuals were offered annual HIVST. In the main trial, there was a ‘prevalence round’ effect, with HIV prevalence amongst self-testers found to be higher in the first year than in the second . It is lThe EQ-5D measure provides two assessments of HRQoL, the EQ-5D utility score and the VAS score. The VAS score reflects individuals’ self-assessment of their health status, whilst the EQ-5D utility score reflects a general population preference for the overall health state delineated across five dimensions with the added benefit that utility scores can inform cost-utility analyses. In our study we found HIV self-testers reported higher VAS scores than those who tested in facility services. HIV self-testers do not have their test result communicated to them by a HIV counsellor, and the higher VAS scores suggests this does not negatively impact on an individual’s HRQoL. Those who self-tested reported higher EQ-5D utility scores than those who accessed facility testing services, even after accounting for differences in HIV test result and socio-demographic characteristics. Previous work from the main trial found the median CD4 count amongst HIV self-testers who initiated ART to be higher than facility-based testers who initiated ART . Moving Also notable is that, despite the high uptake of HIVST in the main trial , interveThis is the first study we are aware of that has estimated the costs of providing HIVST in Africa. We explored in detail all costs associated with HIVST, from the health provider and societal perspectives, compared with facility-based HIV testing, as well as the HRQoL of users of both modalities. We undertook a range of sensitivity analyses to explore the impact of alternative approaches to estimating total societal costs and for valuing HRQoL. This is not, however, a full economic evaluation, and we, therefore, cannot comment on whether or not scaling-up HIVST is a cost-effective option for sub-Saharan Africa. A full economic evaluation would need to incorporate the costs of providing subsequent HIV treatment and the health outcomes of HIV positive individuals identified through the two modalities, among other considerations.HIV testing services in Africa are in urgent need of substantial scale-up. HIVST offers a potential option, and offering it reduces the economic burden on clients. However, enhanced HIVST strategies may be needed to target higher risk individuals or to increase linkage into HIV treatment services amongst those found to be HIV positive. The affordability of HIVST would substantially improve if the costs of HIV self-test kits were lower, or if HIVST could be provided safely and effectively through less restricted and supervised models. Further work is needed to explore the cost-effectiveness of HIVST.


Predominantly breastmilk: mainly breastmilk and less formula milk, Guidelines: rice porridge, vegetables, fruits and low-fat fish and meat, Easy-to-prepare foods: infant cereals, juices, cakes and biscuits and Noodles (in soup) and seafood: noodle and common accompaniments. In adjusted models, higher maternal education attainment was correlated with higher start scores on Predominantly breastmilk, but lowest education attainment increased its adherence over time. Older mothers had higher start scores on Easy-to-prepare foods, but younger mothers had increased adherence over time. Chinese mothers had higher start scores on Predominantly breastmilk but greater adherence to Guidelines over time, while Indian mothers had higher start scores on Easy-to-prepare foods but greater adherence to Predominantly breastmilk with time . Changes in trajectories over time were small. Hence, dietary patterns established during weaning are strongly influenced by maternal socio-demographic factors and remain stable over the first year of life.Little is known about the dietary patterns of Asian infants in the first year of life, nor of their associations with maternal socio-demographic factors. Based on the Growing Up in Singapore towards healthy Outcomes (GUSTO) mother-offspring cohort, cross-sectional dietary patterns were derived by factor analysis using 24-h recalls and food diaries of infants at 6-, 9- and 12-months of age. Dietary pattern trajectories were modeled by mapping similar dietary patterns across each age using multilevel mixed models. Associations with maternal socio-demographic variables, collected through questionnaires during pregnancy, were assessed using general linear models. In  Tracking of eating habits through childhood and into adulthood has been