The adaptation of adenoviruses as gene delivery tools has resulted in the development of high-capacity adenoviral vectors (HC-AdVs), also known, helper-dependent or “gutless”. Compared with earlier generations (E1/E3-deleted vectors), HC-AdVs retain relevant features such as genetic stability, remarkable efficacy of in vivo transduction, and production at high titers. More importantly, the lack of viral coding sequences in the genomes of HC-AdVs extends the cloning capacity up to 37 Kb, and allows long-term episomal persistence of transgenes in non-dividing cells. These properties open a wide repertoire of therapeutic opportunities in the fields of gene supplementation and gene correction, which have been explored at the preclinical level over the past two decades. During this time, production methods have been optimized to obtain the yield, purity, and reliability required for clinical implementation. Better understanding of inflammatory responses and the implementation of methods to control them have increased the safety of these vectors. We will review the most significant achievements that are turning an interesting research tool into a sound vector platform, which could contribute to overcome current limitations in the gene therapy field. Adenoviridae family comprises a wide group of human and animal viruses sharing functional, genetic, and structural characteristics [Mastadenovirus genus, is the adenovirus most frequently adapted as gene therapy vector, and we will use it as a paradigm for the description of general characteristics. However, the entire Adenoviridae family offers a rich source of members [The eristics . Traditieristics . Human a members  whose pe members . Each ve members , allowin members , as well members . Upon ce members . A progr members . Of note members . The end members . The par members . It is e members . However members . In thes members , which din trans in the packaging cells during vector amplification. The E3 region, which is dispensable for the amplification of AdV in cell culture, is also removed in most cases to increase the cloning capacity up to 8 Kb. These first-generation, E1/E3-deleted AdV vectors (FGAdV) demonstrated high transduction efficacy in cell cultures and animal models, and its clinical translation raised high expectations [gutless” vectors) that cellular immune responses against transduced cells were dampened and long-term transgene expression was achieved in vivo. Seminal studies in non-human primates (NHP) demonstrated that a single intravenous administration can sustain secretion of therapeutic proteins from the liver for several years [AdVs can be modified to exploit different properties, giving rise to specialized agents . The lytctations . Furtherctations . Therefoctations , apart fal years ,22. In tal years . These sal years . Of noteThe removal of all viral coding genes dictates the unique properties of HC-AdVs in terms of stability of expression and cloning capacity, which differentiate them from early AdV vector versions. The downside is a greater complexity of the production procedures, because stable expression of all adenoviral genes in packaging cells, in the pattern and amount required for trans-complementation, is not feasible. Therefore, most methods rely on the use of HVs. The main differences among them are the strategies used to avoid HV contamination in the final HC-AdV preparation, as described below.The first method for HC-AdV production dates back to 1996, when Kochanek et al. prepared a plasmid containing 28 Kb of non-viral DNA flanked by AdV ITRs, with the packaging signal in one end . The HV In principle, HC-AdVs can be purified the same as any other AdV. Ultracentrifugation in CsCl density gradients is the traditional method, followed by desalting by size exclusion chromatography (sepharose columns) or dialysis ,41. HoweCommon to all viral vectors, the availability of standardized methods for precise quantification of HC-AdVs is an unmet need. The simplest way to determine the amount of particles (vp) in a purified HC-AdV preparation is based on the absorbance at 260 nm, usually performed after disruption of capsids by detergent (SDS) or enzymatic treatment ,48. SimiAll HC-AdV interactions with the extracellular milieu are common to the parental AdV type used to develop the HV, unless specific capsid modifications have been implemented. This means, for instance, that HC-AdVs derived from the prototypic HAdV5 will bind with high affinity to erythrocytes in circulation, through direct binding of fiber to the primary CAR receptor, or via natural antibodies to complement receptor CR1 . It is n13 vp of an early generation AdV vector [In the same vein, HC-AdVs elicit innate and humoral adaptive immune responses similar to other AdV vectors . Of noteV vector  is a conV vector . It is rIn contrast with the aforementioned considerations, vector-related cellular immune responses against transduced cells are attenuated in the case of HC-AdVs compared with other AdV vectors ,63,64. THC-AdV particles penetrating into mammalian cells are transported through microtubules and introduce their genome in the nucleus, following the highly efficient pathway common to all AdV vectors . During Adenoviridae family provides a wide repertoire of members with specific properties matching many therapeutic needs  . The constration . Coupledstration . The chistration . InteresAdV derived from other host species are being exploited for therapeutic purposes, and some of them have been modified as HC-AdVs . Apart fSince AdV vectors are non-integrative, transgene expression will only be stable if the target cells have a low turnover rate, unless artificial mechanisms are designed to sustain genome replication or chromosomal integration . In concF8) exceeds the cloning capacity of AAVs. Pre-clinical studies in mice showed restoration of circulating FVIII at therapeutic levels using a vector encoding human F8 under the control of the albumin promoter [11 vp/Kg of the vector showed initial signs of efficacy (increase from less than 1% to 3% FVIII levels in serum), according to sponsor´s press releases. However, the appearance of acute thrombocytopenia, increased liver transaminases and elevation of IL-6 prevented the enrollment of more patients in this cohort. Since safer doses of this vector had low therapeutic possibilities, the trial was not continued, and full description of this case is not available in the scientific literature. Although only speculative, one possible explanation for this outcome is a relatively high HV contamination combined with high total to infective particle ratio during mass production of the vector, since the method available at that time was not optimal [LacZ gene from HV-transduced hepatocytes could contribute to liver damage and immunogenicity. Subsequent pre-clinical developments, including improvements in the production methods, showed therapeutic benefit and moderate, dose-dependent toxicity in stringent models such as hemophilic dogs [F8 cDNA [Gene expression from hepatocytes has therapeutic interest not only for hepatic and metabolic diseases, but also for secretion of proteins into circulation. Hemophilia has been considered a suitable target for liver-directed gene therapy from the beginning of this field, because coagulation factors are naturally produced and secreted from this organ. Transduction of all hepatocytes is not required to obtain a therapeutic effect, as far as the circulating levels of the proteins reach a certain threshold. In general, 5% normal values are needed to convert a severe hemophilia into a mild disease, and 30–50% should be obtained for complete clinical normalization . Hemophipromoter . Followipromoter , this st optimal . In addilic dogs ,82,121. lic dogs . The uselic dogs . However[F8 cDNA ,125.F9, cDNA 1.5 Kb) allows the use of AAV vectors without transgene engineering, which has expedited its clinical translation [F9 under the control of liver-specific promoters have shown excellent preclinical results in murine hemophilia B models [12 vp/Kg) was needed to guarantee sustained therapeutic levels of the clotting factor for more than 2 years [11 vg/Kg of an E1-E4-deleted AdV administered through the portal vein caused a severe inflammatory syndrome in one human subject [Gene therapy approaches for hemophilia B followed a similar pattern. In this case, the relatively small size of the mutated gene . HC-AdVs encoding A1AT were among the first vectors of this class to be tested in animal models, including NHP ,131. In 12 vp/Kg). The second serious concern was an elevation of transaminases (ALT) observed 2 months after treatment. Although the increase was mild and transient, it was followed by a reduction and virtually disappearance of the therapeutic effect . In principle, immune responses against the transgene were discarded because the vector expressed the rhesus monkey LDLR cDNA in haploinsufficient animals, and it was under the control of the liver-specific phosphoenol pyruvate carboxykinase (PEPCK) promoter. Although no T-cell responses could be detected against adenoviral proteins, this phenomenon is reminiscent of the situation observed in humans treated with AAV vectors [Systemic administration HC-AdVs have shown therapeutic effect in different models of dyslipidemia, in which elevated and sustained levels of therapeutic proteins are needed in circulation. A pioneer study demonstrated the lifelong correction of cholesterol levels in Apo E-deficient mice upon a single intravenous administration of HC-AdVs, especially when they incorporate Apo E gene and regulatory sequences in the genomic context . Vectors vectors . It rema12 vp/Kg of vector), suggesting that PH1 is still a challenge for current gene therapy technologies.Primary hyperoxaluria type 1 (PH1) is caused by defects in alanine:glyoxylate aminotransferase (AGT), resulting in systemic elevation of oxalate and accumulation of calcium oxalate precipitates in the kidney and other organs. This disease is considered a suitable target for liver-directed gene therapy, since there is clinical evidence that liver transplantation (combined with kidney transplantation in most cases) is therapeutic . HoweverCPS1 cDNA (4.5 Kb) makes it difficult to design efficient AAV vectors. In this case a high dose (5 × 1012 vg/Kg) was also needed for full protection from hyperammonemia in a mouse model [An equivalent vector was employed for the treatment of carbamoyl phosphate synthetase 1 deficiency (CPS1D). HC-AdVs are especially indicated for the treatment of this