Acute cerebellar ataxia (ACA) is a relatively common neurological disease in children. Most common types of ACA are acute post-infectious (APCA) and acute disseminated encephalomyelitis (ADEM). Less common but important causes include opsoclonus-myoclonus syndrome (OMS) and acute cerebellitis. Cerebellar neoplasms and acute hydrocephalus are additional causes of paediatric ataxia. APCA is the most common cause of ACA in children, comprising about 30-50% of total cases. This is a report about an immunocompetent 4-yrs-old male affected by APCA, due to co-infection by human herpesvirus-6 (HHV-6) and adenovirus, with symptoms mimicking myositis. Acute cerebellar ataxia (ACA) is a relatively common neurological disease in children.Common causes are acute post-infectious ataxia (APCA), intoxications and acute disseminated encephalomyelitis (ADEM). Less common but important causes include opsoclonus-myoclonus syndrome (OMS) and acute cerebellitis. Cerebellar tumours and acute hydrocephalus are rare causes of paediatric ataxia.APCA is the most common cause of acute ataxia in children, comprising about 30-50% of the total cases . The mosHere we present the case of a patient with acute onset of weakness and muscle pain, evolving into cerebellar ataxia, due to adenovirus and human herpesvirus 6 (HHV-6) co-infection.A previously healthy 4-year-old boy came to our emergency department (ED) for the acute onset, during previous 12 hours, of lower limbs pain, associated with difficulties in maintaining upright posture up to complete refusal of walking. The pain was not modified by treatment with NSAID . Parents reported a febrile upper airways infection approximately 15 days before, followed by skin rash spread. Trauma was denied. The patient looked ill, with normal vital signs, afebrile; general physical examination was negative. The first neurological examination showed muscle weakness and upper and lower extremities hypotonia, brisk tendon reflexes at limbs, either antigravity tests, autonomous sitting and position were impossible, normal speech pattern. The child refused walking and he was not able to attend his normal activities. The palpation of muscle bellies showed tenderness at the proximal lower limb and the passive mobilization of the knee and hip joints caused pain.Mycoplasma pneumoniae, varicella zoster virus (VZV) and enterovirus in CSF were negative. Serologic analysis on blood sample resulted positive for adenovirus and HHV6 – DNA (specific IgA).The patient was hospitalized to complete diagnostic investigations. Lab tests at admission were normal . Research by polymerase chain reaction (PCR) on throat swab showed positivity for adenovirus-DNA. Abdominal and hip joints ultrasound as well as pelvis and lower limbs X-ray were negative. Lumbar puncture was performed on the day of admission: cerebrospinal fluid (CSF) analysis and culture resulted negative. Research for oligoclonal IgG bands by immunoblot appeared positive both in cerebrospinal fluid and in serum sample. Research by PCR for parvovirus B19, adenovirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus 1 and herpes simplex virus 2, HHV-6, Brain and spinal cord magnetic resonance imaging (MRI) with and without contrast, STIR Total Body MRI and electrophysiological investigations  resulted to be negative.Five days after admission the child was able to stand and walk with support and cerebellar ataxic gait was evident as well as fine tremors and finger-to-nose test frenage. A spontaneous and progressive recovery of motor activity up to a complete normalization occurred around 20 days after. On the base of performed investigations and clinical evolution, it was possible to make a diagnosis of APCA.Mycoplasma, Parvovirus B19 [We present a pediatric case of APCA due to co-infection of HHV-6 and adenovirus with acute onset of weakness and muscle pain at the first visit in ED. APCA is an immune-mediated neurologic disease, relatively common in children, due to an inflammatory cerebellar process. Generally, gait and truncal ataxia with dysmetria are common presenting features. APCA is usually the result of a post-infectious inflammation: this autoimmune phenomenon could be triggered by an inciting infection (or immunization), with the subsequent production of autoantibodies which cross-react with cerebellar epitopes ,3. Childirus B19 ,8 and, airus B19 . CSF exairus B19 .The most severe manifestation of this pathological spectrum is represented by cerebellitis, characterized by acute neurological and systemic symptoms associated with neuroimaging cerebellar abnormalities ,10 and mOur study reports for the first time a myositis-like onset , in a patient who later developed a cerebellar ataxia. This case suggests that ACA should be considered in children who had primary muscle pain and weakness and in a second time ataxia and/or other acute neurological symptoms.We believe that this manuscript could be useful for the management of patients with muscle pain and hypotonia with previous history of respiratory tract infection. APCA should be always suspected, particularly in presence of cerebellar symptoms.Written informed consent was obtained from the patient guardian for publication of this Case Report and any accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal.


Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier , were more likely to know partner’s HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals  compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reports that there were ~260,000 children newly infected with HIV in 2012, most in sub-Saharan Africa . In 2011th Millennium Development Goal (MDG5) aims to reduce maternal mortality ratio by 75% between 1990 and 2015 and targets a 90% facility delivery rate to achieve this goal [Every year, ~300,000 maternal deaths occur worldwide from conditions that are largely preventable or treatable -12. NearThe 2008 Kenya Demographic Health Survey (KDHS) reported that only 43% of mothers delivered in a health facility, a rate similar to 15 years earlier, demonstrating stagnant progress for this indicator . The natEnsuring that HIV-infected women deliver in health facility is therefore crucial to optimize maternal outcomes and to reduce risk of infant HIV infection. The aim of this nested study was to determine correlates of facility delivery among HIV-infected mothers in a rural community in Nyanza Province, western Kenya. Nyanza has the highest HIV prevalence (14.9%) in the country and is one of the regions with low rates (44%) of facility delivery ,18. Use This analysis utilized data obtained from a cross-sectional study of women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC) Health and Demographic Surveillance System (HDSS) area who delivered an infant within a year prior to the survey. The KEMRI/CDC HDSS area is located northeast of Lake Victoria in the Nyanza Province of western Kenya . The HDSThe methodology of the parent study has previously been described . A list Outcomes of interest included self-report of place of delivery. Cofactors assessed for place of delivery included age, education level, marital status, utilization of antenatal care (ANC), use of maternal and infant ARVs, satisfaction with care provided during delivery and knowledge of partner HIV status. Socioeconomic status was assessed by using indicators such ownership of mobile phones, radio, bicycle, cattle and monthly family income. Standardized questions were used to quantitatively measure HIV-related stigma and discrimination . We evalAnalyses were restricted to women self-reporting HIV-positive status or HIV-negative status. Those who reported not knowing their status, and those who reported they were negative but who were known to be HIV-positive through prior HBCT, were excluded. STATA version 10  was used to analyze data on rates and correlates of facility delivery and association of facility delivery with use of maternal and infant antiretrovirals. We used Pearson’s Chi square or Fisher’s exact tests to compare categorical variables, and t-tests were used for continuous variables. Multivariate logistic regression was conducted using covariates statistically associated (p < 0.05) with facility delivery in univariate analysis.Approval for the study was obtained from the Kenya Medical Research Institute (KEMRI) Ethical Review Committee (ERC), and from the Human Subjects Division at the University of Washington. Authorization was also obtained from Provincial Medical Officer, Nyanza and the District Medical Officers of Health. Study participants provided written informed consent to be interviewed and to have their survey data linked to their HDSS record.Between February and June 2011, we enrolled 216 women who self-reported they were HIV-positive (173 from the HIV-positive HBCT sample and 43 from the random sample) and 318 women from the non-HBCT areas who self-reported being HIV-negative.Among the 216 HIV-infected women, most (89.8%) were married and 51.9% had received at least primary level education  were married, 48% had received at least primary level education, 74.2% owned a radio and 50.4% a bicycle  delivered at health facilities. HIV-infected women who delivered at health facilities were more likely to have completed primary education  and be of higher socioeconomic status compared to those with non-facility delivery  and  , be of lower parity , more likely to report having been very satisfied with care provided during delivery  and know the HIV status of their partner  than those with non-facility deliveries. There was a trend for women with facility deliveries to be more likely to use maternal antiretroviral drugs  compared to women with non-facility delivery. The proportion of women with history of prior pregnancy loss, who attended antenatal clinic, and used infant antiretroviral drugs did not differ between mothers who had facility versus non- facility deliveries. Measures of value and morality-related stigma and enacted stigma or discrimination did not differ by place of delivery.In multivariate analysis, earlier initiation of antenatal care  and knowledge of partner HIV status  remained independently associated with facility delivery among HIV-infected women.Among HIV-infected women, cost of services was the most common (42.8%) reason given for women not giving birth at health facilities followed by perceived distance to facility (18.8%) and fear of harsh treatment by health providers (15.2%). Other reasons given were fear of HIV testing at health facility (2.9%), rapid labor so that delivery occurred before reaching the facility (2.9%), lack of transport (2.2%), perceptions that facilities were closed at night (1.4%) and fear of caesarean section (1.1%). Preference for traditional birth attendant was cited as reason for non-facility delivery in only 0.7% of responses.To understand whether HIV-infected women had any determinants of facility delivery distinct from HIV-uninfected women, we assessed cofactors for facility delivery among 318 women from the random sample who reported they were HIV-uninfected. Of these, 127 (39.9%) delivered in a health facility. Similar to findings among HIV-infected women, HIV-uninfected women who delivered at health facilities were more likely to have completed primary education , and be of higher socioeconomic status compared to those with non-facility delivery  and fewer number of