observed in different populations ,2,3,4, dHealth conscious and Family foods dietary patterns, comprising mainly family table foods, at 9-months of age have been related to lower body mass index (BMI) at the same time point [Discretionary dietary pattern trajectories, comprising finger foods that are convenient to prepare, from 6 to 24-months appeared have been associated with lower IQ in adolescence [The importance of healthful dietary patterns during infancy is further supported by recent studies demonstrating associations in infant dietary patterns with growth ,7,8 and lescence . Most ofThe influence of maternal socio-demographic factors in shaping infancy dietary patterns is widely recognized. Dietary patterns that adhere to infant feeding guidelines are often adopted by mothers with higher educational levels ,15,16,17et al. [Weaning represents a transition period during which the diet undergoes rapid changes from milk-based to solid foods, increasing in variety to resemble an adult-like diet. Yet, most studies have limited their scope to a single time-point ,8,12,17 et al.  to addreIn this study, we aim to better understand the dietary patterns of Asian infants by longitudinally examining the dietary pattern trajectories of infants participating in a multi-ethnic Asian mother-offspring cohort study from 6- to 12-months of age. We also examined potential maternal socio-demographic predictors of these dietary pattern trajectories during this period.Our study is based on the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort . BetweenSocio-demographic characteristics such as maternal age, ethnicity, marital and employment status, housing, monthly household income and education level were obtained from the participants during the first clinic visit upon recruitment (<14 weeks gestation). At 26–28 weeks of gestation, self-reported information on pre-pregnancy BMI, tobacco smoking and alcohol consumption were collected. Details on infant gender and birth order were obtained from birth delivery reports.et al. [Mothers were sent 3-day food diaries to record dietary intakes of their children prior to their postnatal clinic visits at 6-, 9- and 12-months and the diaries were collected at the visits. Instructions and further information on food recording were indicated in the diaries. Mothers who did not complete the food diaries were interviewed by trained personnel at the clinic visits, where a 24-h recall was conducted using the 5-stage, multiple-pass interviewing technique [et al. . For expn = 295, 322, 249 at 6, 9 and 12 months, respectively) or 1-day record (chosen by a randomized order) from the food diaries  were grouped into pre-defined food groups. Food groups with low intakes among the infants (n < 3) were further combined based on similarity in culinary usage and nutrient profile [Food items from the 24-h recalls , dietary trajectories were empirically constructed by mapping the dietary patterns extracted by EFA at 6-, 9- and 12-months. This procedure accounts for the repeated measures of dietary pattern scores of each subject. The dietary patterns across the three time-points were examined for their similarity in the types of foods and their loadings to ascertain their suitability to be modeled as trajectories. The mapping of each pattern to a trajectory was based on similar key constituent foods (with high loadings) found in the dietary patterns across the three time-points and this correspondingly determined the name of each trajectory . The modet al. .Of the 1247 women recruited, 486 singleton subjects with complete birth measurements and dietary records at 6-, 9- and 12-months were included in the final subgroup . A 2-tailed n = 486) were similar to those without complete dietary records (n = 438)  . NonethePredominantly breastmilk, Guidelines, Easy-to-prepare foods and Noodles (in soup) and seafood , high-fat ethnic breads and starchy vegetables at 12-months. The Guidelines trajectory followed recommended weaning guidelines [Four dietary pattern trajectories were observed from 6- to 12-months and were labeled  seafood . The Preidelines  and was Easy-to-prepare foods trajectory consisted of foods that require little preparation  at 6-months and progressed to easy-to-prepare foods such as breads, spreads, biscuit and confectionaries at 12-months. The Noodles (in soup) and seafood trajectory was pre-dominantly noodle-based and consisted of common accompaniments such as eggs, seafood products, dried preserved fruits and bean curd (tofu) found in noodle soup meals. An