urea cycle disorder, since the size of the se model . Apart fse model , but thiUGT1A1) was reduced from 3 × 1012 vp/Kg to 5 × 1010 vp/Kg when an enhancer from the ApoE gene was located in the 3’UTR of the transgene, and the vector was delivered by hydrodynamic injection [For diseases requiring high levels of transgene expression, optimization of delivery routes and expression cassettes is crucial, as demonstrated for Crigler-Najjar syndrome type I in the Gunn rat model. The therapeutic dose of a HC-AdV encoding Uridine diphospho-glucuronyl transferase 1A1 (njection . Clinicanjection .PBGD) cause a reduction in the expression of the enzyme, which is involved in the heme synthesis pathway. Patients suffer attacks of severe abdominal pain and neurovisceral disturbances, which can be life-threatening and provoke progressive irreversible neuropathy [PBGD under the control of a potent liver-specific promoter  achieved correction of neurotoxic intermediate metabolites in a mouse AIP model [11 vp/Kg). However, experiments performed in macaques (Macaca fascicularis) showed that sustained expression of PBGD and persistence of vector genomes in the liver required intense immunosuppression [In acute intermittent porphyria (AIP), mutations in one copy of the porphobilinogen deaminase gene , in which accumulation of glycogen in skeletal muscles, hearth and diaphragm plays a major role in the clinical manifestations. In fact, a HC-AdV expressing GAA under the control of liver-specific sequences (PEPCK promoter plus ApoE enhancer) achieved long-term correction of glycogen content in skeletal muscles [12 vg/Kg) [For lysosomal storage disorders (LSD), transduced hepatocytes can become a stable source of therapeutic enzymes secreted into circulation and internalized by target cells through the mannose-6-phosphate receptor . This is muscles . Importa2 vg/Kg) . However2 vg/Kg) .9 vp) was well-tolerated and avoided the generation of NAbs [vs 592 and 728, respectively) and a weaker immune response, although it could be due to a lower transduction rate [The attributes of HC-AdVs, namely the stability of transgene expression and the reduced immunogenicity are particularly important when they are applied in the CNS. In addition, high cloning capacity is often required to allocate large transgenes (such as ion channels), combinations of genes (such as biosynthetic pathways for dopamine production in Parkinson’s disease) or complex regulatory regions to restrict expression to specific cell populations. Parenchymal administration of HC-AdV in rodents , the gene responsible for the devastating Duchenne Muscular Dystrophy (DMD) [Although adenoviral transduction in adult skeletal muscle is not as efficient as in liver, HC-AdVs offer the opportunity to deliver the full cDNAs of genes involved in the most frequent muscular dystrophies, which are often too large to be packaged in other viral vectors. This is the case of hy (DMD) . A HC-Adhy (DMD) . Improvehy (DMD) ,193. Inthy (DMD) . Transduhy (DMD) . Fiber khy (DMD) .For diseases in which therapeutic effects can be obtained by secretion of a therapeutic gene into circulation at moderate levels, the TARGT approach (transduced autologous restorative gene therapy) has been proposed. Patient’s dermal fibroblasts are isolated, transduced in vitro with HC-AdVs and implanted subcutaneously. This strategy has been applied for the expression of erythropoietin (Epo) in end-stage renal failure patients. A phase I-II clinical trial demonstrated the feasibility and safety of this treatment. Epo was detected in circulation, and hemoglobin levels were stabilized for at least 5 months after a single cell implantation . In addiEpisomal maintenance of vector genomes avoids the risk of insertional mutagenesis, but at the same time it precludes the use of standard HC-AdVs when the target cell has an active turnover. Nevertheless, far from being outside the scope of these vectors, HC-AdVs are suitable platforms for stable modification of this type of cells. One possibility to maintain transgene expression is to synchronize vector and host genome replication, without the need for integration. As a proof of concept, the Epstein-Barr virus (EBV) nuclear antigen 1 (EBNA-1) was expressed from a HC-AdV, and sequences acting as origins of replication were incorporated (family of repeats from EBV and a 19 Kb fragment from human chromosome 10). The Cre-loxP system was used to circularize the vector genome in transduced cells. The resulting circular double-stranded DNA molecule was replicated in the S phase of the cell cycle and segregated in daughter cells, maintaining transgene expression for several passages .piggyBack or Sleeping beauty (SB) transposon systems [cis-acting sequences and the transposase are usually contained in separate vectors. In the case of SB, efficient integration requires circularization of DNA. Therefore, a site-specific recombinase is usually expressed together with the transposase. Random integration and the need of co-delivery are compatible with ex vivo approaches, in which high rate of co-infection and further characterization/selection of cells are feasible [However, most efforts are recently aimed at gene editing or controlled chromosomal integration. HC-AdVs offer safe and efficient vector/host genome interactions owing to the efficacy of gene delivery into the nucleus, the extended cloning capacity, the genome stability, and the blunted cellular immune responses against transduced cells. Random integration can be obtained using  systems . To thisfeasible . For in feasible ,203. Genfeasible . Importafeasible . Other afeasible ,206. Howfeasible . So far,feasible ,208, but6 human induced pluripotent stem cells (iPSC) at MOI 350 obtained up to 144 clones harboring integration of the template DNA after positive selection [One potential drawback for in vivo application of all these strategies is the immunogenicity of the transgene products, especially those derived from prokaryotes such as TALEN and CRISPR/Cas9 . Hopefulelection . In 64% election . Based oelection . Proof oExamples with particular clinical relevance for gene integration/editing approaches are the respiratory epithelium and the bone marrow (BM). For sustained amelioration of respiratory manifestations in cystic fibrosis (CF), transduction of basal cells with stem cell properties in the airway epithelium is mandatory. The optimization of delivery routes , coupled with drugs to open intercellular tight junctions (L-α-lysophosphatidylcholine) has improved the access of HC-AdVs to these cells ,217. OncP140K transgene, which confers resistance and proliferation stimulus in response to O6-BG/bis-cloroethyl-nitrosourea (BCNU) treatment. Alternatively, the γ-globin gene has been integrated into the AAVS1 locus by co-administration of a pair of HC-AdVs encoding a CRISPR/Cas9 and the DNA template [In the case of BM, the development of HC-AdVs based on HAdV35 has increased the transduction efficacy in HSCs and the feasibility of gene editing approaches for a wide variety of diseases, as described in detail in a recent review . Of notetemplate .F8 cDNA together with the mgmtP140K selection gene, and another one expressed the SBx100 transposase to promote integration into the host genome. When these vectors were administered in vivo, the levels of FVIII in circulation reached 5% normal values in a mouse model [The BM can be used as a secretory organ for therapeutic proteins such as coagulation FVIII. In this case, one vector carried the se model . Althougse model , permanese model .In some genetic muscular dystrophies such as DMD, early intervention and stable expression of therapeutic genes in myoblasts is important. Some strategies aimed at dystrophin cDNA integration consist of hybrid AdV-AAV vectors, in which integration occurs at the AAVS1 locus in the presence of the AAV Rep protein, as demonstrated in vitro . An alteEF1α) promoter was developed [After many disappointing trials, it is clear that current gene therapy technology does not allow transduction of all the cells in a tumor. However, many immunotherapy approaches can benefit from the properties of HC-AdVs, especially when the expression of transgenes should be placed under the control of drug-inducible systems to avoid toxicity, and when a combination of transgenes is needed. The HC-Ad-TK/TetOn-Flt3L vector encodes the suicide gene thymidine kinase (TK) and the dendritic cell chemoattractant FMS-like tyrosine kinase 3 ligand (Flt3L) under the control of a tet-on inducible system ,164,227.eveloped . The veceveloped .Plasmodium falciparum for vaccination against malaria [https://cen.acs.org/pharmaceuticals/vaccines/Adenoviral-vectors-new-COVID-19/98/i19). These approaches are based on previous experimental vaccines against MERS-CoV [The strong innate immune responses against AdV particles can be exploited for the design of genetic vaccines. As introduced in the previous sections, some evidences indicate that HC-AdVs outperform FGAdVs when they express the same antigen. This is in part due to the cell cycle arrest caused by FGAdVs in DCs ,232. In  malaria . Similar malaria . In this malaria . Althoug malaria , one hyp malaria . The exp malaria ,242,243.MERS-CoV ,245. OthMERS-CoV  and IL-1MERS-CoV  against MERS-CoV . FurtherDuring the past two decades, a vast number of preclinical studies have demonstrated the ability of HC-AdVs to transduce relevant target cells in vivo, especially hepatocytes, neurons and endothelial cells. Stable episomal maintenance of genomes in these cells, resulting in sustained expression of transgenes, has been demonstrated not only in rodents but also in larger animal models, including NHPs. Despite clear evidence of therapeutic effect in a large number of disease models, clinical experience with these vectors is virtually absent. This is in part because translational efforts have been focused in other vector platforms, such as AAV. When therapeutic cassettes can fit into the 4.5 Kb size constraint of AAVs, these vectors have shown similar pre-clinical results than HC-AdVs, but they elicit less inflammatory responses and are easier to produce under GMP conditions. However, the field of HC-AdVs is making progress in delivery routes, methods to prevent and manage side effects, and protocols for large-scale production. We believe these vectors will play an important role in the gene therapy arsenal in the near future. Not only as an alternative to AAVs, but more importantly, covering unmet needs in the fields of gene editing and the transfer of large sequences.


