In grasslands, overgrazing by domestic livestock, fertilization, and introduction of exotic forage species leads to plant communities consisting of a mixture of native and exotic species. These degraded grasslands present a problem for land managers, farmers, and restoration ecologists concerned with improving biodiversity while continuing to use the land for livestock production. Here we assessed the response of butterfly and plant community composition to the use of fire and moderate grazing by domestic cattle on degraded grasslands dominated by exotic plants. We evaluated change by comparing experimental pastures to two reference sites that were grasslands dominated by native plants. We used two burning and grazing treatments: 1) patch-burn graze, a heterogeneously managed treatment, where one third of the pasture is burned each year and cattle have free access to the entire pasture, and 2) graze-and-burn, a homogenously managed treatment, where the entire pasture is grazed each year and burned in its entirety every three years. We tested for change in the butterfly and plant community composition over seven years using Bray-Curtis dissimilarity measures. Over the course of seven years, degraded pastures in both treatments became more similar to reference sites with respect to the butterfly and plant communities. Only two butterfly species and two plant functional guilds exhibited significant linear trends over time, with varying responses. Compositional changes in both the butterfly and plant communities indicate that the use of moderate grazing and fire may shift butterfly and plant communities of exotic-dominated grasslands to be more similar to reference tallgrass prairies over time. Anthropogenic alterations to ecosystems can cause changes in assemblages of plant species, resulting in ecosystems composed of both exotic and native species that differ from ecosystems composed of primarily native species in number of ways, including biodiversity, phenology, photosynthetic mode, productivity, and ecosystem services –5. TheseWe chose to monitor butterflies because they are among the most commonly studied invertebrates , and havDomestic cattle grazing is gaining popularity as a restoration tool in exotic-dominated grasslands , even inPatch-burn grazing has been proposed as a method for altering both palatability and herbivore selectivity, and can reduce the dominance of exotic plants in grasslands –40. PatcIn this study we examined seven years of plant and butterfly response to grazing and fire management within the tallgrass prairie ecosystem of North America using two different treatments: 1) patch-burn graze, where fire is applied heterogeneously to the site, which influences grazing patterns, and 2) graze-and-burn, where fire is applied homogenously. Because the pastures used in this experiment were prairie remnants , we expeOur study sites were located in the Grand River Grasslands, an area spanning over 28,000 ha in Ringgold County, Iowa, and Harrison County, Missouri, U.S.A. . Due to The sites used in this study were a subset of sites from a larger research project established in 2006 that compared burn-only, patch-burn grazed, and burn-and-grazed pastures . All tre-1 (SD = 0.8). Over the seven years of the study the average stocking rate was 2.4 AUM ha-1 (SD = 0.8). Following 2010, stocking rate was altered annually based on end-of-season forage estimates at each site from the previous year to better achieve heterogeneity in vegetation height among patches within the patch-burn graze treatment , the average stocking rate was 3.9 Animal Unit Months (AUM) hareatment  49]. Re. Re-1  using a modified “Pollard walk” method . Observe2 (0.5x1.0m) Daubenmire [Canopy cover of functional guilds was measured in mid-July using thirty 0.5-mubenmire  quadratsubenmire . Variablubenmire . In 2007To quantify change over time, Bray-Curtis dissimilarity between reference and grazed sites was calculated for the butterfly community and the plant groups. For each site, butterfly abundance was totaled among the three patches and percentage estimates for plant cover was averaged among patches. Comparisons between grazed sites and reference sites occurred only within each individual year; i.e. no comparisons in dissimilarity were made among years. Species abundances (for butterflies) and cover by functional guild (for plants) were averaged across the two reference sites for each year and dissimilarity of each grazed site during each year to the average of the reference sites was calculated using the vegdist function in the vegan package  in R verst and ending on the last butterfly sampling day of each year. Data were obtained from five weather stations within a 25-km radius of our study area and the average was used to represent an annual precipitation estimate for the study area.Precipitation data were collected from National Oceanic and Atmospheric Administration’s National Climatic Data Center . We extrWe tested for changes in species abundance of 13 of the most abundant butterfly species and the six plant functional guilds. Our data showed high inter-annual variation in abundance of individual species and individual plant functional guilds  Tables. Butterfly community composition became more similar to reference sites over the seven year period ; Fig 1. Pyrisitia lisa (Little Yellow) and Speyeria idalia , showed a significant linear trend  over the seven year period  Dumort., nom. cons.), Forbs = non-leguminous forbs, Legumes = leguminous forbs, Woody = woody vegetation, WSG = warm-season grasses (C4).Abbreviations are as follows, CSG = cool-season grasses (C3), Fescue = tall fescue ((DOCX)Click here for additional data file.S2 TableTotal abundance is the sum of all butterflies counted from six transects within each site in each year.(DOCX)Click here for additional data file.


We present an infant with acute fever, thrombocytopenia, and leukopenia, coming from an endemic region for tick-borne encephalitis, human granulocytic anaplasmosis, and hantavirus infection. The primary human herpesvirus 6 infection was diagnosed by seroconversion of specific IgM and IgG and by identification of viral DNA in the acute patient's serum. The patient did not show skin rash suggestive of exanthema subitum during the course of illness. Slovenia, a Central European country, is an endemic region for at least three zoonotic infectious diseases that may present as an acute febrile illness associated with thrombocytopenia and leukopenia: tick-borne encephalitis (TBE), human granulocytic anaplasmosis, and hantavirus infection , 2.We present a patient with exanthema subitum without exanthema, mimicking the three zoonotic infectious illnesses mentioned above.In September 2015, an eleven-month-old girl was referred to our department with a 2-day history of high fever without other symptoms. Two days before she got ill, she had been in direct contact with mouse stool. Epidemiological data on previous tick bite was negative. On physical examination, she was febrile (38.9°C) and no other clinical signs were found. Initial laboratory findings revealed thrombocytopenia, leukopenia, and severe absolute neutropenia . She was Anaplasma phagocytophilum, and hantaviruses. Within the next two days, a rapid drop in body temperature to normal was observed. She had no symptoms and no signs of illness thereafter. Since clinical picture and laboratory results were nonspecific, the diagnosis of exanthema subitum was confirmed by microbiological investigations  in infants and can also result in an infectious mononucleosis-like illness in adults . SerologExanthema subitum is characterized by an abrupt rise in body temperature to as high as 40°C followed by a rapid drop to normal within the next 2–4 days which coincides with the appearance of an erythematous maculopapular skin rash that persists for 1–3 days . But onlThe diagnosis of exanthema subitum is usually clinical. In atypical cases, the diagnosis of primary HHV-6 infection is performed by both serologic and direct methods . For patNo therapies are approved currently for the treatment of HHV-6 infection . Intrave Anaplasma phagocytophilum. It is important to differentiate these infections because therapeutic approaches differ considerably. Acute HHV-6 infection in our patient was established by seroconversion of IgM and IgG antibodies against HHV-6 and directly by demonstration of DNA-HHV-6 in patient's blood by PCR (We present the eleven-month-old girl with exanthema subitum with an acute fever, thrombocytopenia, leukopenia, and neutropenia but without skin rash suggestive of primary HHV-6 infection . A carefd by PCR . HHV-6 iIn conclusion, primary HHV-6 infection in infancy can present as an acute febrile illness associated with thrombocytopenia, leukopenia, and neutropenia but without skin rash suggestive of exanthema subitum.