additional dietary pattern emerged at 12-months of age but did not fall into any of the dietary trajectories: the Pulses and grains pattern. This pattern was distinguished by high intakes of nuts and seeds, grains, legumes and lentils and high energy-dense confectionaries. A complete list of food items and their loading scores for each dietary pattern and trajectory is provided in the Easy-to-prepare foods dietary pattern at 9-months (correlation coefficient = 0.123) (The = 0.123) .The dietary pattern trajectory estimates of 486 infants summarized with respect to their maternal and infant characteristics are shown in Predominantly breastmilk trajectory start scores for infants at 6 months were significantly associated with higher maternal education, higher income, Chinese ethnicity, not working outside the home and having more than one child at home. Higher Guidelines trajectory intercepts at 6 months were associated with post-secondary education. Male infants had higher Easy-to-prepare foods trajectory intercepts at 6 months, while their mothers were more likely to be older (>34 years old) and of Indian ethnicity. No significant maternal factors were associated with the Noodles (in soup) and seafood trajectory.The fully adjusted associations between the intercepts and maternal socio-demographic characteristics are shown in Predominantly breastmilk trajectory. Chinese infants had higher positive slopes for the Guidelines trajectory than Malay or Indian infants. Infants with higher slopes for the Easy-to-prepare foods trajectory had younger mothers. Chinese infants had higher slopes for the Noodles (in soup) and seafood trajectory.The fully adjusted associations between maternal socio-demographic characteristics and rates of change in dietary trajectory scores (slopes) over the period of 6 to 12-months are shown in Pulses and grain dietary pattern emerged only at 12-months of age and was associated with Indian ethnicity and mothers with post-secondary education  of the trajectory scores were much smaller than the differences in the start scores (intercepts) in groups defined by maternal socio-demographic characteristics. This suggests that the maternal characteristics that predict dietary patterns at 6-months of age also largely determine the adherence to the same dietary patterns trajectories for the first year of life. To our knowledge, this is the first study to examine these dietary patterns and associations in an Asian population.Predominantly breastmilk pattern resembles the “breastfeeding” pattern and “longer breastfeeding, late contemporary food introduction and use of home-made foods” reported in the ALSPAC [Guidelines pattern in our study corresponds to the healthy/prudent eating pattern [Easy-to-prepare foods pattern corresponds to an unhealthy eating pattern characterized by intakes of sugary desserts, high-fat foods and refined grains [Noodles (in soup) and seafood pattern, which has not been observed in other studies, appears to reflect Asian adult eating patterns. It resembles the “use of adults’ foods” in the EDEN study [In our study, the e ALSPAC  and EDENe ALSPAC ,13, resp pattern ,16,17,20 pattern ,32. The d grains ,17,18. LPredominantly breastmilk trajectory at 6-months was associated with higher maternal education attainment. The IFPS II study reported that a higher “formula” dietary pattern (reverse of breastmilk) at 6-months of age was negatively associated with maternal education [Predominantly breastmilk trajectory and unemployment is supported by evidence from studies showing that women working part-time or unemployed are more likely than their counterparts to breastfeed [Predominantly breastmilk trajectory for employed mothers when they return to work. Similarly, we found higher educational attainment to be associated with higher start scores of the Guidelines trajectory. Mothers with higher education are probably more aware of recommended practices and guidelines for weaning diets. A similar finding was also observed in the IFPS II study [The trajectory intercept values obtained from the mixed models represents the start point of each dietary pattern trajectory (at 6-months of age). To our knowledge, only three cohort studies to date have reported results for infant dietary patterns at 6-months of age ,12,17. Sducation ,34. The eastfeed ,36,37. Ieastfeed . This maPredominantly breastmilk pattern, while Indian ethnicity was associated with the Easy-to-prepare foods pattern. Ethnic differences in dietary patterns has also been observed in the American