Fin = 481.3, p = 0.011), vigorous-intensity physical activity , dominant and nondominant hand grip (kg) , FEV1/FVC , VO2 max (ml/kg/min) , VO2 max predicted (%) , work (watts) , and anaerobic threshold (L/min) . Twelve weeks of individualized aerobic exercise training in the rehabilitation center combined with telephone-based motivational interviewing can increase the total physical activity, vigorous physical activity, and cardiorespiratory fitness of middle-aged and older adults with multimorbidity.The presence of multimorbidity in middle-aged and older adults, which reduces their physical activity and quality of life, is a global health challenge. Exercise is one of the most important health behaviors that individuals can engage in. Previous studies have revealed that aerobic exercise training is beneficial for healthy middle-aged and older adults and those with various chronic diseases, but few studies have designed individualized aerobic exercise training for individuals with multimorbidity. Although individuals with multimorbidity are considerably less adherent to physical activity interventions, telephone-based motivational interviewing may help in strengthening motivation and promoting behavioral change for increasing physical activity and health-related physical fitness. This study aimed to examine whether a 12-week individualized aerobic exercise training in a rehabilitation center combined with telephone-based motivational interviewing is effective in promoting physical activity and health-related physical fitness among middle-aged and older adults with multimorbidity. A randomized controlled trial was conducted. Forty-three participants (aged > 40) were recruited and randomly assigned to the intervention group, comparison group, or control group. The participants’ physical activity and health-related physical fitness were assessed at baseline and at 12 weeks. The results indicated that after individualized aerobic exercise training combined with telephone-based motivational interviewing, the participants reported increased total physical activity ( Multimorbidity is defined as the individual coexistence of two or more chronic diseases/illness conditions ,2,3. ThePhysical inactivity and poor health-related physical fitness are major risk factors for multimorbidity and increase the risk of death by 20–30% ,10. IncrAerobic exercise is safer and can lower the susceptibility to certain preventable chronic diseases, decrease mortality, and improve health in middle-aged and older adults . Aerobic2 max) levels at different aerobic exercise training intensities, and to integrate and evaluate cardiovascular, respiratory, skeletal muscle, and neuromuscular responses to exercise [Individualized aerobic exercise training is a recommended physical activity program designed in a systematic and individualized manner in terms of frequency, intensity, time, type, volume, and progression, known as the FITT-VP principle . In indiexercise ,18,19. Hexercise .Aerobic training should be continued for as a long-term management to sustain this beneficial effect. However, patients with multimorbidity are significantly less adherent to exercise interventions than healthy individuals due to many barriers  to exercise . MotivatTherefore, this randomized controlled trial aimed to examine the differences of effectiveness of a 12-week individualized aerobic exercise training in a rehabilitation center combined with telephone-based motivational interviewing, only telephone-based motivational interviewing, and usual care on the physical activity and health-related physical fitness among middle-aged and older adults with multimorbidity.A randomized controlled trial with three groups was created (registered number: ISRCTN44497123). All eligible middle-aged and older adults with multimorbidity were randomized by a research assistant to one of three groups: (1) the intervention group, which received 12 weeks of a multidisciplinary  individualized aerobic exercise training program in the rehabilitation center combined with telephone-based motivational interviewing; (2) the comparison group, which received 12 weeks of telephone-based motivational interviewing; and (3) the control group, which received 12 weeks of usual care. In this study, multimorbidity was defined as participants with two or more of the following high prevalence chronic diseases based on aging survey report in our country : hyperteEligible participants were recruited by a research assistant from a rehabilitation clinic at a medical center in Taipei city, Taiwan from November 2016 to February 2017. Those who agreed to join the study were referred to a rehabilitation/sports medicine physician for screening to determine whether they had contraindications for aerobic exercise training. The inclusion criteria were as follows: (1) over 40 years old with multimorbidity; (2) no cognitive impairment ; (3) able to communicate in Mandarin; (4) provided informed consent and agreed to be randomized into one of three groups; and (5) current physical activity amount did not meet the WHO recommendations . The exclusion criteria were as follows: (1) aerobic exercise training contraindications according to the updated American College of Sports Medicine (ACSM) recommendations for exercise pre-participation health screening  as demonThe participants were randomly assigned to either the intervention group, the comparison group, or the control group after receiving an individual 20-min face-to-face counseling session and educational brochure about the importance of regular exercise, the benefits of aerobic exercise training for multimorbidity, and physical activity recommendations/general aerobic exercise prescriptions based on WHO/ACSM guidelines ,17.The intervention group received 12 weeks of individualized aerobic exercise training in a rehabilitation center combined with telephone-based motivational interviewing that consisted of: (1) The rehabilitation/sports medicine physician collected and evaluated the participants’ medical history and lifestyle (focused on PA information), discussed the gathered information with the participants, and then designed the individualized exercise prescription according to the ACSM’s exercise management for persons with chronic diseases and disabilities . (2) a tMeanwhile, the comparison group only received 12 weeks of telephone-based motivational interviewing. The control group received 12 weeks of usual care, which consisted of general recommendations for physical activity.The outcomes were measured at baseline and after 12 weeks in all participants. The participants completed self-reported questionnaires on demographic data, self-perceived health status questionnaires, and the International Physical Activity Questionnaire (IPAQ)-Chinese version short form. Objective measurements of health-related physical fitness parameters were performed by a well-trained research assistant.The demographic questionnaires assessed age, gender, marital status, whether the participants had children, educational level, employment status, and number/type of chronic diseases. The self-perceived health status questionnaire consists of five items with a 5-point Likert scale, which scores from 5 to 25. The higher the score, the better the self-perceived health status. It has good content validity, construct validity, and internal consistency; thus, it has been widely used in several studies in Taiwan .The IPAQ-Chinese version short form has well-established reliability and validity . This se2 max), anaerobic threshold (AT), and work, etc., to assess cardiorespiratory fitness. Cycle ergometer-based  graded exercise test (GXT) was conducted using a ramp protocol by increasing the resistance (10 W/min) at a consistent speed of 60 revolutions/minute, supervised by a rehabilitation/sports medicine physician. The participants’ EKG, heart rate, blood pressure, and peripheral blood oxygen concentration were continuously monitored, and the Borg scale was used to evaluate the rate of perceived exertion; the measures assured the safety of the participants. After the health-related physical fitness assessment was completed, the participants rested and relaxed for 5–10 min in place and then left after the researcher confirmed that they felt no physical discomfort.Prior to the health-related physical fitness assessment, the participants were asked to avoid doing vigorous exercises and sleep at least 6–8 h a day, and avoid food, alcohol, and caffeine for at least 3 h prior. They should also wear appropriate clothing for the assessment. The assessments were conducted from 2:00 PM to 5:00 PM, and each participant was assessed for approximately 60 min. The assessment room was kept private, quiet, and well ventilated to make the participants feel comfortable. The health-related physical fitness assessment based on the ACSM’s health-related physical fitness assessment manual and exercise testing guidelines ,19 was pG*Power software  was applied for estimating the sample size . Based oThe randomization sequence was generated using the random number function in Microsoft Excel . A block of 6 randomization was designed and stratified by age  and gender . The researchers involved in the data collection were blinded to the group allocation. Participant blinding was not possible due to the nature of the intervention conditions.Institutional review board approval (TSGHIRB: 1-105-05-156) was obtained from Tri-Service General Hospital in Taiwan. All participants gave written informed consent when they were invited to join the study and were assured that their participation was entirely voluntary and that they could withdraw at any time.The statistical analysis was performed with SPSS Version 22.0 . Descriptive statistics including the means and standard deviations (SD) or number and percentages (%) for the study participants were presented. The Chi-square test or analysis of variance (ANOVA) were used to compare the pre-intervention differences among the three groups. Some variables were not normally distributed, so the Kruskal–Wallis method was used to test the homogeneity of continuous dependent variables with three groups.The mixed model ANOVA is a combination of a between-unit ANOVA and a within-unit ANOVA, allowing for evaluating interaction effects regarding time (pre vs. post) x groups , is standard procedure when evaluating intervention effects in the field of exercise physiology ,40. For p < 0.05 was considered statistically significant. The Bonferroni test was used for post-hoc comparison.Therefore, we used mixed-model ANOVA to estimate the intervention effects of the three groups based on significant interactions of group and time. The intent-to-treat analysis was used. The significance level was set at 0.05 for two-tailed tests, and The participant CONSORT study flow chart is shown in n = 34, 79.1%), hyperlipidemia , diabetes , stroke , cancer , heart disease , kidney disease , asthma , chronic obstructive pulmonary disease , osteoporosis , degenerative arthritis , gout , depression , schizophrenia , and bipolar disorder .The participants’ baseline characteristics are described in Fin = 481.3, p = 0.011) and vigorous-intensity PA  at 12 weeks than did participants in the control group. Moreover, we found that middle-aged and older adults with multimorbidity in the comparison group had a greater increase in walking PA  and a greater decrease in sedentary time (min/day)  compare to that of the control group.The effectiveness of the different interventions on the PA amount and levels based on the mixed model analysis are shown in 2)  at 12 weeks than did those in the comparison group. We also found that the significant group x time interaction for muscular strength revealed that middle-aged and older adults with multimorbidity in the intervention group had a greater increase in dominant hand grip (kg) and nondominant hand grip (kg)  at 12 weeks than did those in the control group. However, there were no statistically significant differences in muscular endurance and flexibility between the three groups.The effectiveness of the different interventions on body composition, muscular strength, muscular endurance, and flexibility based on the mixed model analysis is shown in 1/FVC in three groups were significant change within pre- and post-test . The significant group × time interaction for cardiorespiratory fitness revealed that middle-aged and older adults with multimorbidity in the intervention group had greater increases in FEV1/FVC , VO2 max (ml/kg/min) , VO2 max predicted (%) , work (watts) , and AT (L/min)  at 12 weeks than participants in the control group. Moreover, the significant group × time interaction for cardiorespiratory fitness revealed that middle-aged and older adults with multimorbidity in the intervention group had greater increases in work (watts)  and AT (L/min)  at 12 weeks than participants in the comparison group.The effectiveness of the different interventions on cardiorespiratory fitness based on the mixed model analysis are shown in 1/FVC, VO2 max, VO2 max predicted, work, and AT) among middle-aged and older adults with multimorbidity. Our results are consistent with those of previous studies, which reported that providing supervised, hospital-based aerobic exercise training results in positive effects on PA [The results revealed that 12-week individualized aerobic exercise training combined with telephone-based motivational interviewing had significant beneficial effects on total PA, vigorous-intensity PA, muscular strength in dominant and nondominant hand grip, and several outcomes of cardiorespiratory fitness , but no significant effect on cardiorespiratory fitness and functional exercise capacity [As revealed in our results, middle-aged and older adults with multimorbidity in the intervention group exhibited increased total PA and vigorous-intensity PA and the comparison group also had significantly higher walking PA and significantly lower sedentary time at 12 weeks than the control group. A systematic review and meta-analysis reported the same situation wherein motivational interviewing had an effect in increasing the PA levels in people with chronic health conditions relative to the control groups  we addressed the population with multimorbidity who will become the major clients of healthcare services in the near future, (2) we designed a multidisciplinary individualized aerobic exercise training program in a rehabilitation center in accordance with the ACSM’S guidelines and gold standard CPET to ensure the effectiveness of the intervention, (3) we combined the program with telephone-based motivational interviewing to reinforce the behavioral change and engage in exercise, (4) and we collected and evaluated the gold standard outcomes of the cardiorespiratory fitness that are seldom mentioned in this population.Based on the study results, we recommend the combination of coached/supervised individualized aerobic exercise training with motivational interviewing following individualized exercise prescription recommendations to obtain the benefits of physical activity and improved health-related physical fitness among middle-aged and older adults with multimorbidity. Integrated aerobic exercise training program with multidisciplinary team can be used to initiate health promotion campaigns that revolve around patient-centered care. Furthermore, introducing resistance exercise training to middle-aged and older adults with multimorbidity would possibly further enhance their PA, health-related physical fitness, physical functioning, and quality of life.To the best of our knowledge, this is the first 12-week individualized aerobic exercise training combined with telephone-based motivational interviewing randomized controlled trial among middle-aged and older adults with multimorbidity. A 12-week multidisciplinary individualized aerobic exercise training in the rehabilitation center combined with telephone-based motivational interviewing can increase total PA, vigorous-intensity PA, hand grip strength and cardiorespiratory fitness. A 12-week telephone-based motivational interviewing can also increase the amount of walking PA and can decrease sedentary time. Therefore, further research focused on larger samples and with a longer follow-up period to evaluate the efficacy/adherence of individualized aerobic exercise training combined with telephone-based motivational interviewing is recommended.