Melon necrotic spot virus (MNSV) and demonstrated the efficacy of hexanoic acid (Hx) priming, which prevents the virus from systemically spreading. We analysed callose deposition and the hormonal profile and gene expression at the whole plant level. This allowed us to determine hormonal homeostasis in the melon roots, cotyledons, hypocotyls, stems and leaves involved in basal and hexanoic acid-induced resistance (Hx-IR) to MNSV. Our data indicate important roles of salicylic acid (SA), 12-oxo-phytodienoic acid (OPDA), jasmonic-isoleucine, and ferulic acid in both responses to MNSV. The hormonal and metabolites balance, depending on the time and location associated with basal and Hx-IR, demonstrated the reprogramming of plant metabolism in MNSV-inoculated plants. The treatment with both SA and OPDA prior to virus infection significantly reduced MNSV systemic movement by inducing callose deposition. This demonstrates their relevance in Hx-IR against MNSV and a high correlation with callose deposition. Our data also provide valuable evidence to unravel priming mechanisms by natural compounds.Unlike fungal and bacterial diseases, no direct method is available to control viral diseases. The use of resistance-inducing compounds can be an alternative strategy for plant viruses. Here we studied the basal response of melon to  Tobacco mosaic virus (TMV) replicase interacts with and alters the subcellular localisation of several members of the auxin/indole acetic acid (Aux/IAA) protein family -12-oxo-phytodienoic (OPDA) has been observed to be involved in callose deposition during the activation of defense responses against Botrytis cinerea (Plant hormones and reactive oxygen species (ROS) play important roles in regulating transcriptomic changes during stress responses. The three phytohormones that influence the regulation of plant–virus interactions are salicylic acid (SA), jasmonic acid (JA), and abscisic acid (ABA). SA is essential for establishing local and systemic resistance because both SA biosynthesis and signaling are activated when viral effectors by ractions . In compractions . So it iractions . JA is aractions . Virus iractions . ABA hasractions . Remarka cinerea . Some ev cinerea .A. thaliana has provided relevant information on compatible plant-virus interactions, and has indicated that the transcriptome of host cells undergoes significant reprogramming during infection , have demonstrated that ROS can activate defense genes, and that regulation of antioxidant enzymes can be relevant for determining susceptibility or resistance to plant viruses  is a potent priming agent with a wide range of host plants and pathogens . Treatin cinerea  and the . tomato . Hx can . tomato .Cucumber mosaic virus (CMV) -benzothiadiazole (BTH), a functional analog of SA that protects tobacco against TMV , and tomus (CMV) .Melon necrotic ringspot virus (MNSV). This plant virus belongs to the genus Carmovirus in the family Tombusviridae, and causes systemic necrotic spots on the leaves and streaks on stems of melon, cucumber, and watermelon, as well as occasional plant collapse (“sudden death”)  of melon plants to  death”) . The MNS death”) . The ope death”) . The ORFh”) (nsv . As withh”)  collected in the Murcia Region (Spain), and was kindly provided by Dr. F. Botella  .The MNSV-Al isolate used herein was originally obtained from field melon plants  . MNSV-inThirteen inoculation-plus-sampling experiments were run. Each experiment consisted of growing 36 melon plants in 12 different pots (3 plants per pot), of which 10 pots (30 plants) were mechanically inoculated by rubbing purified virus particles on the fully expanded cotyledons of 7- to 9-day-old seedlings before leaves emerged. The other two pots (six plants) were either mock-inoculated or kept healthy to be used as controls.-2 s-1. The mock-inoculated and healthy control plants were similarly treated.Bioassays were performed in a climatic chamber with a day/night period of 16/8 h. Temperatures were 25 and 18°C, respectively, with irradiance of 210 μmol photons mThree experiments were performed to test the effectiveness of Hx in melon plants as an inducer of resistance against MNSV. In the first experiment, Hx was applied to saturation by foliar spray at 16 mM and by soil drench with 1 L of Hx at 4 mM for 3 and 1 days before infection, and 24 h after infection, as a curative treatment. For the second experiment, two sequential Hx treatments were selected (25 mM), applied by soil drench at 72 and 24 h before MNSV inoculation, and with another application at 24 h post-inoculation. The third experiment involved the same experimental template, but no post-inoculation treatment.-1 of DAB at pH < 3 for 24 h in the dark. They were subsequently discolored in 96% ethanol and rehydrated in distilled water. Callose deposition in response to MNSV infection was quantified from the digital photographs of the aniline blue-stained cotyledons at 24 hpi and 5, 12, and 18 dpi, as described by 1). The number of yellow pixels that corresponded to the stained callose was counted with the GNU Image Manipulation program (GIMP2). For the double staining of H2O2 and callose, plant material was stained with DAB and subsequently stained with aniline-blue, as described above.Cotyledons were collected for 3′3-diaminobenzidine (DAB) staining at 24 hpi and 5, 12, and 18 dpi. Cotyledons and leaves were cut and placed immediately in 1 mg mL3), according to the manufacturer’s instructions. The melon tissue samples for RNA isolation were collected at 24 hpi and 5 dpi. Highly pure RNA was used for the RT reaction. The RT reaction was performed according to the manufacturer’s instructions for the Omniscript Reverse Transcriptase kit (QIAGEN4). The primers employed for the qRT-PCR are listed in Supplementary Table Actin gene expression level was used as an internal housekeeping control. At least three independent experiments were performed to confirm the results. In each experiment, three biological replicates were utilized to generate means and to determine statistical significance.Gene expression by qRT-PCR was performed with the RNA samples extracted from cotyledons and roots using the Total Quick RNA Cells and Tissues kit , 2H4-SA (to quantify SA), dihydrojasmonic acid  were added prior to extraction (5). The chromatographic system was interfaced to a Quattro LC (quadrupole–hexapole–quadrupole) mass spectrometer (Micromass6). Version 4.1 of the MASSLYNX NT software (Micromass), was used to process the quantitative data from the calibration standards and plant samples. The concentrations of hormones and metabolites were determined in each sample by normalizing the chromatographic area for each compound with the fresh weight of the corresponding sample.For the hormonal analysis, fresh material was frozen in liquid N, ground and freeze-dried. Fresh tissue (0.5 g) was immediately homogenized in 2.5 mL of ultrapure water, and 100 ng mLtraction . After e7 and SA was acquired from Sigma–Aldrich. Plants were harvested and assessed for disease symptoms evaluations.For hormonal treatments, plants were grown and inoculated as described above. One day before inoculation, plants were treated by foliar spray with 100 μM of OPDA, 1 mM of SA or 100 μM of OPDA+1 mM SA. OPDA was purchased from Larodan Fine ChemicalsA statistical analysis was carried out by a one-way analysis of variance in the Statgraphics-Plus 5 software for Windows V.5 . Means were expressed with standard errors and compared by a Fisher’s least-significant difference test at the 95% confidence interval. All the experiments were repeated at least three times.Figure 1A). At that time virus systemic movement began and necrotic symptoms were clearly visible on primary leaves at 12 dpi . The histological analyses performed by aniline blue staining demonstrated pathogen-induced callose accumulation at the infection site , but no callose was present in the non-inoculated plants (data not shown). The analysis of hydrogen peroxide (H2O2) accumulation by 3,3′-diaminobenzidine (DAB) staining showed dark spots around the infection site at 5 dpi, which reflects the oxidative stress associated with this viral infection . The DAB and aniline blue double staining demonstrated that callose and H2O2 co-located on the lesion area as part of the plant response to MNSV infection . In a late infection stage (18 dpi), ROS and callose accumulated at the infection sites on leaves, which indicates the systemic activation of these defenses in response to MNSV . In this case, ROS accumulated to a lesser extent than at the primary infection sites and co-localized with callose .Upon MNSV inoculation, lesions appeared on cotyledons at 2 or 3 dpi, and had fully developed by 5 dpi , we selected the application of two sequential treatments with 25 mM of Hx by soil drench at 72 and 24 h before MNSV inoculation, and another one at 24 h post-inoculation. Disease severity was based on local infection by recounting spots per cotyledon, and on the secondary one by determining the number of plants with systemically symptoms on their leaves. The spray treatment significantly reduced local symptoms and systemic infection . Interestingly, the Hx treatment by soil drench completely blocked MNSV systemic movement , and no significant reduction in local symptoms was noted compared with the untreated plants. We moved on to confirm the prevention of virus systemic spread without the post-inoculation Hx treatment. Hence only the treatments before inoculation were used for further studies . Given the importance of Hx treatment for clearly blocking long-distance viral movement, we searched the biochemical and molecular mechanisms of Hx-IR against MNSV under these experimental conditions. For this purpose, virus entry into the phloem sap was determined by dot blot analysis at 24 hpi and 5 dpi, when disease symptoms still not observed in leaves in control and Hx-treated plants (data not shown). Thus, for further studies we selected control plants in which systemic movement was confirmed at these time points.We tested the efficacy of natural priming agent Hx as an inducer of resistance against MNSV in melon plants. We set up Hx treatments in melon plants based on previous Hx-IR data in tomato plants against syringae . After cFigures 3A,B). This supports a relevant role of callose priming for Hx-IR in melon plants against MNSV, as previously reported in other pathosystems . At 5 dpi in roots, both CalSS and PDLP6 were induced in the Hx-treated and Hx-MNSV plants . These findings support the notion that Hx-priming alters the callose metabolism in different tissues, which reflects the relevance of roots in preventing MNSV systemic movement.To verify the importance of callose metabolism and the relationship between this polymer accumulation and the block of MNSV movement in the primed plants, the expressions of callose synthase 2O2) accumulation at 5 dpi in the MNSV-inoculated cotyledons compared to the untreated plants . Changes in ROS production were associated with Hx-IR in the tomato plants infected with B. cinerea, which alleviated oxidative damage . The early basal response (24 hpi) to MNSV was also associated with a slight reduction in SA in roots and hypocotyls, and with an increase in JA-Ile in roots . Hx-IR significantly increased ferulic acid in hypocotyls, and slightly increased JA and SA in relation to the basal response. Not many changes were observed in the roots of the Hx-treated plants in this stage, save a slight reduction in JA-Ile . We analyzed the expression of the selected genes in this early infection stage in cotyledons and roots. ICS2 and PR1 (SA); AOS, COI1 and HSP17.4 ; WRKY70 ; PAL (phenylpropanoids); and GST (ROS detoxification). The most relevant changes observed in the Hx-treated plants at 24 hpi were the significant induction of ICS2, PR1, and GST in cotyledons, and that of Hsp 17.4 in roots . This reflects the activation of SA- and OPDA-signaling and the antioxidant metabolism as part of Hx-IR. Interestingly, the induction of the SA-pathway occurred