population, where White and African-American mothers scored higher on “guidelines” and “easy-to-prepare foods” patterns compared to their Hispanic counterparts [Maternal ethnicity was strongly associated with the start scores of our diet trajectories. Chinese mothers tended to start their infants on the terparts , suggestEasy-to-prepare foods trajectory were also associated with older mothers. In contrast, previous findings suggest that younger mothers tend to provide their children with more convenient foods, perhaps owing to time constraints [We observed that higher start scores on the straints . DiffereNoodles (in soup) and seafood trajectory, suggesting it may be less influenced by cultural or socioeconomic factors.No key maternal determinant emerged in the full model analyses for the et al [The trajectory slopes represent the rate of change of each dietary pattern trajectory between 6- and 12-months. The means and standard deviations of the trajectory slopes were small (<0.05 ± 0.10) compared to the intercepts (<0.51 ± 1.04), suggesting that infants tend to maintain their dietary patterns over time. The range of the slopes we observed is similar to that reported by Smithers et al .Predominantly breastmilk trajectory, suggesting a greater adherence to this pattern over time. This may not be ideal as the World Health Organization (WHO) recommends that solid foods be introduced shortly after 6-months of age [Mothers with lowest educational attainment and primiparous had higher slopes for the s of age  to ensurs of age ,40. In as of age ,32,41.Easy-to-prepare foods trajectory with time, possibly owing to limited knowledge and experience with infant nutrition [Mothers in the youngest age group (18–29) tended to have greater adherence to the utrition .Predominantly breastmilk trajectory over time, Chinese mothers adhere more to the Guidelines and Noodles (in soup) and seafood trajectories over time, reflecting a transition to an increasing pattern of table and adult foods. We also observed a Pulses and grain dietary pattern emerging at 12-months, particularly in Indian mothers of higher education status.Maternal ethnicity continues to be a prevailing determinant of the slope of the dietary pattern trajectories. We observed that while Indian mothers have greater adherence to the Our study captures the important time points of an infant’s weaning diet and fills an important data gap on early feeding patterns. The modeling of dietary pattern trajectories has enabled us to take a longitudinal approach to assessing the overall diet. Compared to conventional cross-sectional analyses, this technique allows us to observe the introduction of new foods through time and the dietary transition during the weaning period. Furthermore, the representation of dietary pattern scores as intercepts and slopes has enabled us to explore the extent to which changes in diet over time are influenced by socio-demographic variables. While the trajectory intercepts signify the cross-sectional dietary pattern scores at 6-months of age, the slopes illuminate the dynamic changes in dietary patterns over time, which cannot be observed in the cross-sectional studies.Limitations of our study also merit comment. First, single 24-h recalls or 1-day dietary records may not be a good representative of an infant’s usual diet due to day-to-day variation in intakes. However, we have demonstrated high correlation of dietary pattern scores across the 3-days of the food diaries, reflecting good reproducibility of the single day dietary records. Second, GUSTO participants were not randomly sampled from the general population, with deliberate over-sampling of Malay and Indian mothers, and were recruited from two maternity hospitals in Singapore. However, these recruitment sites are the two largest maternity hospitals in Singapore and consist of both private and subsidized patients.We examined trajectories of four distinct dietary patterns across three time points between 6- and 12-months. The trajectories were largely determined at the start points (intercepts), and changes over time (slopes) were small. This suggests the importance of establishing the “right” diet at the start of complementary feeding, as dietary changes are more difficult once habits are established. By understanding the key maternal socio-demographic factors that influence dietary patterns during complementary feeding, health professionals and policy-makers can provide more targeted and culturally-appropriate support and advice for mothers and their infants.