Type 2 diabetes mellitus (DM) is a risk factor for cardiovascular diseases and is common among patients undergoing coronary artery bypass grafting (CABG) surgery. The main objective of our study was to investigate the impact of DM type 2, and its treatment subgroups, on short- and long-term mortality in patients with acute coronary syndrome (ACS) who undergo CABG.The study included 1307 patients enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for ACS and underwent CABG. Of them, 527 (40%) patients were with and 780 (60%) were without DM.Compared with the non-diabetic group, the diabetic group of patients comprised more women and had more comorbidities such as hypertension, dyslipidemia, renal impairment, peripheral vascular disease and prior ischemic heart disease. Overall 30-day mortality rate was similar between DM and non-DM patients . Ten-year mortality rate was higher in DM compared with non-diabetic patients , and higher in the subgroup of insulin-treated patients compared to non-insulin treated patients . Multivariable analysis showed that DM increased the mortality hazard by 1.61-fold, and insulin treatment among the diabetic patients increased the mortality hazard by 1.57-fold.While type 2 DM did not influence the in-hospital mortality hazard, we showed that the presence of DM among patients with ACS referred to CABG, is a powerful risk factor for long-term mortality, especially when insulin was included in the diabetic treatment strategy. Currently, overall cardiovascular disease affects approximately 32.2% of all type 2 diabetes mellitus (DM) patients worldwide, while cardiovascular disease is a major cause of mortality among people with type 2 DM, accounting for approximately half of all deaths . DiabetiPrevious studies have demonstrated increased short- and long-term mortality in diabetic patients undergoing coronary artery bypass grafting (CABG) or even isolated valve surgery  comparedThe main objective of our study was to investigate the impact of DM type 2, and its treatment subgroups, on short- and long-term mortality in patients with ACS who undergo CABG.The ACS Israeli Survey (ACSIS) is a voluntary biennial prospective national registry of all patients with ACS hospitalized in the 25 coronary care units and cardiology departments in all the public health hospitals in Israel over a 2-month period (from March to April) .ACSIS is managed by the Working Group on Acute Cardiovascular Care of the Israel Heart Society, in participation with the Israeli Center for Cardiovascular Research. Demographic, historical, and clinical data from all patients were recorded on pre-specified forms. Patient management was at the discretion of the attending physicians. Admission and discharge diagnoses were recorded as determined by the attending physicians based on clinical, electrocardiographic, and biochemical criteria.All patients in each medical center signed an informed consent form prior to participating in the ACSIS registry, and each center received approval from its institutional review board . BetweenClinical outcomes included 30-day major adverse cardiovascular events , in-hospital complications, and long-term all-cause mortality.All data from the 25 participating hospitals were collected and pooled into a designated database. All centers used standardized definitions for data collection, including demographic parameters, medical history, chronic and peri-procedural medical treatment, echocardiography measurements, procedure information and outcome measures. All patients were prospectively followed up for clinical events at 30 days and for late mortality. Mortality data were ascertained from the Israeli Ministry of Interior Population Registry through January 2018.Data are presented as mean ± standard deviation for normal, or median for abnormal distribution. Continuous variables were tested with the Kolmogorov–Smirnov test for normal distribution. Categorical variables are given as frequencies and percentages. A Chi square test was used for comparison of categorical variables between the groups, a Student t-test was performed for comparison of normally distributed continuous variables, and a Mann–Whitney U test for non-normal distribution.Multivariable logistic regression analysis was used to identify factors associated with 30-day mortality. All statistically different variables p < 0.1) in Table  in TableStatistical significance was assumed when the null hypothesis could be rejected at p < 0.05. All p-values reflect results of two-sided tests. Statistical analyses were conducted using R (version 3.4.1).In our study cohort there were 780 non-diabetic patients, and 527 patients with DM type 2. Of them, 273 were treated with oral antihyperglycemic medications, 89 with insulin , and 165 with diet only. Presentation of the ACS was ST-segment elevation MI in 35%, non-ST-segment elevation MI in 45% and unstable angina pectoris in 20% . Compared with the non-diabetic group, the diabetic group of patients were more frequently women and had more comorbidities such as hypertension, dyslipidemia, renal impairment, peripheral vascular disease and prior ischemic heart disease , and between the subgroups of insulin-treated DM and non-insulin-treated DM . Other 30-day major events were similar between the DM and non-DM patients, such as stroke , recurrent MI  and MACE (p = 0.264). Major events were also similar between the non-insulin dependent and insulin-dependent DM patients: stroke , recurrent MI  and MACE (p = 0.615). These results were similarly consistent in the subgroups of the different ACS presentations and were reported as counts and crude event rates . The only significant variables that were associated with 30-day mortality rate were older age, male gender and dyslipidemia  compared with those without DM who had ACS treated by CABG  . Wit et We report here that in-hospital mortality among diabetic and non-diabetic patients after ACS was 4.2% and 4%, respectively. Furthermore, we have shown that DM was not associated with short-term cardiovascular events after CABG. Although patients with stable CAD were also studied, other comparisons between DM and non-DM patients who underwent CABG showed no difference in early outcomes. Abizaid et al. reported similar in-hospital mortality rates between diabetic and non-diabetic patients (2.1% vs. 1.2%) . Marui eThe DM group in our study included patients who were treated either with insulin, oral antihyperglycemic drugs or with diet. Interestingly, not only overt diabetes, but also genetic predisposition to type 2 DM was significantly associated with a greater severity of coronary atheromatous burden in patients with ACS, independently of traditional risk factors . There wWe reported that the prevalence of women was higher in the DM group. The fact that diabetic women presented with more comorbidities is in keeping with recent findings showing that, in both percutaneous and surgical revascularization, women presented with worse outcomes at 1 year; albeit there were no gender differences at 5 years of follow-up . PreviouWhile DM increases the risk of heart failure, mostly due to CAD, in some cases it is secondary to diabetic cardiomyopathy . InsulinA selection bias could have been introduced by the fact that, while primarily the ACSIS registry included patients admitted only to cardiology wards and intensive cardiac care units nationwide, in the main it did not include patients hospitalized in internal medicine wards. There was insufficient anatomical information regarding the complexity of CAD, the specific artery involved, and the surgical techniques performed. Therefore, it is difficult to draw conclusions regarding the association between specific interventions in native arteries or grafts and clinical outcomes. Information regarding patients treated with insulin analogs compared with human insulin was lacking in the ACSIS registry, and therefore we could not draw any conclusions regarding specific treatment that could improve cardiovascular morbidity in insulin-dependent DM patients.We have shown that the presence of DM among patients with ACS who are referred to CABG is a powerful risk factor for long-term mortality, especially if the diabetic treatment strategy includes insulin. Accordingly, the high-risk population of insulin-dependent DM may require specific and/or more intense cardiovascular protective therapies after CABG. Further studies are needed to examine whether novel interventions, such as GLP-1 analogs or SGLT2 inhibitors, could improve the long-term outcomes of these patients.