with no significant free-SA accumulation in either cotyledons or hypocotyls . The early OPDA accumulation in the infected cotyledons seemed to activate OPDA-dependent signaling pathways in roots, the next tissue involved in virus movement, by higher accumulation of Hsp17.4 expression .To establish the molecular mechanisms that underlie the prevention of virus spread by Hx-IR, we analyzed the hormonal and metabolite balance of the tissues involved in MNSV movement in melon plants. The most significant biochemical changes noted at 24 hpi occurred in cotyledons and hypocotyls of the Hx-primed and MNSV infected plants. These plants displayed a significant increase in OPDA and JA-Ile in cotyledons, which was associated with ferulic acid accumulation . The most significant change associated with Hx-IR in this infection step was the increased OPDA accumulation in cotyledons and roots . This reinforces the importance of oxylipin OPDA in plant defense responses. In this stage the gene expression analysis showed that Hx-IR significantly increased PR1, WRKY70, and GST compared to the induction observed in the basal response . This once again suggests SA pathway activation and the antioxidant response in the Hx-primed plants upon MNSV infection.In the second infection phase (5 dpi), when MNSV moved to phloem sap, the plant basal response accumulated SA, OPDA, and ferulic acid, and reduced JA-Ile . This contrasts with the metabolic alteration observed in the infected plants that presented significant systemic infection at this point , and strongly suggests a key role in the blockage of long-distance viral movement.Finally at 12 dpi when systemic infection was established in the MNSV plants, the most relevant metabolic change in the Hx-primed plants with no systemic virus movement was OPDA accumulation in completely necrotised cotyledons . At a local level, the SA application lowered the number of spots/cotyledons. However, the OPDA and OPDA+SA treatment did not change local infection compared to the control . Applying OPDA or SA alone resulted in a slighty smaller number of plants showing systemic symptoms . Interestingly, the application of both OPDA and SA significantly reduced viral movement, which lowered the number of melon plants with systemic symptoms to below 16%. The treatment with SA, OPDA and SA+OPDA induced callose deposition in cotyledons 5 days after MNSV inoculation . This demonstrates that accumulation of both OPDA and SA is crucial in the Hx-IR of melon plants to MNSV by contributing to early callose accumulation at the infection site.For this purpose, OPDA, SA, or OPDA + SA were applied by foliar spray 24 h before infection, and local and systemic disease severity was evaluated  and Potato virus X (PVX) double infections enhanced resistance, but applying it later increased susceptibility.The biphasic behavior of JA signaling is noteworthy. JA-Ile content significantly increased at 24 hpi in the Hx-MNSV plant cotyledons. Although thaliana . InteresIn late infection stages (12 dpi) when MNSV had systemically spread, the SA and ferulic acid levels had significantly risen in leaves. ABA seems to accumulate in this late plant response phase. A significant increase in SA content in stems accompanied a higher JA content. The Hx-treated plants that displayed no systemic infection showed a completely different metabolic profile in leaves, with lower levels of all the analyzed metabolites, and no changes in stems. The cotyledons of the systemically infected plants exhibited significant metabolic changes, such as accumulation of SA, OPDA, JA, ferulic acid, and ABA. This hormonal disruption is common in plants susceptible to viral infection by simultaneously inducing several antagonistic hormones .Figure 10B). However, the melon plants treated with both molecules displayed a significant reduction in the plants that displayed systemic symptoms, which came closer to that observed in the Hx-treated plants . This demonstrates that these hormones have a synergic effect on the resistance of melon plants against MNSV, which could play a prominent role in Hx-IR. Previous data have revealed that exogenous SA applications confer resistance against different viruses, although mechanisms are specific depending on both the host and the infecting virus  during their compatible interactions (Cucurbita pepo results from low viral accumulation in inoculated tissues, rather than from systemic movement (GST could also help to maintain optimal ROS levels for proper signaling.Given the relevant changes in OPDA and SA associated with both basal and Hx-IR against MNSV, and their connection with callose accumulation in other pathosystems , we treang virus . In Nicoractions . SA-medimovement . No prevIn short, our study provides a global picture of host defenses in response to the virus MNSV in the non-model melon plant. We also demonstrate for the first time the efficacy of natural priming agent Hx to prevent virus systemic movement. The determination of metabolites in different plant tissues in early and late infection stages reveals the relevance of OPDA, SA, and ferulic acid in local responses against MNSV, as well as pathogen-induced callose deposition in both basal and Hx-IR. Treating melon plants with both OPDA and SA significantly reduces virus systemic spread by mediating the increase in pathogen-induced callose deposition. Hence our results contribute to unravel the mechanisms that underlie the priming effect of natural compounds, and demonstrate the potential of these treatments to prevent the virus from spreading.PG-A, VP, and CG-B planned and designed the research. JN, MS-S, and IF performed the experiments. EF-C realized hormonal analysis, qPCR procedures, DAB and callose staining. EF-C analyzing the results and wrote the manuscript with the technical support of CG-B who participated in drafting the manuscript as well. VP and PG-A participated in the correction of manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Less than one-third of patients who are estimated to be infected with multidrug-resistant tuberculosis (MDR-TB) receive MDR-TB treatment regimens, and only 48% of those who received treatment have successful outcomes. Despite current regimens, newer, more effective and cost-effective approaches to treatment are needed. The aim of the study was to project health outcomes and impact on healthcare resources of adding bedaquiline to the treatment regimen of MDR-TB in selected high burden countries: Estonia, Russia, South Africa, Peru, China, the Philippines, and India.This study adapted an existing Markov model to estimate the health outcomes and impact on total healthcare costs of adding bedaquiline to current MDR-TB treatment regimens. A price threshold analysis was conducted to determine the price range at which bedaquiline would be cost-effective.Adding bedaquiline to the background regimen (BR) resulted in increased disability-adjusted life years (DALYs) averted, and reduced total healthcare costs (excluding treatment acquisition costs) compared with BR alone in all countries analyzed. Addition of bedaquiline to BR resulted in savings to healthcare costs compared with BR alone in all countries analyzed, with the highest impact expected in Russia (US$194 million) and South Africa (US$43 million). The price per regimen at which bedaquiline would be cost-effective ranged between US$23,904-US$203,492 in Estonia, Russia, Peru, South Africa, and China (high and upper middle-income countries) and between US$6,996-US$20,323 in the Philippines and India (lower middle-income countries); however, these cost-effective prices do not necessarily address concerns about affordability.Adding bedaquiline to BR provides improvements in health outcomes and reductions in healthcare costs in high MDR-TB burden countries. The range of prices per regimen for which bedaquiline would be cost-effective varied between countries.The online version of this article (doi:10.1186/s12913-016-1931-3) contains supplementary material, which is available to authorized users. Multidrug-resistant tuberculosis (MDR-TB), defined as tuberculosis caused by strains resistant to isoniazid and rifampicin, poses challenges to global TB control. Extensively drug-resistant TB (XDR-TB), caused by MDR-TB strains that are also resistant to any fluoroquinolone and to at least one of the three injectable second-line drug classes   may resuBedaquiline received accelerated and conditional approval in the United States and Europe, respectively, for the treatment of pulmonary MDR-TB in combination with other anti-tuberculosis drugs when an effective treatment regimen cannot otherwise be provided , 5. The A study commissioned by the WHO previously explored the cost-effectiveness (CE) of adding bedaquiline to 20 month MDR-TB treatment regimens in six low- to middle-income settings  , coverinThe primary objective of the study was to evaluate health outcomes, expressed in terms of disability-adjusted life years (DALYs) averted, following addition of bedaquiline to the background regimen (BR) in the treatment of MDR-TB in an economically diverse group of high MDR-TB burden countries   , 13, hadPatients could become lost to follow-up (default) anytime while on treatment. Patients initially diagnosed with XDR-TB (‘Active XDR-TB’ state) could experience similar outcomes (relative disability weight of 1.20 for XDR-TB) to those initially diagnosed with MDR-TB except that no subsequent treatment was allowed due to the limited treatment options in this more severe patient group. Patients with XDR-TB who failed treatment transitioned to end of life care , where they experienced higher mortality and worse health outcomes.Data on the efficacy of treatment and the risk of morbidity and mortality in patients with MDR-TB were obtained from various sources, including the C208 study - a Phase II, placebo-controlled, randomized trial of bedaquiline in newly diagnosed MDR-TB patients , 13. In Comparative data were sourced in the form of hazard ratios (HRs) from published clinical trial data  Table 11 and appRates of sputum culture conversion for patients receiving BR treatment alone were estimated from a post-hoc patient-level analysis of published clinical data from the C208 study , 13. TheThe HR on sputum culture conversion for bedaquiline compared with BR was applied for the duration of bedaquiline treatment (i.e. 24 weeks), after which patients were assumed to experience no further reduction in the rate of sputum culture conversion. The HR on sputum culture conversion for patients with XDR-TB was generated based on proxy data from patients with pre-XDR-TB collected in an open-label bedaquiline study ; this waDisability adjusted life years (DALY), and years of life lost due to premature mortality were sourced from two sources: a global burden of disease study that reported disability weights for active TB and the UK life tables , 17. TheCost data were sourced from country-specific databases –23, hospThe primary patient outcomes assessed were DALYs averted. The percentage of patients with cure  , and theper capita gross domestic product (GDP) is the threshold cost per DALY where an intervention can be considered cost-effective [According to WHO recommendations, three times the ffective . ThreshoIn addition, a probabilistic sensitivity analysis (PSA) was conducted to assess the likelihood of bedaquiline plus BR being cost-effective versus BR alone at prices ranging from 50% of the lowest price at which the drug would meet the minimum standard for the WHO CE threshold, to double the highest price. Details of the PSA and the probabilistic distributions can be found in Additional file Over a 10-year time horizon, treatment with bedaquiline plus BR resulted in higher DALYs averted, compared with BR alone. The highest incremental change in DALYs was observed in China where the introduction of bedaquiline to the BR was associated with just 8.87 DALYs per patient compared to 11.86 DALYs per patient with BR alone. This represents a 25.15% reduction in DALYs per patient