While weight gain following breast cancer is considered common, results supporting these findings are dated. This work describes changes in body weight following breast cancer over 72 months, compares weight with normative data and explores whether weight changes over time are associated with personal, diagnostic, treatment or behavioral characteristics.A population-based sample of 287 Australian women diagnosed with early-stage invasive breast cancer was assessed prospectively at six, 12, 18 and 72 months post-surgery. Weight was clinically measured and linear mixed models were used to explore associations between weight and participant characteristics (collected via self-administered questionnaire). Those with BMI changes of one or more units were considered to have experienced clinically significant changes in weight.More than half (57%) of participants were overweight or obese at 6 months post-surgery, and by 72 months post-surgery 68% of women were overweight or obese. Among those who gained more weight than age-matched norms, clinically significant weight gain between 6 and 18 months and 6 and 72 months post-surgery was observed in 24% and 39% of participants, respectively . Clinically-significant weight losses were observed in up to 24% of the sample (median [range] weight loss between 6 and 72 months post-surgery: −6.4 kg [−1.9--24.6 kg]). More extensive lymph node removal, being treated on the non-dominant side, receiving radiation therapy and lower physical activity levels at 6 months was associated with higher body weights post-breast cancer .While average weight gain among breast cancer survivors in the long-term is small, subgroups of women experience greater gains linked with adverse health and above that experienced by age-matched counterparts. Weight change post-breast cancer is a contemporary public health issue and the integration of healthy weight education and support into standard breast cancer care has potential to significantly improve the length and quality of cancer survivorship. Maintaining a healthy body weight and avoiding excessive weight gain throughout life are common public health messages with respect to breast cancer prevention and recovery ,2. OverwFollowing a breast cancer diagnosis, weight gains exceeding five kilograms have been observed over periods between six months -22 and sWhile earlier studies, particularly those that assessed the effects of chemotherapy compared changes in weight and body composition against patients who just received localised treatment ,28, the Ethical approval was obtained from a university human research ethics committee  and access to patients followed the standard procedures of the local cancer registry. All women provided written, informed consent.The Pulling Through Study (PTS) was a prospective, population-based, cohort study designed to track and assess the physical and psychosocial recovery of Australian women newly diagnosed with breast cancer. The design and sample characteristics of the PTS) have been detailed elsewhere . BrieflyConsent was later received to follow-up the original sample of 287 women at six years  post-surgery. Of the 287 original participants, 11 withdrew from the study and were therefore not recontacted. The records of the remaining 276 women were cross-referenced with the mortality database at the Queensland Cancer Registry in August 2008 to determine vital status, including date and cause of death. At the 72-month follow-up , 23 were2 (meters). BMI scores of <18.5, 18.5-24.9, 25–29.9 and 30+ were categorized as underweight, healthy weight, overweight and obese, respectively.Clinical Assessment: Standard procedures and the same calibrated scales were used throughout the study period. Weight was measured to the nearest 0.1 kilogram (kg) using Seca™ scales, with participants wearing light clothing and no shoes, at 6-, 12-, 18- and 72-months post-surgery. Height was assessed using a KDS™ 2m tape, and recorded to the nearest centimeter at 6 months post-surgery. BMI was calculated by weight (kilograms)/heightSelf-administered Questionnaire: Participants were asked to self-report weight at 6 , 12 and 18 months post-surgery and height at 6 months post-surgery . BMI was calculated as above. At 6 months post-surgery, participant-administered questionnaires were used to collect information on personal , treatment  and behavioral  characteristics. Physical activity was measured using the Active Australia survey  with ‘seWeight change observed in the PTS sample was compared with weight change reported in the sample of the Australian Diabetes, Obesity and Lifestyle - AusDiab study . The AusChi-square tests were conducted to assess whether there were any group differences on categorical variables between the women who provided self-report and clinically-assessed data, compared to those women who provided self-reported data only; a statistically significant difference between groups was defined as p < 0.05. Means and corresponding standard deviations were calculated and reported when continuous data were approximately normally distributed, while median and range were presented when data were skewed or