Few prospective data exist on incidence of post kala-azar dermal leishmaniasis (PKDL) and visceral leishmaniasis (VL) relapse after different treatment regimens.A Phase IV trial included 1761 VL patients treated between 2012–2014 with single dose AmBisome , miltefosine-paromomycin , or AmBisome-miltefosine . Follow-up for PKDL and VL relapse was scheduled for 6, 12 and 24 months after treatment, lasting until 2017. Patients with lesions consistent with PKDL were tested by rK39 rapid test, and if positive, underwent skin-snip sampling, smear microscopy and PCR. Probable PKDL was defined by consistent lesions and positive rK39; confirmed PKDL required additional positive microscopy or PCR. PKDL and relapse incidence density were calculated by VL treatment and risk factors evaluated in Cox proportional hazards models.Among 1,750 patients who completed treatment, 79 had relapse and 104 PKDL. Relapse incidence density was 1.58, 2.08 and 0.40 per 1000 person-months for SDA, AmB-Milt and Milt-PM, respectively. PKDL incidence density was 1.29, 1.45 and 2.65 per 1000 person-months for SDA, AmB-Milt and Milt-PM. In multivariable models, patients treated with Milt-PM had lower relapse but higher PKDL incidence than those treated with SDA; AmB-Milt rates were not significantly different from those for SDA. Children <12 years were at higher risk for both outcomes; females had a higher risk of PKDL but not relapse.Active surveillance for PKDL and relapse, followed by timely treatment, is essential to sustain the achievements of VL elimination programs in the Indian sub-continent. Efforts to eliminate visceral leishmaniasis (VL) in the Indian subcontinent have had an unprecedented impact on the number of cases over the past decade, however, the disease is known to be cyclical and previous periods of low incidence have been followed by a major resurgence. The disease is thought to be maintained between epidemics as post-kala-azar dermal leishmaniasis (PKDL), a skin disease affecting 5 to 15% of apparently cured VL patients in the Indian subcontinent. PKDL is difficult to cure and since PKDL patients are not systemically ill, they seldom seek treatment, meaning that PKDL is likely to be a major obstacle to elimination. A key question is how different VL treatment regimens affect the risk of subsequent PKDL. We followed-up a cohort of more than 1700 patients treated with three different drug regimens in an effectiveness trial in Bihar and found that patients treated with miltefosine-paromomycin had a lower risk of relapse but higher PKDL incidence, while AmBisome treated patients had the reverse pattern. In order to sustain the gains already made, active surveillance for PKDL and relapse is essential, along with timely treatment, and new VL treatment regimens that avoid future PKDL are needed. India has seen an unprecedented decrease in visceral leishmaniasis (VL) incidence over the past decade, with yearly case numbers lower than at any time since the 1970s . PreviouPost-kala-azar dermal leishmaniasis (PKDL) has long been postulated to act as the major inter-epidemic reservoir . PKDL isRecent xenodiagnosis data confirms that PKDL patients are infectious to sand flies, with higher prevalence of infectiousness among nodular than macular cases , supportA key question, therefore, is how different VL treatment regimens affect the risk of subsequent PKDL. Government-mandated first line VL drug regimens have changed over time , adherence is variable and passive diagnosis of PKDL is highly incomplete. Thus, retrospective analyses may contain inherent biases that impede valid inferences about risk. We undertook prospective follow-up of a cohort of more than 1700 patients treated between August 2012 and October 2014 with three different drug regimens for VL in an effectiveness trial in Bihar .This protocol was approved by the Institutional Ethics Committee of Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), the Indian Council of Medical Research and National Vector Borne Disease Control Program. All participants provided written informed consent. For children, consent of parents or of a legal representative was obtained.This analysis presents extended follow-up data from a cohort of participants in a multicenter phase IV clinical trial of three treatment regimens for VL . PatientThe original trial included follow-up visits at 7–20 days and 6 months after treatment . The NatFinal cure was defined as complete resolution of clinical signs and symptoms of VL. If VL treatment was stopped by the attending clinician for any reason, or the patient failed to finish treatment against medical advice, the outcome was defined as incomplete treatment. The outcome was classified as relapse if the patient had recurrence of VL clinical symptoms after initial clinical recovery and parasites were demonstrated in spleen or bone marrow aspirate. A patient with new onset skin lesions  suggestive of PKDL and positive rK39 rapid test was considered to have probable PKDL. Probable PKDL patients were referred to RMRIMS for skin snip sampling, followed by microscopy of the stained skin smear and polymerase chain reaction (PCR) to detect leishmanial DNA. The outcome was defined as confirmed PKDL if the patient had positive results by smear, PCR or both. A patient was considered lost to follow-up if study personnel were unable to trace the patient.The sample size was determined by the original trial design, in which 300 patients per arm was calculated to be sufficient for 5% precision around a failure rate of 5% for each arm. Differences between groups were tested using Chi Square test, Fisher Exact test, Wilcoxon Rank Sum, or Kruskal-Wallis tests, as appropriate. We considered the last visit attended by the patient to define total follow-up time, since both study outcomes (relapse and PKDL) were determined at each visit. For incidence density and Kaplan-Meier survival analyses, the censoring date was the last date on which the patient had follow-up, or the date of onset of relapse or of PKDL lesions. Confidence intervals around incidence density were calculated using Poisson regression. Risk factors for relapse and PKDL were assessed in Cox proportional hazard models. Analyses were conducted in SAS 9.4 .The original effectiveness trial enrolled 1761 VL patients . PatientA total of 79 relapses and 104 PKDL cases were diagnosed over the course of follow-up. Relapse cases were observed in 47 patients treated with SDA (5.3%), 25 patients treated with AmB-Milt (7%) and in 7 patients treated with Milt-PM (1.4%). PKDL cases were observed in 39 patients treated with SDA (4.8%), 18 patients treated with AmB-Milt (5.7%) and 47 patients treated with Milt-PM (9.7%) . Since fRelapse incidence density was 1.58, 2.08 and 0.40 per 1000 person-months for SDA, AmB-Milt and Milt-PM, respectively. PKDL incidence density was 1.29, 1.45 and 2.65 per 1000 person-months for SDA, AmB-Milt and Milt-PM. The group treated with Milt-PM had significantly lower relapse but higher PKDL incidence density than the other two groups .In univariable analyses, both relapse and PKDL were significantly more frequent among children 12 years or younger, compared to those older than 12 years at the time of VL treatment . RelapseTwenty years ago, VL patients were almost universally treated with pentavalent antimonial drugs and conventional amphotericin B was largely used as rescue therapy for those failing a prolonged course of pentavalent antimony . Since tOur data demonstrate the divergent timing of VL relapses and PKDL. Whereas the median time to VL relapse was 6 months and 95% occurred by 17 months of follow-up, PKDL cases had an onset median of 25.4 months after kala-azar treatment and new cases were still occurring 4 years after treatment. These findings highlight the importance of prolonged follow-up for PKDL after clinical trials, as well as the risk posed by late-occurring cases of PKDL in communities where VL appears to be eliminated. Indeed, further PKDL cases are likely to occur in this patient cohort. The relative timing of relapse vs PKDL in our cohort data is similar to that reported in a recent analysis reporting retrospective and prospective data from participants in several clinical trials in Bangladesh . The divIn common with previous analyses, younger age significantly increased the risk of both PKDL and relapse , 21, 22.VL relapse and PKDL risk varied by drug regimen, but interestingly, Milt-PM, the regimen with the lowest relapse rate, was associated with the highest incidence of PKDL, while the two AmBisome-containing regimens, SDA and AmB-Milt, showed the reverse pattern. Further assessment of immune response during and after treatment with these regimens might shed light on the reasons for this pattern, as well as the mechanisms underlying development of PKDL , 25. UltOur study faced several crucial challenges and limitations, the most important of which was the difficulty of achieving confirmed diagnoses of PKDL under field conditions in India. We succeeded in confirming two-thirds of the PKDL cases in this analysis by microscopy and/or PCR, while the remaining third was clinically evaluated by a study physician; thus, we believe our case definitions are quite reliable. However, this kind of effort is impossible outside of a funded research study and PKDL diagnosis remains a major challenge in Bihar . In the Both VL relapse and PKDL are conditions with major public health implications for the sustained control of VL in the Indian subcontinent. Our data demonstrate that we do not yet have an ideal treatment regimen for kala-azar. Clearly, to achieve and sustain kala-azar elimination in the Indian subcontinent, new, preferably oral treatments that are safe and highly efficacious are needed.S1 Checklist(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Staphylococcus aureus bloodstream infection (SA-BSI) is an infection with increasing morbidity and mortality. Concomitant Staphylococcus aureus bacteriuria (SABU) frequently occurs in patients with SA-BSI. It is considered as either a sign of exacerbation of SA-BSI or a primary source in terms of urosepsis. The clinical implications are still under investigation. In this study, we investigated the role of SABU in patients with SA-BSI and its effect on the patients’ mortality. We performed a retrospective cohort study that included all patients in our university hospital (Charité Universitätsmedizin Berlin) between 1 January 2014 and 31 March 2017. We included all patients with positive blood cultures for Staphylococcus aureus who had a urine culture 48 h before or after the first positive blood culture. We identified cases while using the microbiology database and collected additional demographic and clinical parameters, retrospectively, from patient files and charts. We conducted univariate analyses and multivariable Cox regression analysis to evaluate the risk factors for in-hospital mortality. 202 patients met the eligibility criteria. Overall, 55 patients (27.5%) died during their hospital stay. Cox regression showed SABU (OR 2.3), Pitt Bacteremia Score (OR 1.2), as well as moderate to severe liver disease (OR 2.1) to be independent risk factors for in-hospital mortality. Our data indicates that SABU in patients with concurrent SA-BSI is a prognostic marker for in-hospital death. Further studies are needed for evaluating implications for therapeutic optimization. Staphylococcus aureus bacteremia (SA-BSI) is a severe and frequent bacterial infection . The morThe study was conducted at three different tertiary care hospitals of Charité Universitätsmedizin Berlin, with 3011 beds in total. Prior to the study, we obtained an official ethics-vote from the Charité Universitätsmedizin ethics committee . The investigation was performed as a retrospective cohort study that aimed to include all cases of SA-BSI in patients 18 years of age or older, between 1 January 2014 and 31 March 2017. Cases were identified in the Charité microbiology database as patients with blood cultures positive for Staphylococcus aureus who had had urine that was sampled within 48 h prior or after first S. aureus-positive blood culture. For all of the patients enrolled in this study, the following demographic and clinical characteristics were collected: age, sex, in-hospital death, length of hospital stay (LOS), day of BSI onset, and stay on an intensive care unit (days). Length of stay in total and after BSI onset were defined as length of stay until death or discharge. We assessed the PITT Bacteremia Score on the day of BSI onset retrospectively from patient files in order to evaluate the severity of the bloodstream infection . The ChaCases were defined as patients with SA-BSI during the study period. The onset of SA-BSI was defined as the date of the sampling of the first blood culture with growth of Staphylococcus aureus. SA-BSI