Table .Table 3TAddition of bedaquiline to the BR resulted in a higher percentage of patients experiencing successful outcomes (cured or treatment completed) compared with BR alone. Incremental change in successful outcomes ranged from 51.62% in China (where the introduction of bedaquiline was associated with an increase in successful outcomes from 31.16% to 47.25%) to 60.78% in the Philippines (where the introduction of bedaquiline was associated with an increase in successful outcomes from 17.85% to 28.69%) , between 31.34% and 40.80% fewer cases of acquired resistance were observed when bedaquiline was added to the BR compared with BR alone. China saw a 31.34% reduction, with 52.90 cases of acquired resistance when bedaquiline was added to the BR, versus 77.04 with BR alone. South Africa saw a 40.8% reduction, with 28.20 cases of acquired resistance when bedaquiline was added to the BR, versus 47.58 with BR alone (Table In the lower-middle income countries (India and the Philippines), the introduction of Bedaquiline to the BR was also associated with fewer cases of acquired resistance. India saw a reduction of 31.61%, with 1,274 cases of acquired resistance when bedaquiline was added to the BR, versus 1862.89 with BR alone  in Estonia, Russia, Peru, and China ranged between US$23,904-US$203,492. The range for South Africa was lower at US$29,151-US$72,701, while the Philippines and India demonstrated a lower range, at US$6,996-US$20,323 ; the estimated required funding for 2015 is US$8 billion . Our stuThe mortality imbalance observed in the C208 trial was unexplained. Subsequent analysis by an independent investigator determined that there was no causal relationship with bedaquiline and a missing = failure analysis used within the study accounted for these deaths, considering them as treatment ‘failures’. In addiIncreases in outpatient care costs observed with the addition of bedaquiline reflected increases in monitoring costs associated with the implementation of any new treatment. Addition of bedaquiline to a BR has been shown to result in faster and higher culture conversion rates compared with BR alone , an outcThe current study expands on the results of a prior study conducted on behalf of the WHO, by using a comprehensive Markov state transition model over a longer time horizon , and incorporating more detailed transitions and events such as patient-level data to inform the state transitions, as well as covering additional countries . The WHOThe price threshold analysis shown in this study suggests that prices higher than the price of bedaquiline in a high income setting, such as the United States, would meet WHO criteria for cost-effectiveness in several of the countries analyzed. While these prices may be cost-effective, many would raise the question as to whether or not such prices are affordable; in Table The key strengths of the current study include its comprehensive health state structure, the use of patient-level data to inform state transitions, and the extent to which the model captures WHO guidance on treatment strategies for MDR-TB.A limitation of the current analysis was that the clinical data were based on the multinational Phase II study for bedaquiline  and thusTreatment with bedaquiline plus BR is expected to improve health outcomes through reduced DALY burden compared with BR alone. Addition of bedaquiline to BR resulted in total healthcare cost offsets (excluding treatment acquisition costs). At prices required to satisfy the WHO CE threshold, the probability that bedaquiline would be cost-effective was 32%–94% in the high burden countries analyzed.


Investigations into Notch signaling in macrophages may lead to a more effective way for immune intervention in the treatment of cancer in the future.Macrophages play both tumor-suppressing and tumor-promoting roles depending on the microenvironment. Tumor-associated macrophages (TAMs) are often associated with poor prognosis in most, but not all cancer. Understanding how macrophages become TAMs and how TAMs interact with tumor cells and shape the outcome of cancer is one of the key areas of interest in cancer therapy research. Notch signaling is involved in macrophage activation and its effector functions. Notch signaling has been indicated to play roles in the regulation of macrophage activation in pro-inflammatory and wound-healing processes. Recent evidence points to the involvement of canonical Notch signaling in the differentiation of TAMs in a breast cancer model. On the other hand, hyperactivation of Notch signaling specifically in macrophages in tumors mass has been shown to suppress tumor growth in an animal model of cancer. Investigations into how Notch signaling is regulated in TAMs and translates into pro- or anti-tumor functions are still largely in their infancy. Therefore, in this review, we summarize the current understanding of the conflicting roles of Notch signaling in regulating the effector function of macrophages and the involvement of Notch signaling in TAM differentiation and function. Furthermore, how Notch signaling in TAMs affects the tumor microenvironment is reviewed. Finally, the direct or indirect cross-talk among TAMs, tumor cells and other cells in the tumor microenvironment  The biological functions of macrophages are diverse and not only limited to their role as the first line of defense during innate immune response. In addition to their protective role against infections, the known roles of macrophages have expanded in recent years, and their involvement in organ development, tissue homeostasis, and metabolic dysfunctions, such as diabetes and obesity, are increasingly appreciated. Cancer is another area in which macrophages have emerged as a crucial player in the creation of a tumor microenvironment that supports tumor growth and metastasis, in opposition to their traditional role as an innate immune cell, whose function is to eliminate cancer cells . TherefoThe critical functions of the evolutionarily well-conserved Notch signaling pathway in myeloid lineage cell development and, in particular, monocyte/macrophage development are well recognized and have been reviewed extensively elsewhere , 3. Recevia various receptors, actively eliminate the source of danger by phagocytosis and chemical mediators, and trigger inflammation by producing inflammatory cytokines to alert other immune cells. After the elimination phase, wounds are healed mainly by anti-inflammatory wound-healing macrophages -activated macrophages M(LPS) or LPS in combination with IFNγ M(LPS + IFNγ) , 20, 21.and nos2 –25. Usintor IRF8 . In additor IRF8 , 20. IntRbpj, CSL/RBP-Jκ, possibly through canonical Notch signaling, was found to be required for activation of M(IL-4) or M(chitin), including the expression of the gene signature associated with M(IL-4), such as Arg1 expression , which normally induces anti-inflammatory macrophages. Notch signaling was long considered to be irrelevant; however, an indicator that Notch signaling is activated in the form of cleaved Notch1 was observed in this condition, albeit with different kinetics than those reported in M(LPS + IFNγ) . More impression . This inpression , 29. Togpression .via different combinations of ligand–receptor interactions have long been suspected. For example, two ligands, Dll1 and Dll4, send different signals through the same receptor, Notch1, that are either pulsatile or sustained, thereby inducing different cell fates  showed higher CCR2 expression than their M-CSF-induced counterparts M(MC). After CCL2 stimulation, M(GC) exhibited enhanced LPS-mediated IL-10 production, indicating an anti-inflammatory role. These phenomena were confirmed by an in vivo study in which Ccr2-deficient bone marrow-derived macrophages displayed profiles indicative of inflammatory macrophages  model of cancer was shown to repress tumor-promoting activity by enhancing the anti-tumor phenotype and suppressing the pro-tumor phenotype. The mechanism of anti-tumor activity is reported to be mediated in part by microRNAs (miRNAs) . miRNAs Rbpj in macrophages resulted in reduced activity of CD8+ T cells by diminishing the cytotoxic activity against tumor cells in a B16 cell melanoma model , and these macrophages lost the ability to control tumor growth  . Because choroid . Moreove choroid . Loss of choroid .hi to Ly6Clo monocytes in a Notch2-dependent manner (Vascular cell adhesion molecule (VCAM) 1 is highly expressed in TAMs, whereas loss of VCAM1 in macrophages reduces the number of hematopoietic stem cells in the spleen and the inflammation in atherosclerosis due to an inability of macrophages to attach to vascular endothelial cells . Althougt manner . This st+ MHC IIlow or negative), but not pro-inflammatory macrophage-like (CD206− MHCIIhi) TAMs have been reported to express PD1 in both a mouse model and in human cancers over time with disease progression (+ T cells (via cell–cell interaction in promoting tumor progression (via an immune checkpoint inhibitor.As described above, TAMs can directly support tumor growth by secreting factors, such as TGFβ . TAMs algression . The so-gression . Althoug T cells . Cancer- T cells . Becausegression , it is pNotch signaling clearly plays important roles in TAMs, either to promote or suppress tumor growth. Therefore, Notch signaling in TAMs can be a drug target for manipulating host anti-cancer immunity. If Notch signaling in TAMs is pro-tumoral, suppressing it would benefit the host. In contrast, if TAMs require Notch signaling to become more inflammatory anti-tumor macrophages, it needs to be stimulated. Various types of gamma-secretase inhibitor that is a pan-Notch signaling inhibitor are often used to suppress Notch signaling in cancer clinical trials . Unfortuin vitro (Notch signaling in macrophages clearly affects their biological functions both directly and indirectly. Notch signaling also affects TAMs and functions in monocyte recruitment, tumor-mediated training, and angiogenesis. Notch signaling in TAMs is, therefore, an attractive signal to manipulate to promote anti-tumor immunity. Macrophages have been reported to be epigenetically modified by stimuli that contribute to “trained immunity” and “tolerance,” at least in vitro . If the TP is responsible for designing the article concept and scope, reviewing 50% of the content, and conceptualizing the figure. WW is responsible for reviewing 20% of the content. PK is responsible for reviewing 30% of the content and designing the table and part of the scope of the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patients with schizophrenia have a high mortality risk. The role of clozapine in the long-term mortality risk is insufficiently known. The objectives of the current study were to determine in i) all-cause long-term mortality rates and ii) specific-cause mortality rates and ratios in patients with schizophrenia with and without clozapine treatment.We systematically searched EMBASE, MEDLINE and PsycINFO and included studies that used a long-term follow-up design  and reported on mortality in adults diagnosed with schizophrenia-spectrum disorders receiving clozapine treatment.Altogether, 23 studies fulfilled our criteria, reporting on 1,166 deaths during 203,231 patient years for patients treated with clozapine. Pooling five cohort studies that included sufficient sample sizes and length of follow-up, we found an unadjusted mortality rate of 7.34 per 1,000 patient years (95%CI=4.39–10.28). Long-term, crude mortality rate ratios were significantly lower in patients treated with clozapine compared to patients without clozapine treatment  as well as compared to other antipsychotic medications . We found incomplete and inconsistent reporting of specific-cause mortality rates. Statistical heterogeneity was high in all analyses.Future studies with substantial length of follow-up and uniform reporting of confounders are needed to validate these findings of a significantly lower mortality risk in patients using clozapine, in particular for the risk of cardiovascular mortality.