categorical.Proportions and 95% confidence intervals (CI) of women in BMI categories and the proportion of women who gained, lost and had stable weight between 6 and 18 months and 6 and 72 months post-surgery were also presented. A change of 1 BMI unit or more is associated with adverse health events, and therefore considered a clinically meaningful change . TherefoWeight change between 6 and 18 months and 6 and 72 months post-surgery for each PTS participant was compared with the mean weight change observed in a 1- and 5-year assessment period for female AusDiab  participIn exploring the baseline  personal, diagnostic, treatment, and behavioral characteristics associated with weight, and to maximize the use of all available data at each time-point and the repeated nature of the study design, all available clinically-assessed weights for 211 women were analyzed using linear mixed models. A random intercept was fitted for each individual and a random slope was also fitted with respect to time. Only characteristics that were clinically  or theoretically-relevant (hypothesis based on the literature) were included in the final model. Interactions between time and all other characteristics were also included in the model, but were subsequently dropped as no effect modification was observed . All analyses were performed using SPSS v18.0  and R . Mixed models were fitted using package lme4 in R. Least square means were estimated from the mixed models using the package lsmeans; statistical significance was defined as p < 0.05.Approximately half of PTS participants were aged 55 years or older (48.4%), 75.0% underwent lumpectomy, and the majority had axillary node resection (86.5%) Table . Three-qTable Table Following adjustment for potential confounding , the relationship between higher body weight and a number of these characteristics  remained clinically and statistically significant  were overweight or obese, and by six-years post-breast cancer 68% of women were overweight or obese; this compares to fewer than 50% of age-matched controls . While mIn this cohort, the two women reporting the most extreme weight losses 23 and 24 kg) had early stage disease and good prognosis, suggesting that extreme weight loss was unlikely to be associated with cachexia of advanced disease. Nonetheless, for the 15% to 24% of the sample who lost weight, it is unclear from our data whether this loss was intentional, or not, and if intentional whether it resulted from weight loss strategies that are aligned with current guidelines aimed at durable change  . Moreove kg had eOver half of the PTS participants gained weight in the short 6 to 18 months) and longer-term (6 to 72 months) post-surgery. Of these women, 80% gained more weight than the average weight gain experienced by age-matched counterparts. Further, by 18- and 72-months post-breast cancer diagnosis, 24% and 39% of women, respectively, gained a magnitude of weight  that is8 months Understanding characteristics associated with weight at diagnosis and weight change post-surgery may provide insight into the potential for identifying subgroups of women who would benefit most from a ‘healthy weight’ program. Our results suggest that women treated on the non-dominant side, those with more extensive axillary lymph node dissection, those receiving radiation treatment and those not engaging in sufficient levels of physical activity each week tended to be heavier post-surgery. With the exception of physical activity, these characteristics are non-modifiable, are modest confounders of the association between physical activity and weight, and warrant further exploration as potential effect modifiers in future research. Nonetheless, since overweight, obesity and weight gain post-breast cancer are common and persistent contemporary breast cancer survivorship issues that challenge quality and quantity of life, the integration of healthy weight management into standard breast cancer care for all women appears necessary.Our findings demonstrating that those meeting national physical activity guidelines  have clinically lower body weights than those insufficiently active or sedentary are not surprising. Evidence-based clinical recommendations for achieving healthy weight and/or weight loss for the general population  includes a multicomponent approach, involving physical activity, as well as diet and behavior modification . It is aPotential limitations of this work are that the PTS sample was diagnosed over 10 years ago (2002) and loss to follow-up in this cohort was greater than 20%, which threatens the generalizability of findings ,48. NoneIn summary, weight at six months post-diagnosis of breast cancer and weight change post-surgery remains a contemporary public health issue. There is a real need for the incorporation of weight management strategies into breast cancer care for all women diagnosed, though it may be even more important for women in certain subgroups . In doing so, the potential for prevention and/or attenuation of breast cancer treatment-sequelae, subsequent chronic disease and improvements in quality and quantity of life following breast cancer is significant.