was considered to be hospital-onset if it occurred after the second day of hospitalization (>48 h after admission). SABU was defined as a detection of Staphylococcus aureus in a urine sample. Urinary Catheter prior to onset was defined as an indwelling urinary catheter for any length of time within seven days prior to onset of SA-BSI. Effective antimicrobial treatment was defined as flucloxacillin or cefazolin i.v. treatment in MSSA and vancomycin, linezolid, daptomycin, or ceftaroline treatment in MRSA after lab results were available (72 h) ,20. Mortp-value of <0.05 considered to be significant. Univariate survival analysis was performed as a Kaplan–Meier curve stratified by SABU.Descriptive univariate analyses were performed for the total cohort, being stratified by in-hospital death and by SABU. The median and the interquartile range (IQR) were calculated for continuous parameters; the number and percentage were calculated for binary parameters. Univariate differences were tested while using the Wilcoxon rank-sum test for continuous variables and the Chi-square test for binary variables. All tests of significance were two-tailed with a p-value < 0.100 in the univariate analysis and potential influence on the endpoint: SABU, Pitt-Score, ICU admission after onset of SA-BSI, urinary catheter prior to sampling, peptic ulcer, diabetes with and without complication, renal disease, and moderate to severe liver disease. As the duration of antimicrobial therapy depended on the LOS after BSI onset, it was not included. We calculated adjusted hazard ratios (HR) with a 95% confidence interval for in-hospital death after onset of SA-BSI while using a stepwise forward approach. For the final model, variables with p-values of ≤0.05 were included and variables with p > 0.05 were excluded while using a stepwise forward approach. All of the analyses were performed while using SPSS  and SAS .We performed a Cox-proportional hazard regression adjusting for LOS after BSI in order to analyze potential factors on in-hospital mortality in a multivariable analysis. The variables included in the analysis were the ones with a ® . The samples were cultured for up to forty-eight hours. If a blood stream infection was suspected, the blood cultures were drawn and incubated for up to seven days while using standard blood culture bottles . Gram staining and subculturing were performed if growth was detected. MALDI TOF MS® and Vitek 2® automated system  were used for identification and susceptibility testing of bacterial strains. They were interpreted while using EUCAST definitions.Urine sampling was performed with native mid-stream or catheter urine in a standard 10mL sterile Urin-MonovetteIn the study period, 1139 patients were diagnosed with S. aureus bacteremia. In addition, 206 patients also had at least one urine culture examination within 48 h before or after SA-BSI. Of these patients, we had complete datasets of 202 patients . The remn = 55). Univariate analysis showed that patients that died during their treatment in hospital had a median PITT bacteremia score of two . In comparison, patients that were discharged from hospital had a significantly lower score of one . Patients that died during their hospital stay were more likely to have been admitted to an ICU after the onset of SA-BSI when compared to surviving patients. They also had shorter LOS overall and stayed for shorter periods after the onset of SA-BSI  or an S. aureus-positive (SA-positive) urine culture  showed a higher risk of death in patients with SA-BSI and concurrent SABU than those with SA-BSI only .In a Cox regression analysis, we took the length of hospital stay into consideration. In this analysis, a Pitt Bacteremia Score of >1, SA-positive urine culture, as well as moderate to severe liver disease, were independent risk factors .Displayed is the multivariable hazard regression function of patients with S. aureus bloodstream infection that is stratified by positive urine culture and adjusted for length of stay after onset of SA-BSI, Pitt bacteremia score, SABU, S. aureus bacteriuria. SA-BSI, S. aureus bloodstream infection. LOS, length of stay.We identified SABU as an independent and clinically relevant risk factor for in-hospital mortality in patients with SA-BSI. This finding is consistent with earlier reports ,13. HoweSABU is considered to be a secondary seeding to SA-BSI . Others S. aureus bloodstream infection, which was previously known [Our multivariable logistic regression identified moderate to severe liver disease to be an independent risk factor for in-hospital mortality after ly known ,25. Morely known .The Pitt Bacteremia Score showed an independent direct correlation with hospital mortality in patients with SA-BSI. This finding is in line with other studies ,28. RothS. aureus isolates were neither tested for relation nor virulence factors in order to account for differences. (iv) Only a small portion of patients received a treatment strategy the followed national and international guidelines. While it is necessary to validate our results after improvement in the management of patients with SA-BSI, the choices of substances and the duration of antimicrobial treatment were independent of urine sample results.In-hospital mortality of patients with SA-BSI was 27%. Similar in-hospital mortality rates have been described for patients with SA-BSI in comparable settings . Hence, Our study demonstrates that SABU is a relevant prognostic marker for in-hospital mortality in patients with SA-BSI. This suggests a potential benefit from intensified treatment strategies, as well as from efforts to identify the primary source of SA-BSI. Further clinical studies are needed to confirm this finding.


In March 2020, efforts to slow transmission of SARS-CoV-2, the virus that causes COVID-19, resulted in widespread closures of school buildings, shifts to virtual educational models, modifications to school-based services, and disruptions in the educational experiences of school-aged children. Changes in modes of instruction have presented psychosocial stressors to children and parents that can increase risks to mental health and well-being and might exacerbate educational and health disparities  using NORC’s AmeriSpeak panel  reported that their child received virtual instruction, 30.9% reported in-person instruction, and 23.4% reported combined instruction . ParentsParents of children receiving virtual instruction were more likely than were parents of children receiving in-person instruction to report that their children experienced decreased physical activity (62.9% versus 30.3%), time spent outside (58.0% versus 27.4%), in-person time with friends (86.2% versus 69.5%), virtual time with friends (24.3% versus 12.6%), and worsened mental or emotional health (24.9% versus 15.9%) . ParentsParents of children receiving virtual instruction were also more likely than were parents of children receiving in-person instruction to report loss of workFindings from this survey of parents of children aged 5–12 years indicate that parents whose children received virtual or combined instruction were more likely to report higher prevalence of risk on 11 of 17 indicators of child and parental well-being than were parents whose children received in-person instruction. Among nine examined indicators of children’s well-being, five differed significantly by the instruction mode that children received. These differences reflected higher prevalences of negative indicators of well-being for children receiving virtual or combined instruction than for children receiving in-person instruction. Parents of children receiving virtual or combined instruction more frequently reported that their child’s mental or emotional health worsened during the pandemic and that their time spent outside, in-person with friends, and engaged in physical activity decreased. Regular physical activity is associated with children’s improved cardiorespiratory fitness, increased muscle and bone strength, and reduced risk for depression, anxiety, and chronic health conditions ; therefore, these differences in physical activity are concerning . Finally, causality between instruction mode and examined indicators of well-being cannot be inferred from this cross-sectional study.Parents of children receiving in-person instruction reported the lowest prevalence of negative indicators of child and parental well-being. Children receiving virtual or combined instruction and their parents might need additional support to mitigate stress, including linkage to social and mental health services and opportunities to engage in safe physical activity to reduce risks associated with chronic health conditions. Culturally applicable support programming and resources might be warranted to meet community needs, ensure equitable access to services, and address health or educational inequities for families from racial and ethnic minority groups. These findings highlight the importance of in-person learning for children’s physical and mental well-being and for parents’ emotional well-being. Community-wide actionsCOVID-19–associated schooling changes present stressors to children and parents that might increase risks to mental health and well-being.In a probability-based survey of parents of children aged 5–12 years, 45.7% reported that their children received virtual instruction only, 30.9% in-person only, and 23.4% combined virtual and in-person instruction. Findings suggest that virtual instruction might present more risks than does in-person instruction related to child and parental mental and emotional health and some health-supporting behaviors.Children not receiving full-time, in-person instruction and their parents might need additional supports to mitigate pandemic impacts.


Methods: Patients treated by implantation of DRSs for stent recoil in the ostial right coronary artery or the left main stem were identified from the hospital database. Baseline clinical and procedural characteristics were compared to patients who underwent re-intervention for in-stent-restenosis in similar segments by either implantation of conventional drug-eluting stents (DES) or paclitaxel-coated balloons (PCB). Clinical follow-ups were performed up to three years following re-intervention with the assessment of death, target lesion reintervention (TLR), and major adverse cardiac events (MACE) as a combination death, myocardial infarction and target vessel revascularization. Kaplan–Meier analyses were performed for event-free survival between the three groups. Results: Between 05/2013 and 07/2019, 28 patients underwent DRS implantation of aorto-ostial coronary lesions. In comparison with 49 patients with DES implantation and 29 patients undergoing PCB treatment, no relevant differences in baseline parameters were identified. Median follow-up was 714 days, with an available follow-up of >1 year after intervention in 82.1% of patients. In the entire study cohort at two years after re-intervention, the TLR rate was 16% (17 patients), the MACE rate 37% (39 patients), and all-cause mortality 9% (10 patients), with no significant differences between the three groups. Conclusions: DRS implantation for treating stent recoil of aorto-ostial coronary lesions resulted in a high rate of TLR, and was associated with similar risk for death and MACE compared to treatment of in-stent-restenosis with DES or PCB. Randomized, larger comparisons of contemporary DES in patients exclusively presenting with stent recoil are necessary to further define the efficacy and safety of this approach.Background: Interventional treatment of aorto-ostial coronary stenoses is limited by stent recoil and suboptimal angiographic results, leading to restenosis and frequent re-interventions. As a potential bail-out strategy for stent recoil, implantation of an additional stent to increase radial force has been reported. Thus, we sought to investigate clinical outcomes after additional implantation of a Dynamic Renal It was developed for the use in renal arteries, known for frequent recoil after angioplasty. Aorto-ostial coronary lesions such as stenosis of the ostial right coronary artery or the ostial left main stem have been recognized as challenging targets for percutaneous coronary intervention (PCI) due to an increased risk of restenosis which can be caused by stent recoil . Stent rIn our center, the DRS has been used in selected cases with stent recoil or large diameter coronary arteries as compassionate use. The present study reports the clinical outcomes of patients that underwent implantation of a DRS as a second stent strategy in aorto-ostial lesions. ®) upon recoil of a contemporary drug-eluting stent. Patients who underwent any DRS implantation were retrieved from the electronic health record database. Patients who were treated with DRS in lesions other than aorto-ostial