Adult T-cell leukemia/lymphoma (ATLL) is a rare and aggressive disease caused by human T-cell lymphotropic virus type 1 that predominantly affects Japanese and Caribbean populations. Most studies have focused on Japanese cohorts. We conducted a retrospective analysis of 53 cases of ATLL who presented to our institution between 2003-2014. ATLL in the Caribbean population presents more often as the acute and lymphomatous subtypes, is associated with complex cytogenetics, and has a high rate of CNS involvement. The overall response rate to first-line therapies with anthracycline-based regimens was poor (32%), with a median survival of only 6.9 months. A complete or partial response to first-line regimens was associated with better survival. There was no difference in survival between patients who received chemotherapy alone versus chemotherapy with antiviral agents. Allogeneic transplantation was performed in five patients, two of whom achieved complete remission despite residual or refractory disease. Recipients of allogeneic transplantation had significantly improved overall survival compared to non-transplanted patients. This is the first analysis to describe ATLL pathological features, cytogenetics, and response to standard therapy and transplantation in the Caribbean cohort. Adult T-cell leukemia/lymphoma (ATLL) is a rare mature T-cell malignancy first described in Japan in 1977 –4, whichThe pathogenesis of ATLL in HTLV-1-infected individuals may differ from one population to another. In a comparison between Japanese and Caribbean cohorts, Japanese patients displayed a higher incidence of ATLL, male predominance, and older peak age of onset . AnotherSurvival of ATLL patients remains poor despite therapy. The regimen with the best outcomes as reported in a randomized trial by the Japanese Clinical Oncology Group (JCOG) is VCAP-AMP-VECP , doxorubicin, ranimustine, and prednisone (AMP), and vindesine, etoposide, carboplatin, and prednisone (VECP)), also known as LSG15 . While sGiven the limited scope of published data on Caribbean ATLL, a current and complete description is needed to further characterize the nature of this entity as distinct from the Japanese variant. We report the clinicopathologic features, treatment patterns, and disease outcomes of ATLL in a large, predominantly Caribbean cohort from a single institution in Bronx, New York.We identified 53 cases of ATLL treated at Montefiore Medical Center between 2003 – 2014 [Table Based on the Shimoyama classification, 36 (68%) patients had acute subtype, 14 (26%) had lymphomatous, and three (6%) had chronic/smoldering disease. Patients presented with generalized lymphadenopathy (77%), bone marrow involvement (58%), hepatosplenomegaly (57%), skin (30%), lung (21%), gastro-intestinal (17%), or bone lesions (14%). Of the 27 patients whose CSF was tested for CNS involvement at presentation, nine were positive (33%). Patients with acute and chronic subtypes tended to present with lymphocytosis (51%) with a mean value of 17,490  cells/microliter. Elevated LDH was seen in all patients with a mean value of 1299 (252 – 9610) units/L. Hypercalcemia was also a common feature (64%), with a mean value of 12.03 (7.4 – 20) mg/dL. Of the patients tested for HIV (70%), none were positive. The majority of patients had the classic CD4+/CD8- CD25+ ATLL immunophenotype (83%), while fewer had an atypical phenotype (CD4+/CD8+ or CD4-/CD8-) (17%).Of 53 total patients, 15 28%) had positive CSF cytology and/or flow cytometry at any time during their disease. Three had clinical CNS symptoms (20%), and five had evidence of CNS disease on radiographic imaging (33%) [Table 8% had poOut of 22 patients tested for cytogenetic abberations, 10 had complex karyotypes, and three patients had abnormalities limited to one chromosome Table . AneuploOutcomes with front-line therapy for patients with acute or lymphomatous subtype were poor Table . Most paA total of seven patients were treated with hematopoietic stem cell transplantation in our cohort. Autologous transplantation was performed in two chemotherapy-sensitive patients, one with acute subtype and one with lymphomatous, as a consolidation therapy after first-line anthracycline-based chemotherapy . Both patients received BEAM conditioning . The progression free survival (PFS) after autologous transplant was 13 months and nine months, respectively, with overall survival of 19.8 and 18.5 months, respectively.Allogeneic hematopoietic stem cell transplantation  was performed in five patients Table . ATLL suThe median overall survival (OS) was 6.9 months Figure . There wIn this study we outline a tertiary medical center's experience with ATLL, a rare, poor-risk disease with a high mortality rate. Montefiore Medical Center (MMC) in the Bronx serves a large urban population, with many immigrants and descendants of immigrants from the Caribbean. The significant volume of ATLL cases encountered at MMC makes our institution one of the primary centers to diagnose and treat ATLL in the United States. Since most of these patients are from the Caribbean Basin, our experience closely reflects the ATLL experience from that part of the world. This study reveals diagnostic and therapeutic challenges as well as actuarial efficacy of currently accepted treatment strategies. Our study is unique as it describes the natural history, cytogenetics, and outcomes of front-line therapies and stem cell transplantation in a Caribbean ATLL cohort.ATLL patients diagnosed in the Bronx have a higher incidence of acute and lymphomatous subtypes. The median age at diagnosis is 54 years and approximately 30% of patients have severe concurrent comorbidities/infections or are elderly, making them ineligible for intensive chemotherapy. Interestingly, no patients were co-infected with HIV; whether this is a true association is currently unknown. In this cohort there was a high prevalence of features of higher risk disease  . The ratFirst-line chemotherapy for ATLL in the United States is most commonly an anthracycline-based regimen such as CHOP or EPOCH . Multi-aSeven patients underwent stem cell transplantation. Of the five patients that underwent allo-HSCT, two had a long term CR, still in remission at the time of this report. Unique features in both of these patients included: partially chemotherapy-responsive disease, treatment with antivirals as a part of the induction regimen, and maintenance on IFN+AZT prior to allo-HSCT. Whether these features have an impact on outcomes with allo-HSCT in this population needs to be further investigated. Of the three patients who failed allo-HSCT, two had early relapses within 100 days. The disease responded to withdrawal of immunosuppression in one patient, suggesting a graft-versus-lymphoma effect, though the patient ultimately succumbed to GVHD. A recent non-Japanese ATLL study found improved outcomes in patients who underwent allo-HSCT in comparison to autologous transplant , and earCurrently, most studies impacting ATLL management involve Japanese patients. Our study provides insight into the problems faced by the ATLL population in the United States and should focus clinical trials to areas of need accordingly. Urgent clinical trials with improved front-line chemotherapy regimens, in combination with biological agents, are needed to achieve a better quality of response. Differences in HTLV viral load, TAX expression and TCR repertoire of Allo transplant patients in CR vs <CR may be suitable biomarkers to explore in future studies. Allogeneic stem cell transplant should be considered upfront. The timing of antivirals and continuing antivirals/interferon pre- and post-transplant needs to be evaluated. Additionally, T-cell adaptive immunotherapy should be explored in this disease.Patient records were queried using the Clinical Looking Glass ® (CLG) software to identify all cases of HTLV positivity and ATLL by searching pathology and laboratory reports of patients who presented to Montefiore Medical Center (MMC) between 2003 and 2014. CLG is an interactive software application developed at MMC that integrates demographic, clinical, and administrative datasets and allows them to be reproduced in a programmable format for statistical access. Electronic medical records were manually reviewed to confirm diagnoses and for relevant data points. The diagnosis of ATLL was confirmed based on clinical history, pathological findings, and HTLV-1 antibody positivity. Cases were classified by subtype using the Shimoyama criteria . Index dData generated by CLG and complemented with individual chart review were transferred to a computer spreadsheet . For the analysis of categorical variables, we reported proportions and p values calculated with Pearson chi square or Fisher exact test as appropriate. Kaplan-Meier curves were used to compare survival and statistical significance was examined using the log rank test. Statistical analyses were performed with Stata v12  and a two-tailed alpha of 0.05 was used to denote significance.