The National Eye Institute 39-Question Visual Function Questionnaire (NEI VFQ-39) is an indicator of vision-related quality of life (QoL). The NEI VFQ-39 is used to assess the QoL in patients with non-infectious posterior uveitis, intermediate uveitis, or panuveitis, treated with subconjunctival (SCJ) or intravitreal (IVT) sirolimus as an immunomodulatory therapeutic (IMT) agent, delivered subconjunctivally (SCJ) or intravitreally (IVT) (the SAVE Study). Thirty subjects with non-infectious uveitis were randomized  for a prospective clinical trial. The 39-Question Visual Function Questionnaire (VFQ-39) was administered at baseline (BL), month 6 (M6), and month 12 (M12) visits. The survey measures self-reported vision health status for patients with chronic eye disease and assesses the effects of visual impairment on both task-oriented visual function and general health domains. In accordance to the NEI-VFQ Manual, each patient’s questionnaire was converted to a scaled score between 0 (worst) and 100 (best), and median scores were calculated for each of the subcategories and overall composite score at BL, M6, and M12. Wilcoxon signed-rank test was performed.Twenty-six patients completed the VFQ-39 at BL and M6, whereas 23 patients completed it at M12. Patients showed a significant improvement in pooled composite scores from BL to M6 and BL to M12. Analysis by treatment groups showed that intravitreal injection of sirolimus is better tolerated.Sirolimus has demonstrated bioactivity as an IMT and corticosteroid-sparing agent to treat non-infectious uveitis. Patients receiving intravitreal injection of sirolimus showed overall improvement of vision-related health while those receiving subconjunctival injections did not. Larger randomized control trials with sirolimus are indicated to validate these results.NCT00908466ClinicalTrials.gov: The online version of this article (doi:10.1186/s12348-015-0044-1) contains supplementary material, which is available to authorized users. Uveitis is an ocular disease that results from inflammation and tissue damage, which compromises the uvea of the eye . UveitisTopical, periocular, intraocular, and systemic corticosteroids are the mainstay of primary immunosuppressive therapy as well as the only United States Federal Drug Agency (US-FDA)-approved drug class in the United States for treatment of non-infectious uveitis . HoweverSirolimus is an immunosuppressant that works through its inhibition of the mammalian target of rapamycin (mTOR) and subsequent inhibition of inflammatory cytokine production . SirolimThe National Eye Institute Visual Function Questionnaire 39-Item  is a self-administered survey that has been widely used to assess patient vision-related functioning. The NEI VFQ-39 survey contains 39 questions that evaluate 12 subscales of quality of life (QoL) including general health, general vision, ocular pain, near vision, distance vision, social function, mental health, role difficulty, dependency, driving, color vision, and peripheral vision. Each question has multiple choices that are scored on a five-, six-, or ten-point scale.The NEI-VFQ has been used previously in several studies to assess the impact of ocular disorders and their treatments on visual function. These studies indicate that the questionnaire is a reliable and valid indicator of vision-related quality of life in patients with non-infectious uveitis and other ocular diseases -9.The index analysis was performed to assess changes in QoL of patients receiving sirolimus as a therapy for non-infectious uveitis in the SAVE (Sirolimus as therapeutic Approach to uVEitis) study using patient-reported changes in QoL as an indicator.A randomized, open-label safety, and bioactivity clinical study was conducted at the Wilmer Eye Institute on 30 patients with non-infectious intermediate uveitis, posterior uveitis, and panuveitis in accordance with the SAVE Study protocol . These pActive disease was defined as having at least 1+ vitreous haze using the Standardized Uveitis Nomenclature (SUN) Working Group scale and/or at least 1+ vitreous cell count using the Foster and Vitale scale. Inactive disease was defined as having vitreous haze of 0.5+ or less and vitreous cell count of 0.5+ or less, using the SUN Working Group and Foster and Vitale scales.Patients were randomized and divided into two treatment groups. Group 1 received intravitreal (IVT) injections of 352 μg of sirolimus in the study eye on days 0, 60, and 120. Group 2 received subconjunctival (SCJ) injections of 1,320 μg of sirolimus in the study eye on days 0, 60, and 120. Starting at day 180, study subjects were eligible to receive additional subconjunctival or intravitreal sirolimus, based on their initial group randomization, every 2 months if they were found to have active disease as defined above. The end-of-study visit was at month 12.The NEI