lesions, i.e. the ostial right coronary artery or the left main stem, were excluded. Lesions were considered as ostial if they arised within 3 mm of the vessel origin. All angiograms and patient records were reviewed to verify that DRS implantation was due to observed stent recoil. Stent recoil was defined as remaining radiographic stent underexpansion after adequate expansion of a non-compliant balloon. Stent recoil before DRS implantation was visually graded into mild (≤25% of vessel diameter), moderate (>25% and ≤50% of vessel diameter) or severe (>50% of vessel diameter). After DRS implantation, recoil was re-assessed and graded as resolved, improved and unchanged. Patients forming comparator groups were equally identified from the electronic health record. To this end, patients that underwent repeated intervention with a second DES or with a paclitaxel-coated balloon (PCB) for relevant in-stent-restenosis in the left main stem or in the ostial right coronary artery were identified. Patients who experienced stent thrombosis or who were treated with plain balloon angioplasty were excluded. This single-center, retrospective observational study sought to report clinical outcomes after treatment of aorto-coronary ostial stenoses with additional implantation of a dedicated recoil-resistant bare-metal stent  within two years after the index procedure was defined as primary efficacy outcome. As secondary safety outcomes, the occurrence of all-cause death as well as or major adverse cardiac events (MACE), defined as a composite of all-cause death, myocardial infarction and target vessel revascularization (TVR) at 2 years were investigated. Discrete variables are reported as counts (percentages) and continuous variables as median with interquartile range. For discrete variables, we tested differences between groups with the χ2-test or Fisher’s exact test when expected cell sizes were less than 5. To compare continuous variables, the Kruskal–Wallis test was used. The incidence of clinical endpoints between the three treatment groups was compared by log-rank testing. Cumulative event rates were calculated and graphically described according to the Kaplan–Meier method. All tests were two-sided and results were regarded as statistically significant at an α-level of 5%. We used IBM SPSS statistics, version 23.0  for all statistical analyses.The study was approved by the ethics committee of the Albert-Ludwigs-Universität Freiburg, Germany, (number: EK-Freiburg 238/19) and is in accordance with the ethical guidelines of the 1975 Declaration of Helsinki, as revised in 1983.Between 05/2013 and 07/2019, 28 patients underwent DRS implantation due to recoil of conventional stents observed in aorto-coronary lesions. As a comparator group, 78 patients were identified to have undergone repeat intervention of aorto-ostial coronary lesions between 01/2013 and 12/2015. In this group, 49 patients were treated with a second-generation drug-eluting stent and 29 patients underwent balloon dilatation with subsequent paclitaxel-eluting balloon treatment . p-value 0.09) . Regarding cholesterol levels, there were differing trends for total cholesterol  and low density lipoprotein-cholesterol (LDL-cholesterol) , with the lowest level of total cholesterol in the DRS group and the lowest LDL-cholesterol in the PCB group. For all other variables, no significant differences or statistical trends were observed between the three groups. The median age of the patients treated with DRS was 75 years, while patients treated with DES or PCB tended to be younger with a median age of 71 years (ue 0.09) . In the Regarding procedural characteristics, all patients in the DRS group had severe angiographic coronary artery calcification. Assessment of stent recoil in the DRS group is depicted in p log-rank test 0.84). The risk for MACE as a safety outcome, defined as a composite of all-cause death, myocardial infarction and TVR), was statistically not different between the groups (p log-rank test 0.90), occurring at a rate of 32% (9 of 28 patients) in the DRS group, 41% (20 of 49 patients) in the DES group and 38% (11 of 29 patients) in the PCB group (p log-rank test 0.81).During a median follow up of 717 (375–1114) days, TLR as primary outcome occurred in 4 out of 28 patients in the DRS group (14%), in 8 of 49 patients (16%) with DES implantation and in 6 of 29 patients (20%) with PCB treatment. In Kaplan Meier analyses A, these CB group B. RegardLong-term outcomes of PCI in aorto-ostial coronary lesions with DES is less favorable compared to the results of PCI in non-ostial lesions ,6. SeverThis study reports for the first time the use of a bare-metal stent with very high radial strength, the Dynamic Renal stent, as a second stent for lesions with observed stent recoil. Compared to previous case series of double-stenting in aorto-ostial coronary lesions, our study comprises more patients and compares the results of DRS implantation to comparator groups treated with DES and PCB. Overall, we did not observe relevant differences between the three treatment strategies. Nevertheless, these results should not be used at first sight to argue against the implantation of a DRS in cases of stent recoil in aorto-ostial coronary lesions. Conversely, it must be taken into account that the patients in the comparator groups were treated for in-stent restenosis that occurred after initial, successful implantation of a DES whereas DRS implantation was carried out as a bail-out strategy in cases of visible stent recoil. It is also noteworthy that DRS implantation did not uniformly resolve the observed stent recoil. In our opinion, optimal lesion preparation by debulking of calcifications through rotational atherectomy before placement of the first stent must thus be emphasized. In our study, the PCB group had a more aggressive lesion preparation compared to the DES group. This might serve as an explanation for the comparable outcome of PCB treatment not adding radial force but further supporting the importance of lesion preparation. Also, ultrasound guidance for stent placement has been associated with better outcomes ,15. ThisCertainly, our study has some limitations. First, it is a non-randomized retrospective analysis and selection bias could have occurred. However, patients with DRS as well as comparator groups were retrieved electronically by predefined criteria independent of individual patient characteristics. Second, the overall number of patients treated for stent recoil with DRS is still small, yet, this is to date the largest series of double stenting for stent recoil. Third, due to the observational, retrospective character of the study, no routine assessment of stent recoil by intravascular ultrasound or enhanced stent visualization technology was performed. Fourth, the comparator groups were not primarily groups with stent recoil but indeed patients with relevant in-stent-restenosis. In this context, it must be noted that stent recoil is usually caused by heavy calcifications whereas in-stent-restenosis is due to exaggerated extracellular matrix deposition. Nevertheless, both conditions are associated with high TLR rates and underline the need for more effective treatment options for aorto-ostial coronary lesions.In conclusion, the present data demonstrate that in cases of stent recoil in aorto-ostial coronary lesions, the implantation of a second, bare-metal stent with high radial force remains associated with high TLR and MACE rates at two years of follow-up. Further studies are needed to evaluate whether the outcome after PCI of aorto-ostial coronary lesions can be reconciled to outcomes of PCI for non-ostial lesions. These studies should specifically address which combination or selection of ultrasound guidance, lesion modification and stents with high radial force allows to achieve high success rates in PCI in aorto-ostial coronary lesions.


Circumcised men may increase sexual risk-taking following voluntary medical male circumcision (VMMC) because of decreased perceptions of risk, which may negate the beneficial impact of VMMC in preventing new human immunodeficiency virus (HIV) infections.We evaluated changes in sexual behaviour following VMMC.We conducted a prospective cohort study amongst sexually active, HIV-negative adult men undergoing VMMC in Gaborone, Botswana, during 2013–2015. Risky sexual behaviour, defined as the number of sexual partners in the previous month and ≥ 1 concurrent sexual partnerships during the previous 3 months, was assessed at baseline (prior to VMMC) and 3 months post-VMMC. Change over time was assessed by using inverse probability weighted linear and conditional logistic regression models.We enrolled 523 men; 509 (97%) provided sexual behaviour information at baseline. At 3 months post-VMMC, 368 (72%) completed the follow-up questionnaire. At baseline, the mean  number of sexual partners was 1.60 , and 111 (31% of 353 with data) men reported engaging in concurrent partnerships. At 3 months post-VMMC, 70 (23% of 311 with data) reported fewer partners and 19% had more partners. Amongst 111 men with a concurrent partnership at baseline, 52% reported none post-VMMC. Amongst the 242 (69%) without a concurrent partnership at baseline, 19% reported initiating one post-VMMC. After adjustment for loss to follow-up, risky sexual behaviour post-VMMC (measured as mean changes in a number of partners and proportion engaging in concurrency) was similar to baseline levels.We found no evidence of sexual risk compensation in the 3 months following VMMC. This phenomenon, known as risk compensation or behaviour disinhibition, may reduce the effectiveness of VMMC in preventing new HIV infections. Although RCTs conducted in Kenya and Uganda indicated that risk compensation behaviour did not increase following circumcision,14 Although the two studies, both conducted in South Africa, found minimal or no evidence of risk compensation, no studies have examined risk compensation in Botswana, where the rate of multiple and concurrent sexual partnerships is particularly high. Recently published findings from a large population-based sample found that 31% of sexually active adults in Botswana had concurrent sexual partners in the past year.15Men circumcised in non-clinical trial settings may also encounter different experiences and behave differently. However, little is known about how sexual behaviour changes in real-world settings, as there have been only two studies that examined men’s sexual behaviours before and after undergoing VMMC.We conducted a prospective cohort study amongst men aged 18–49 years undergoing VMMC in Botswana to evaluate the changes, if any, in the frequency of high-risk sexual behaviour following VMMC, including the total number and timing of sexual partnerships during the previous 3 months.16This clinic-based prospective cohort study was designed to assess (1) the frequency, type and severity of adverse events immediately following VMMC; (2) the prevalence and correlates of re-initiation of sexual activity and (3) changes in risky sexual behaviour following VMMC. The current analysis reports on the third primary objective. The study was conducted by the International Training and Education Center for Health (I-TECH), a collaboration with the University of Washington and the University of California, San Francisco. Recruitment and enrolment of study participants occurred before undergoing VMMC, but after individuals completed group education and individual counselling with clinic staff (including HIV testing) and provided written, informed consent for the procedure. Neither the pre-procedure activities described above nor the procedure itself was performed by study staff. The overall objective of Botswana’s National Safe Male Circumcision programme is to reach a male circumcision prevalence rate of 80% amongst 0–49-year-old HIV-negative males. A complete description of the programme, including details on the procedure itself, can be found elsewhere.Adult men undergoing VMMC through the National Safe Male Circumcision programme were enrolled between November 2013 and April 2015 at two government-run clinics providing free circumcision services in Gaborone, the capital city of Botswana. Participant eligibility criteria included: age ranging 18–49 years, residence within 25 km of Gaborone, ever had sexual intercourse and documented HIV-negative test result. All participants provided written informed consent for participation in the study in addition to the consent obtained by clinic staff for the circumcision procedure.17For study planning purposes, we computed sample size requirements (and corresponding power) based on the dichotomous outcome and engagement in concurrent sexual partnership(s) during the previous 3 months. We used McNemar’s test for two correlated proportions to determine the number of