In addition, the negative change in preoperative versus POD1 Snellen VA (p = 0.021) and the presence of split fixation involving the inferonasal quadrant on preoperative Humphrey visual field (p = 0.044) were significant risk factors for snuff-out. Transient vision loss occurred in 76 of 242 eyes (30.8%). In conclusion, vision loss is not uncommon after Baerveldt surgery, with snuff-out occurring in 2.4% of cases in this study.This study aims to determine the course of vision loss after Baerveldt aqueous tube shunt placement and identify risk factors associated with unexplained severe long-term vision loss, or snuff-out. We retrospectively reviewed 247 eyes of 222 patients who underwent Baerveldt implantations at one of two academic institutions. Postoperative vision loss at 6 months following surgery was categorized as mild-to-moderate versus severe and long-term versus transient. Long-term vision loss, defined as 3 or more lines of Snellen visual acuity (VA) loss compared with preoperative VA, occurred in 63 of 247 eyes (25.5%), and 39 had mild-to-moderate and 24 had severe loss. Of these 63 eyes, 18 had no identifiable cause of vision loss. On multivariate analysis, poorer Snellen VA on postoperative day 1 (POD1) was found to be a significant risk factor for long-term vision loss ( Glaucoma drainage implants have become an increasingly popular surgical option in cases of refractory glaucoma or failed previous trabeculectomies . Their uGraefe was the first to report that central vision may be compromised soon after surgery in chronically glaucomatous eyes with reduced visual fields , 3. We eHowever, no prior studies have explored the phenomenon of snuff-out after aqueous tube shunt placement. In this study, we sought to determine the prevalence of and risk factors associated with short- and long-term vision loss and recovery with special attention to unexplained long-term vision loss after aqueous tube shunt surgery. Our study looked specifically at Baerveldt implant , which is one of the two most commonly used types of glaucoma drainage devices. Baerveldt implants are silicone, nonvalved shunts, which require placement of a dissolvable or removable suture around the tube or placement of the plate and tube separately in a two-staged procedure.While it has been highly debated in the literature whether snuff-out truly exists after trabeculectomy, to our knowledge, no prior studies have explored this phenomenon after aqueous shunt surgery. This is the first study to note the prevalence of decreased vision after tube placement, with the distinction made between transient vision loss and recovery versus long-term vision loss, as well as mild-moderate versus severe vision loss, and to identify risk factors associated with long-term, unexplained vision loss.2 Baerveldt implantations performed at the University of Southern California (USC) Eye Institute, Keck School of Medicine, Los Angeles, between January 1998 and May 2011, as well as the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, between November 2005 and January 2012. The Institutional Review Boards at USC and Harvard University approved the study protocol, and all study procedures were compliant with the Health Insurance Portability and Accountability Act and the Declaration of Helsinki for research involving human participants.We retrospectively reviewed all 350 mmInclusion criteria were a minimum of 6-month follow-up period, baseline visual acuity (VA) of counting fingers or better, and one of the following glaucoma diagnoses: primary or secondary open-angle, chronic angle-closure, pseudoexfoliation, pigmentary, traumatic, low-tension, juvenile, or iridocorneal endothelial syndrome. Exclusion criteria were aphakia, other concurrent surgical procedures, or a diagnosis of neovascular, congenital, or uveitic glaucoma. The following preoperative characteristics were noted: age, sex, race, lens status, diagnosis, history of prior aqueous shunt surgery, IOP, Snellen VA, cup-to-disc ratio, Humphrey visual field (HVF) mean deviation, presence of split fixation based on HVF testing, and number of quadrants with split fixation.We defined split fixation in the same way as our prior study on vision loss after trabeculectomy: a sensitivity of less than 10 dB involving any paracentral points in the four cardinal quadrants  on 24-2 HVF examination [Data were evaluated for documentation of postoperative vision loss, which was categorized as mild-to-moderate versus severe. Mild-to-moderate vision loss was defined as a decrease of 3 to 5 lines in Snellen VA compared with preoperative, baseline VA. Severe vision loss was defined as a decrease of more than 5 lines in Snellen VA or semiquantitative categories of low vision  compared to baseline VA. The determination of mild-to-moderate versus severe vision loss was based on the lowest observed VA within the 6-month postoperative period.Vision loss was then categorized as long-term versus transient. Postoperative vision loss was considered long-term if Snellen VA did not recover to within 3 lines of the preoperative VA by the 6-month follow-up period. Conversely, postoperative vision loss was considered transient if there was a return in vision to within 3 lines of the preoperative VA at the 6-month follow-up interval, with note made of the number of days for visual recovery. The postoperative course was reviewed in all cases of long-term vision loss to identify any clinical findings or occurrences that accounted for the vision loss. Cases of severe, long-term vision loss without any identifiable explanation were further characterized as “snuff-out.”p ≤ 0.05, unless multiple comparisons were conducted, in which case the Bonferroni correction was applied.Statistical analysis was performed with STATA 13.1 for Windows . All descriptive statistics were reported as mean ± standard deviation. Statistical significance was defined as p ≤ 0.25. Elimination proceeded one variable at a time, with each iteration of the model tested for correct specification using the Box-Tidwell test. Nested model iterations were compared using the Bayesian Information Criterion (BIC) and likelihood-ratio test, and elimination proceeded until the BIC indicated no further improvements. Each model was then evaluated for influential observations and data entry errors through inspection of Pearson residuals, deviance residuals, and Pregibon leverages. Robustness of model fit was evaluated through difference of chi-squares and deviances.Preoperative and postoperative variables were compared between patients with long-term, unexplained vision loss and all others using logistic regression analysis. Entry into the initial model was determined via univariate regression based on A total of 247 eyes of 222 patients were included in the study. All eyes underwent Baerveldt tube shunt placement without reported intraoperative complications or concomitant surgical procedures. A majority of patients demonstrated evidence of advanced glaucomatous disease. Over 73% had a preoperative cup-to-disc ratio ≥0.9, and the average mean deviation on HVF 24–2 was −15.2 ± 8.7 dB. Fifty-one percent of all preoperative visual fields (95 of 186 HVFs) had split fixation in at least 1 cardinal quadrant.Long-term vision loss was observed in 63 of 247 eyes (25.5%). Thirty-nine of these cases (61.9%) were mild-to-moderate, and 24 (38.1%) were severe. Long-term vision loss could be explained in 45 cases (71.4%). The most common causes were progression of glaucoma, cataract, and corneal edema, accounting for 9, 8, and 8 cases, respectively. All other attributable causes of long-term vision loss are listed in p = 0.005) (p = 0.072). Factors significantly associated with snuff-out were the change in preoperative versus POD1 Snellen VA  and the presence of split fixation in the inferonasal quadrant on preoperative HVF . No other variables examined reached statistical significance in the final multivariate regression analysis.Preoperative and postoperative characteristics were compared between cases of unexplained long-term vision loss and all other cases . Logisti= 0.005) . The preOur findings suggest that vision decrease is a common occurrence postoperatively and that snuff-out, though uncommon, does occur after aqueous tube shunt implantation. To the best of our knowledge, no prior reports specifically explored the course of and risk factors associated with snuff-out after aqueous tube shunt surgery. However, several studies have described visual acuity outcomes in general after Baerveldt implantation, as summarized in These previous studies often sought to compare the efficacy of Baerveldt shunts with trabeculectomy or alternative shunt types. They only compared VA at baseline with a single time point after aqueous shunt surgery, with no comments made regarding the course of vision loss and recovery. Moreover, these studies had varying follow-up periods with notable differences in inclusion and exclusion criteria, such that a direct comparison of results between these studies and the present one is not possible. Nevertheless, these prior studies reported an overall mean reduction in logMAR Snellen VA ranging from 0.16 units to 1.6 units (mean of 0.53) with a follow-up period ranging from one to five years after Baerveldt implantation. When visual acuities in this study were converted into their logMAR equivalents, the overall mean reduction in VA was 0.16 units ± 0.49, which is comparable to the aforementioned studies.A few studies specified the degree of vision loss or gain based on the change in Snellen VA from baseline to postoperative period. Christakis et al. looked at 114 eyes in 114 patients who were randomly assigned to Baerveldt shunt placement and, after three years of follow-up, found that approximately 18% of patients lost 3-4 lines of Snellen VA and approximately 23% lost ≥ 5 lines of Snellen VA . This suTwo other study series distinguished a loss of 2 or more Snellen lines after Baerveldt placement, with rates ranging from 30% to 46% over a follow-up period of one to five years –7, 10–12The Tube Versus Trabeculectomy (TVT) and Ahmed Baerveldt Comparison (ABC) studies attempted to identify causes of vision loss –7, 10–12In the ABC studies, Barton et al. separated patients into 4 strata: Stratum 1: primary glaucoma with previous surgery, Stratum 2: secondary glaucoma (excluding neovascular and uveitic glaucoma), Stratum 3: neovascular glaucoma, and Stratum 4: uveitic glaucoma . At one- unexplained vision loss. While this has not been characterized with respect to aqueous shunt surgery, several published studies have explored the risk of snuff-out after trabeculectomy [While these prior studies explored reasons for vision loss, this paper sought to identify and predictulectomy , 19–24. One speculation as to why split fixation may be a risk factor for snuff-out is the fact that fixation is supplied by the maculopapular fiber bundle, which is often a late portion of retinal nerve fiber layer to be compromised in glaucomatous optic nerve damage. Therefore, the presence of split fixation may suggest that the underlying glaucoma is often so advanced that loss of any remaining fixation points may occur more easily, especially after a traumatic event such as glaucoma surgery, and thereby lead to snuff-out postoperatively.Limitations of this study include the flaws inherent in a retrospective study, including the nonrandomization of patients and the lack of regular HVF examinations. The decision to perform tube shunt placement was made by the treating physician on the basis of overall patient status but was not strictly standardized. Of the 247 eyes included in this study, only 186 eyes had undergone preoperative HVF testing. Visual fields were not performed in the remaining 61 patients due to poor preoperative visual acuity (≤20/200) and/or excessively high IOP necessitating urgent tube placement. In addition, because snuff-out is an uncommon phenomenon, it was necessary to include both eyes from some patients to gain proper statistical power for this retrospective review. However, none of the 18 eyes with unexplained long-term vision loss were from the same patient. Moreover, there was no statistically significant difference in the results when only one eye of these patients was randomly selected for the analysis. Finally, there may have been a bias toward underestimating the incidence of snuff-out if surgeons suspected this possibility in patients with advanced vision loss and therefore did not operate with equal frequency on these patients.In conclusion, our findings suggest that transient vision loss is common and takes an average of 2.5 months to recover following Baerveldt placement. Long-term vision loss occurs less commonly but still comprises a significant proportion of patients and should thus be included in patient education about the risks and benefits of surgery. Snuff-out, or severe unexplained long-term vision loss, was an uncommon phenomenon, occurring in 2.4% of cases after Baerveldt implantation. Poorer POD1 VA may herald a worse prognosis in the long term, and the level of visual field loss, especially the presence of inferonasal split fixation on preoperative HVF, may help identify patients at the highest risk for snuff-out. The results of this study aim to elucidate the course of vision loss and recovery after Baerveldt placement and to better identify risk factors for unexplained long-term vision loss and snuff-out.This is the first study that seeks to explore the phenomenon of snuff-out, or unexplained severe long-term vision loss, after aqueous tube shunt placement. Predictive risk factors for snuff-out are the degree of vision loss on POD1 and the presence of split fixation involving the inferonasal quadrant on preoperative visual field testing. Long-term vision loss is not uncommon after Baerveldt tube shunt implantation, with snuff-out occurring in 2.4% of cases in this study.