VFQ 39 was self-administered at baseline (BL), month 6 (M6), and month 12 (M12) of the study. Patient composite and subscale scores were calculated according to the protocol in the NEI VFQ Manual . The meaPooled patient data was analyzed to assess response to study treatment regardless of study group or category. Subsequently, patient data was divided into treatment groups (SCJ vs IVT) and treatment categories and then analyzed for differences in subscale and composite scores.P value of <0.05 was considered significant.The Wilcoxon signed-rank test was used to determine significance of changes between baseline, month 6, and month 12 for all groups. A 95% confidence interval with a 5% level of significance was used, therefore, a The VFQ-39 was filled by 26 patients at BL and M6 and by 23 patients at M12. A total of six patients had exited the study before the M12 endpoint and one patient did not fill out the M12 questionnaire.P < 0.001).Median subscale and composite scores for the pooled data are shown in Table P = 0.01)  in the ocular pain scores. However, group 1 also reported significant improvements in the areas of general vision, near activities, distance activities, vision-specific social functioning, and vision-specific mental health. Only group 1 displayed significant improvement in composite score from BL to M12 (P = 0.03)  in ocular pain scores and vision-specific mental health scores. However, only patients in category 1 showed a significant increase in the NEI VFQ-39 composite scores at month 12 (P < 0.001). Specifically, patients showed greatest score improvements in the subscales of ocular pain and vision-specific mental health (P < 0.001). Patients in group 2 showed a greater increase in ocular pain scores from BL to month 6; however, the effect seemed to have plateaued off and no significant improvement was observed in this group beyond month 6. Group 1 continued to show improvement until month 12. Improvements were also reported in vision-specific social functioning, vision-specific role difficulties, and vision-specific dependency.In this QoL analysis of study subjects in the SAVE Study, NEI VFQ-39 scores have demonstrated that both intravitreal and subconjunctival injections of sirolimus were well tolerated. After 12 months, pooled data from patients treated with sirolimus (regardless of the mode of injection) showed a statistically significant improvement in composite scores for NEI VFQ-39 (P < 0.01). In addition, patients receiving IVT injections (Group 1) show significant improvements in overall vision-related functioning after 12 months compared to baseline. Results indicate that sirolimus treatment provides a significant decrease in ocular pain regardless of route of administration. However, IVT injection results in improvement in the additional areas of general vision, near activities, distance activities, vision-specific social functioning, and vision-specific role difficulties.When divided into treatment groups, it is apparent that IVT injection of sirolimus showed a significant improvement in a higher number of subscales at M12 compared to SCJ administration. Patients receiving sirolimus injections in both the groups showed a significant improvement in ocular pain after 12 months  due to steroid-related adverse events over the course of the study.While sirolimus has demonstrated bioactivity as an IMT and corticosteroid-sparing agent to treat non-infectious uveitis, the analyses from our NEI VFQ-39 assessments have indicated that patients receiving sirolimus also show an overall improvement of vision-related health.n = 26), it is not certain that these results are applicable to the larger population of patients with non-infectious uveitis. Currently, randomized phase 2 and phase 3 studies of intravitreal sirolimus in non-infectious uveitis are being conducted in the United States and throughout the world to investigate the efficacy of sirolimus. Additional QoL analyses of patients enrolled in these larger randomized control trials with sirolimus will be very helpful to determine if sirolimus is effective in not only controlling the disease but also beneficial in improving the quality of life of patients suffering from non-infectious uveitis.Our study is among the very first being reported in the literature on the assessment of QoL in patients with uveitis undergoing therapy with local administration of an IMT. An important limitation of our study is the small sample size. Due to the small sample size (Locally delivered sirolimus has demonstrated bioactivity as an IMT and corticosteroid-sparing agent to treat non-infectious uveitis. Patients receiving intravitreal injection of sirolimus showed overall improvement of vision-related health while those receiving subconjunctival injections did not. Larger randomized control trials with sirolimus are indicated to validate these results.