participants enrolled and the corresponding power to detect the smallest, clinically meaningful difference in the proportion of men who report engaging in a concurrent sexual partnership between baseline and 3 months post-circumcision.B and PFU represent the total proportion of individuals reporting high-risk sexual behaviour at baseline and follow-up, respectively; P01 and P10 represent the proportion of individuals who increase or decrease their high-risk sexual behaviour between baseline and follow-up, respectively. We explicitly chose to test a one-sided alternative that high-risk sexual behaviour increases at follow-up  to reflect the conceptual definition of risk compensation. Thus, assuming a baseline prevalence of sexual concurrency (PB) of 19%,18 10% were unable to undergo VMMC because of medical or other contraindications and 20% were lost to follow-up, power was estimated to be > 80% to detect a 5% increase in the proportion of men who engage in high-risk sexual behaviour at 3 months post-circumcision (relative to baseline) based on a sample size of 523 participants. Power was estimated to be 99% for a 10% increase at 3 months post-VMMC.Specifically, P19 Lastly, we constructed two indicators evaluating the accuracy of participants’ knowledge regarding the effect of VMMC on female-to-male and male-to-female HIV transmission. Specifically, we classified men as having correct knowledge if they indicated that VMMC partially protects a man from getting HIV from a woman but does not affect a woman’s chances of getting HIV from a man.In addition to the primary endpoints, the baseline questionnaire also collected information on demographics , socioeconomic indicators , frequency and intensity of alcohol consumption, age at sexual initiation and history of transactional sex. We also collected information on the primary reason for getting circumcised , whether the participant believed circumcision would have a negative, positive or no impact on the quality of sex, and administered a four-question scale developed in South Africa to assess attitudes towards condom use, monogamy and HIV risk in the context of circumcision.TM) questionnaire and survey development software adapted for low literacy and computer naïve populations .Before undergoing circumcision, all study participants were asked to complete a baseline sexual behaviour questionnaire through an audio computer-assisted self-interviewing (ACASI) tool in a private office room at the study site. This interviewing technique circumvented Social Desirability bias by allowing the participant to complete the questionnaire in a standardised format without having to share their responses with study personnel directly. However, if the participant was unable or preferred not to use the ACASI tool, the study nurse was available to administer the questionnaire. The tool, available in both English and the local language, Setswana, was developed by using Questionnaire Development System  guidelines for adult VMMC. At each visit, participants completed the follow-up survey through ACASI during their clinic appointment. A follow-up visit at 12 months was planned to coincide with annual HIV testing as per standard of care in Botswana. Each study participant was provided with a wallet-size reminder card noting the date of each follow-up visit. Participants received BWP100 (approximately USD$8 at study initiation) at each post-operative visit as compensation for their time and travel costs.20The current analysis is restricted to data collected at baseline and the 3-month follow-up visit when the sexual behaviour questionnaire was repeated. Study data were collected and managed by using Research Electronic Data Capture (REDCap), a secure, web-based application designed to support data capture for research studies hosted at the Institute for Translational Health Sciences at the University of Washington.21 Concurrency was then assessed by using the following three questions (based on UNAIDS recommendations for data collection), each of which was asked of participant’s three most recent sexual partners: ‘How long ago did you first have sexual intercourse with this person?’ ‘When was the last time you had sexual intercourse with this person?’ and ‘Are you still having sex with this person?’The primary outcomes of the current analysis were (1) the number of sexual partners in the previous 1 month and (2) one or more concurrent sexual partnerships during the previous 3 months. In accordance with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommendations, we defined a concurrent sexual partnership as ‘overlapping sexual partnerships in which sexual intercourse with one partner occurs between two acts of intercourse with another partner’.To evaluate the change in the number of sexual partners and engagement in concurrent sexual partnerships before and after undergoing VMMC, we constructed change scores for each endpoint, which subtracted participants’ baseline response from that reported at the 3-month follow-up interview.For the continuous outcome, the number of sexual partners (past 1 month), we fit an intercept-only inverse-probability weighted linear regression model to estimate the mean change in the number of partners at 3 months post-VMMC (compared to baseline). For the dichotomous outcome, engagement in concurrent sexual partnerships (past 3 months), we fit an inverse-probability weighted conditional logistic regression model (stratified on the participant) to estimate the change in the proportion of participants reporting sexual concurrency at 3 months post-VMMC (compared with baseline).24 Inverse-probability weighting adjusts for loss to follow-up by empirically breaking the association between observed predictors (collected at baseline) and participation at follow-up, allowing for unbiased estimation in the weighted sample, provided a regression for participation is correctly specified and no unobserved correlates of non-participation and risky sexual behaviour exist. Inverse probability weights for participation at follow-up were constructed from a multivariable logistic regression model, which considered the following 24 potential covariates based on subject-matter knowledge: age, relationship status, religious affiliation, education, employment status, household assets or characteristics, reason for circumcision, correct knowledge of circumcision benefits, beliefs about circumcision, alcohol use, age at first sex, number of sexual partners  and transactional sex. We also created 117 two-way interaction terms by taking the cross-product of each demographic and socioeconomic covariates with each knowledge, belief and behavioural covariate. To build the multivariate logistic regression model required by inverse-probability weighting, we used a stepwise, forward selection procedure to identify covariates from the list of candidate predictors listed above. The entry and exit criteria were set to a p < 0.2. We included missing indicators for each selected variable to maximise the number of cases included in the final models and to maintain a constant sample size across analyses.Inverse probability weighting was used to adjust for potential selection bias because of non-trivial (anticipated to be 20% before study start) loss to follow-up.In post-hoc analyses, we sought to identify attitudes, beliefs and/or behaviours reported at baseline that may be predictive of engagement (irrespective of what the participant reported at baseline [i.e. pre-circumcision]) in high-risk sexual behaviour at 3 months post-VMMC. Specifically, we fit separate univariable- and multivariable-adjusted modified Poisson regression models (weighted by the inverse of the probability of participation at follow-up) for each of our primary outcomes  for each of the following covariates: alcohol consumption, reasons for circumcision, correct knowledge of circumcision benefits, beliefs about circumcision, age at first sex and transactional sex. All multivariable models were adjusted for potential confounding by the following demographic and socioeconomic covariates : age, relationship status, religious affiliation, education, employment and household use of wood as cooking fuel.All analyses were conducted by using SAS software version 9.4 .Ethical approvals were obtained from the Health Research and Development Committee at the Botswana Ministry of Health (MOH) (#00699) and the University of Washington Institutional Review Board (#42047).Between November 2013 and October 2015, research staff screened 577 men preparing to undergo VMMC for study participation . A totaln = 105) or refused the sexual behaviour questionnaire (n = 36) were more highly educated  and underwent circumcision for personal hygiene reasons  compared with respondents at 3 months post-VMMC. In contrast, non-respondents were less likely to live in larger households . No other baseline characteristics were significantly associated with the response at 3 months post-VMMC.n = 311 with available data) of men reported the same number of partners at 3 months post-VMMC, 70 (23%) reported fewer partners and 59 (19%) had more partners (n = 353 with available data) reported engaging in one or more concurrent sexual partnerships. By 3 months post-VMMC, 58 (52% of 111) had ended the concurrent partnership. In contrast, amongst the 242 (69%) who did not report any concurrent sexual partnerships at baseline, 47 (19% of 242) had initiated a concurrent partnership at 3 months (p = 0.61) and the proportion engaging in concurrency was 0.04 .At baseline, the mean (95% CI) number of sexual partners (past 1 month) was 1.60 . Although the majority  study, a cluster-randomised test-and-treat trial conducted in rural Uganda and Kenya, identified alcohol use as a significant predictor of HIV acquisition in developing an HIV risk score.12 In contrast, we employed a pre–post intervention design in which sexual behaviour was assessed before and after participants underwent VMMC. This is important because men who choose to undergo circumcision may differ systematically from men who do not in ways that are related to risky sexual behaviour but are not easily measured. In our study, each participant served as his own control over time enabling us to control for bias resulting from fixed, systematic differences regardless of whether they are recorded by research staff. A second key strength of our results is the use of ACASI to collect sexual behaviour information. Given the sensitive and private nature of participation in sexual activities, individuals may underestimate or in some cases overestimate engagement in risky sexual behaviour. Indeed, multiple studies have shown that this type of information bias is particularly prevalent in studies on sexual behaviour, which utilise face-to-face interviewing techniques.29 Misreporting of high-risk sexual behaviour amongst men undergoing VMMC may underestimate prevalence, hindering the effectiveness and safety of circumcision programmes. To mitigate this potential form of information bias, we used ACASI, an interviewing technique that allows the participant to complete the questionnaires privately and without directly sharing their responses with study staff.Most of the existing data around risky sexual behaviour and VMMC relies on cross-sectional surveys (i.e. collected at a single point in time) in which the sexual behaviours of circumcised and uncircumcised men are compared.Our study is subject to limitations. Firstly, 28% of men either did not return for follow-up at 3 months post-VMMC and/or did not provide information on risky sexual behaviour post-VMMC. Adjustment for selection bias because of this sub-optimal retention relies on the assumption that, conditional on a set of observed covariates, men who did and did not return for follow-up are exchangeable, and its appropriateness depends on our ability to identify, measure and control for all covariates associated with loss to follow-up. Based on subject-matter knowledge, we considered 24 demographic, socio-economic and behavioural covariates and 117 two-way interaction terms in the multivariable model required by the inverse probability weighting procedure. However, as with any observational study, bias because of unmeasured factors is possible.Despite these limitations, our results provide reassurance that men undergoing VMMC in Botswana are unlikely to be systematically engaging in risk compensation. Such behaviour, if practised widely, has the potential to undermine the public health benefits of VMMC. Instead, we found that in the 3 months following VMMC, both the overall number and timing of sexual partners were similar to pre-circumcision levels. Botswana’s circumcision programme continues to provide HIV prevention through the circumcision procedure itself and is not being jeopardised by the perception of reduced risk of HIV acquisition.