The aim was to investigate the associations between mental disorders and three different measures of labour-market marginalisation, and differences between native Swedes and immigrants.The study comprised 1,753,544 individuals, aged 20–35 years, and resident in Sweden 2004. They were followed 2005–2011 with regard to disability pension, sickness absence (≥90 days) and unemployment (≥180 days). Immigrants were born in Western countries , or in non-Western countries . Mental disorders were grouped into seven subgroups based on a record of in- or specialised outpatient health care 2001–2004. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed by Cox regression models with both fixed and time-dependent covariates and competing risks. We also performed stratified analyses with regard to labour-market attachment.Individuals with mental disorders had a seven times higher risk of disability pension, a two times higher risk of sickness absence, and a 20% higher risk of unemployment than individuals without mental disorders. Individuals with personality disorders and schizophrenia/non-affective psychoses had highest risk estimates for having disability pension and long-term sickness absence, while the risk estimates of long-term unemployment were similar among all subgroups of mental disorders. Among persons with mental disorders, native Swedes had higher risk estimates for disability pension  than Western immigrants  and non-Western immigrants , slightly higher risk estimates for sickness absence  than Western , and non-Western  immigrants but lower risk estimates for unemployment  than Western  and non-Western immigrants . There were similar risk estimates among sub-regions within both Western and non-Western countries. Stratification by labour-market attachment showed that the risk estimates for immigrants were lower the more distant individuals were from gainful employment.Mental disorders were associated with all three measures of labour-market marginalisation, strongest with subsequent disability pension. Native Swedes had higher risk estimates for both disability pension and sickness absence, but lower risk estimates for unemployment than immigrants. Previous labour-market attachment explained a great part of the association between immigrant status and subsequent labour-market marginalisation. Mental disorders are due to the usual early age of onset, the strong impact on occupational functioning, the relative frequent and increasing occurrence, and the high prevalence of relapses one of the main causes of marginalisation on the labour market –3. LabouSweden has since the 1970s, like many other Western countries, experienced increasing immigration. This increase is foremost due to non-Western immigrants from Africa, Asia and South-America, consisting mainly of refugees and relatives seeking reunification, with a more diverse cultural and ethnic origin than the native population . Non-WesThe aim was to investigate: 1) the associations between mental disorders, divided into seven subgroups, and three different measures of labour market marginalisation, i.e. disability pension, sickness absence and unemployment and 2) if there were differences regarding labour market marginalisation between immigrants, split in seven subgroups based on region of birth, and native Swedes.n = 47,027), and individuals with missing information on region of birth (n = 319). A total of 1,753,544 individuals met the inclusion criteria.The study base comprised 1,800,890 non-pensioned young adults between 20 and 35 years of age who were resident in Sweden at 31st of December in 2004. Excluded from the analyses were individuals with granted disability pension before 2004  Statistics Sweden: age, sex, educational level, family composition, type of living area, date of emigration, labour market attachment and days of unemployment; 2) The Social Insurance Agency: sickness absence and disability pension (date and number of days) from 1994 and onwards; 3) The Swedish National Board of Health and Welfare: date and cause of in- or specialised outpatient health care; date and cause of death.Region of birth was grouped according to the following regions: 1) Sweden; 2) Western countries, mainly consisting of labour immigrants: a) Nordic countries, b) EU except Sweden, Finland and Denmark, c) Europe outside EU excluding former Soviet Union and Nordic countries and d) North America/Oceania, and 3) non-Western countries mainly consisting of refugees and individuals seeking family reunification: a) Africa, b) Asia, including former Soviet Union and c) South-America.The exposure measure was defined as having a mental disorder, measured as a main diagnosis of a mental disorder from in- or specialised outpatient health care between 2001 and 2004. All diagnoses were defined by the corresponding codes of the International Classification of Diseases (ICD), version 10. Mental disorders were classified according to codes F00–99, and somatic disorders were classified according to all remaining codes. When dividing mental diagnoses into subgroups, the chronologically last main diagnosis was used. We divided the diagnoses into: affective disorders (ICD-10 codes F30–39), behavioural, emotional and developmental disorders , organic disorders/mental retardation , personality disorders (ICD-10 code F60), schizophrenia/non-affective psychoses (ICD-10 codes F20-F29), neurotic/stress-related/somatoform disorders (ICD-10 codes F40-F48) and substance abuse disorders (ICD-10 codes F10-F19) [The cohort was followed from 2005 to 2011 with regard to the following measures of labour market marginalisation: 1) Disability pension, 2) Long-term sickness absence, defined as ≥90 annual net days of sickness benefit payed by the Swedish Social Insurance Agency during the follow-up period, and 3) Long-term unemployment, defined as ≥180 annual days registered as full time unemployed at the Swedish Public Employment Service during the follow-up period.Covariates in the analyses were: I) Socio-demographic factors: sex, age, family composition, type of living area, educational level  with 95% confidence intervals (CIs) were computed for individuals with mental disorders between 2001 and 2004, both dichotomised and categorised into seven subgroups as stated above, in comparison to individuals without mental disorders during the specified time period. Furthermore, the analyses compared groups of individuals originating from three major regions, divided into 7 sub-regions, with regard to a record of previous mental disorder. Death and emigration were modelled as competing events in all regression models. In the analyses with regard to long-term sickness absence and long-term unemployment as outcome measures, also disability pension was modelled as a competing event. Information on somatic disorders during baseline and the follow-up period was introduced as a dichotomised time-dependent covariate in analyses regarding all outcome measures. Parts of the analyses were also stratified by labour market attachment during 2004. In the analyses with regard to long-term sickness absence and disability pension as outcome measures, information on long-term unemployment during baseline and during the follow-up period was additionally introduced as a time dependent covariate. In the analyses with regard to long-term unemployment as the outcome measure, long-term sickness absence was modelled as a time dependent covariate in addition. Furthermore, tests for effect modification between mental disorders and immigrant status, regarding all three outcome measures, were applied through the partial likelihood ratio test . All anaThe cohort included 1,480,483 native Swedes (84.4%), 131,486 Western immigrants (7.5%) and 141,575 non-Western immigrants (8.1%). Among native Swedes, there was a higher proportion of men compared to women, while the opposite was found among both Western and non-Western immigrants (Table p = 0.004), sickness absence (p < 0.001) and unemployment (p < 0.001).The univariate analyses showed a diverging pattern for the associations between mental disorders and the three different measures of labour market marginalisation; disability pension (HR: 11.6), long-term sickness absence (HR: 3.6) and long-term unemployment HR: 2.2) , long-term sickness absence  and long-term unemployment  than individuals without mental disorders. Individuals with personality disorders or schizophrenia/non-affective psychoses had highest risk estimates for having disability pension and long-term sickness absence, while the risk estimates of long-term unemployment were similar for all subgroups of mental disorders. Among individuals with mental disorders, the risk estimates for disability pension were lower among immigrants compared to native Swedes. Native Swedes with mental disorders had a slightly higher risk for long-term sickness absence compared to both Western and non-Western immigrants with mental disorders. There was a gradient showing that immigrants from non-Western countries had the highest risk estimates for long-term unemployment followed by immigrants from Western countries and native Swedes, regardless if they had mental disorders or not. The risk estimates were rather similar between sub-regions in both Western and non-Western countries, however with some minor exceptions. The stratified analysis showed that immigrants had higher risk estimates than native Swedes for having disability pension and long-term sickness absence in a cohort of individuals having gainful employment, but lower risk estimates of both long-term sickness absence and disability pension in a cohort of individuals without gainful employment.The link between mental disorders and having an unstable position on the labour market is well established in earlier research , 24. ThiImmigrants from non-Western countries had highest rates of both mental and somatic disorders in 2001–2004. Based on these findings higher risk estimates for subsequent labour market marginalisation based on medical assessments (i.e. sickness absence and disability pension) can be anticipated. Still, our findings suggest the contrary, namely lower risk estimates for both disability pension and long-term sickness absence among immigrants from non-Western countries compared to natives. Treatment before granting of disability pension due to mental disorders has been shown to differ between native Swedes and foremost immigrants from non-Western countries . MoreoveAdjustment for sociodemographic factors reduced the differences in risk estimates between immigrants and native Swedes regarding all outcome measures. Also other studies have reported that sociodemographic factors are of great importance when explaining differences in rates of disability pension between immigrants and the native population , 31. TheAs mentioned above, the construction of the social insurance system might be one of the explanations to discrepancies in labour market marginalisation between native Swedes and immigrant groups. Differences in pathways to different measures of labour market marginalisation may thus be a consequence of the regulations within the social insurance system in Sweden. Moreover, stratification by previous labour market attachment showed that immigrants, in comparison to native Swedes, had decreasing risk estimates for having sickness absence, the more distant they were from having gainful employment. Income from work is a prerequisite for having sickness absence. In Sweden it is, however, possible to be granted basic levels of disability pension and unemployment benefits without earlier income from work. In spite of that, we showed that immigrants had decreasing risk estimates compared to native Swedes also regarding disability pension and unemployment. This may be due to the fact that the basic level of both unemployment benefit and disability pension is on a rather low level, resulting in the fact that some individuals do not seek those benefits after all. Another explanation might be that immigrants do not have adequate knowledge on the structure of the social insurance system, at least during the first years in the new country.Strengths of this study include the use of nationwide high quality data from Swedish registers providing large study populations with practically no loss to follow-up –35. AnotThis study had also some limitations. Mental disorders were defined by in- or specialised outpatient care, which mostly reflects medically more serious mental disorders. Individuals treated in primary health care could not be included. In this study immigrants were divided into groups regarding regions of birth country. Those groups are, however, heterogeneous and differences between individuals within these groups are likely to exist. Although the analyses were adjusted for previous labour market marginalisation and stratified for labour market attachment, there might still be remaining residual confounding due to the complicated bidirectional causal pathways between marginalisation on the labour market and mental disorders, reported in previous studies , 36.Mental disorders among young adults were associated with an increased risk of all three measures of labour market marginalisation, strongest with subsequent disability pension. Native Swedes had higher risk estimates for both disability pension and sickness absence, but lower risk estimates for unemployment compared to both Western and non-Western immigrants, indicating that processes towards labour market marginalisation might differ between native Swedes and immigrants with mental disorders. Previous labour market attachment explained a great part of the association between mental disorders, immigrant status and labour market marginalisation. In studies comparing immigrants with natives with regard to subsequent labour market marginalisation, it is important to consider different measures of subsequent labour market marginalisation in order not to underestimate the consequences of mental disorders. It is, however, also important to consider previous labour market attachment in order not to overestimate the differences between immigrants and native Swedes.


We examined the impact of extreme temperatures on mortality in 12 counties across Hubei Province, central China, during 2009–2012. Quasi-Poisson generalized linear regression combined with distributed lag non-linear model was first applied to estimate county-specific relationship between temperature and mortality. A multivariable meta-analysis was then used to pool the estimates of county-specific mortality effects of extreme cold temperature (1st percentile) and hot temperature (99th percentile). An inverse J-shaped relationship was observed between temperature and mortality at the provincial level. Heat effect occurred immediately and persisted for 2–3 days, whereas cold effect was 1–2 days delayed and much longer lasting. Higher mortality risks were observed among females, the elderly aged over 75 years, persons dying outside the hospital and those with high education attainment, especially for cold effects. Our data revealed some slight differences in heat- and cold- related mortality effects on urban and rural residents. These findings may have important implications for developing locally-based preventive and intervention strategies to reduce temperature-related mortality, especially for those susceptible subpopulations. Also, urbanization should be considered as a potential influence factor when evaluating temperature-mortality association in future researches. Climate change has broad direct or indirect impacts on the vast majority of the world’s population, thus it is widely considered as the greatest global threat for human health in the 21st century2Temperature-mortality relationships have been described as U-, V-, W, or J-shaped in numerous previous epidemiological studies5678947111314Studies investigating temperature–mortality associations started later in mainland China, compared with those conducted in high-income countries/regions. In recent years, mortality impact assessment of extreme temperatures has gotten increasing attention in China. Furthermore, a number of multi-city studies have been conducted across a large span of latitudes and various climate characteristics68121618A Chinese national analysis divided the selected 66 communities into northeast, north, northwest, east, central, southwest, and south China, and demonstrated distinct temperature-mortality relationships in the seven geographical regionsIn this study, we conducted a provincial analysis from 12 urban and rural counties across Hubei Province in China, to assess the impact of extreme temperatures on mortality, and explore the potential differences in cold- and heat- related mortality effects between urban and rural counties at the provincial level. The findings may contribute to developing effective adaptation and intervention strategies in response to climate change for local government and the public in Hubei, China.In this epidemiologic investigation, we examined temperature-mortality relationships using consistent statistical methods in 12 counties across Hubei Province of central China during 2009–2012. The analysis identified distinct exposure-response and lag-response patterns at the provincial level in mortality effects of high and low temperatures, which may differ greatly in subgroups stratified by some individual factors, such as age, education attainment and place of death. Further, our data revealed some slight differences in heat- and cold- related mortality effects on urban and rural residents. These findings may have important implications for public health policies in Hubei Province, China.Based on the 12 selected counties included in our study, we found an overall inverse J-shaped association between mean temperature and mortality at the provincial level. However, temperature-mortality associations varied greatly from a worldwide perspective4721142324As shown by a global analysis using data from 384 locations in 13 countries and regions11Consistent with most previous findings, our study demonstrated that heat effects appeared immediately and usually lasted only 2 or 3 days, whereas cold effects were 1–2 days delayed but more long-lasting. In our analyses assessing mortality effect of temperature, 21 days was determined as the maximum lags, since using short lags cannot completely capture the effects of both low and high temperatures9In this study, several potential individual-level modifiers were identified in cold- and heat-related mortality impacts, and the differences of these effect estimates between subgroups mainly focused on the effects of cold temperatures . We foun272829181432615Education attainment is regarded as one of the most important factors reflecting one’s overall socioeconomic status. A number of previous studies28343515Previously, persons living in urban counties were identified as more vulnerable to extreme heat, which was attributed to the urban heat island effect and high population densitySeveral limitations of this study should be noted. Firstly, we did not adjust for air pollution in the analysis due to data unavailability. A number of recent investigations have revealed that both cold- and heat-related mortality risks kept almost unchanged with and without air pollutants being controlled7302014This study suggested that short-term exposures to both low and high temperatures were associated with increased mortality in Hubei, China, while the cold effect was more pronounced and long-lasting than the heat effect. Females, the elderly, and those with high education attainment and dying outside the hospital were more vulnerable to extreme temperatures. Also, urbanization should be considered as a potential influence factor when evaluating temperature-mortality association in future epidemiological studies. These findings may have important implications for developing locally-based preventive and intervention strategies to reduce temperature-related mortality, especially for those susceptible subpopulations.2. DSPs distributed across Hubei Province included twelve counties, which were selected as the provincially representative sample in the present studyThe National Disease Surveillance Points (DSPs) System of China established in 1980 was administrated by the Chinese Center for Disease Control and Prevention (China CDC). The system during the study period consisted of 161 nationally representative urban and rural sites from 31 provinces covering 78 million people, roughly 6% of Chinese populationCounty-specific daily non-accidental mortality data from January 1, 2009 through December 31, 2012 were obtained from the National Death Registration Reporting Information System of DSPs. Generally, for every death case, the Medical Certificate of Cause of Death must be completed in a very standardized form by the hospital or community/village doctor with the practicing physician qualification. The death information can be then registered into the network reporting system of the local CDC. Non-accidental causes of deaths were categorized using codes A00–R99 from the International Classification of Diseases 10th Revision (ICD–10). Daily non-accidental deaths were also divided into several subgroups stratified by gender, age , education attainment , and place of death .http://cdc.cma.gov.cn). Meteorological data for each community were obtained from one basic-reference surface weather observation station or automatic station. Limited by data availability and based on the assumption that weather data would not vary substantially within a city, we used meteorological data of Wuhan City for two of her urban districts (Jiangan and Qiaokou), and Xiaogan City for two of her rural counties (Yingcheng and Yunmeng).County-specific daily meteorological data on maximum, mean, and minimum temperature and relative humidity for the same period were obtained from the China Meteorological Data Sharing Service System . Cumulative temperature–mortality associations for different days of lag, such as lag 0–2, lag 0–7 and lag 0–14, can also be obtained by conducting similar procedures.In the second stage, we conducted a multivariate meta-analytical modelTo check the main findings of this study, sensitivity analyses were performed by changing df (3–6 per year) in the smoothness of time. We also changed df (4–6) for humidity, and varied the maximum lags from 22 to 28 days in the temperature-DLNMs.p < 0.05 were considered statistically significant. All the analyses were performed with the R software . County-specific temperature–mortality associations were estimated using R package “dlnm”. Multivariate meta-analysis was conducted using package “mvmeta”.The statistical tests were two-sided, and effects of How to cite this article: Zhang, Y. et al. Impact of temperature on mortality in Hubei, China: a multi-county time series analysis. Sci. Rep.7, 45093; doi: 10.1038/srep45093 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.