children  remained independently associated with facility delivery among HIV-uninfected womenSimilar to HIV-infected women, cost of services was the most common (38.6%) reason given by HIV-uninfected women for not giving birth at health facilities followed by perceived distance to facility (16.8%). Other reasons given were rapid labor so that delivery occurred before reaching the facility (10.5%), fear of harsh treatment by health providers (10.5%), fear of HIV testing at health facility (3.2%), perceptions that facilities were closed at night (2.7%) and fear of caesarean section (1.8%). Lack of awareness of benefits of facility delivery was cited as a reason in 3.2% of responses.In this community-based study, we found that only 46.8% of HIV-infected and 39.9% of HIV-uninfected women delivered in a health facility. HIV-infected women stated that cost, distance, and fear of harsh treatment were primary disincentives for facility delivery, with <3% stating that fear of HIV testing was a disincentive. Among HIV-infected women, knowledge of partner HIV status, higher sociodemographic and educational status, and earlier ANC attendance were associated with facility delivery, however, markers of stigma were not. We identified specific groups of women at risk for non-facility delivery, and this may inform interventions to promote facility delivery. In contrast to some previous studies, we did not find that proportions of HIV-infected women who delivered at health facilities were lower than those of HIV-uninfected women ,22. CofaThe proportion of HIV-infected women who delivered at facility, though slightly higher than among HIV-uninfected women assessed in the same survey, was low and similar to that reported for women in general population in Nyanza Province, the region where the study was conducted . Rates oAmong HIV-infected women, facility delivery offers an important opportunity to support PMTCT. The 2011 UNAIDS Global Plan for eliminating new HIV infections among children requires that 90% of HIV-infected women use perinatal antiretroviral drugs . FacilitHIV infected-women who knew the HIV status of their partner were more likely to deliver in health facilities. This suggests a potential role for couple HIV counseling and testing to increase uptake of maternal child health services. Our findings are consistent with studies showing improved uptake of PMTCT interventions with male partner involvement ,25. KnowIn our study, women of lower economic status were less likely to deliver at health facilities, perhaps due to insufficient finances for transport or facility care. Higher rates of facility delivery have been reported with abolition of user fees for maternity services in several African countries -31. In JConsistent with other studies, we found that higher education levels among women were associated with facility delivery irrespective of HIV status -44. In tmHealth technology to promote earlier antenatal care and facility delivery.Most women in our study made at least one ANC visit providing opportunity to interact with health workers and learn the importance of facility delivery. We found that HIV-infected women who initiated antenatal care earlier were more likely to deliver at health facilities, consistent with some previous studies ,45. EarlIntriguingly, rates of facility delivery among HIV-infected did not differ by stigma measures, marital status, prior pregnancy loss or maternal age. Fear of HIV-related stigma and discrimination has been reported to discourage HIV-infected mothers from delivering in health facilities . The proOur study has several strengths. The population-based approach allowed us a unique opportunity to access mothers who did not utilize MCH services; these mothers would have been missed if the study had been facility-based. Working within the HDSS area where home-based HIV counseling and testing had been conducted enabled oversampling of HIV-infected women, providing an opportunity to explore HIV as a correlate of facility delivery with a relatively small sample size. Limitations of the study included dependency on self-report for place of delivery and the cross-sectional design. Most women did not know monthly family income and surrogate measures such as ownership of phones or radios that vary in costs may be a suboptimal proxy for economic status.The low utilization of skilled care at birth poses a serious challenge to attainment of the 5th Millennium Development Goal and of the 2015 Global Plan goal to eliminate pediatric HIV. Our findings suggest that promoting earlier antenatal care and engaging partners may contribute both to decreased infant HIV infection and better general maternal and child outcomes.


Methylobacter) methanotrophs. Both type Ib and type II (Methylosinus/Methylocystis) methanotrophs were adversely affected by the disturbance, but type II methanotrophs showed recovery over time, indicating relatively higher resilience to the disturbance. This revealed distinct, yet unrecognized traits among the methanotroph community members. Our results show that recurring desiccation-rewetting before a recovery in community abundance had an accumulated effect, compromising methanotrophic activity. While methanotrophs may recover well following sporadic disturbances, their resilience may reach a ‘tipping point’ where activity no longer recovered if disturbance persists and increase in frequency.Alternate prolonged drought and heavy rainfall is predicted to intensify with global warming. Desiccation-rewetting events alter the soil quality and nutrient concentrations which drive microbial-mediated processes, including methane oxidation, a key biogeochemical process catalyzed by methanotrophic bacteria. Although aerobic methanotrophs showed remarkable resilience to a suite of physical disturbances induced as a single event, their resilience to recurring disturbances is less known. Here, using a rice field soil in a microcosm study, we determined whether recurrence and frequency of desiccation-rewetting impose an accumulating effect on the methanotrophic activity. The response of key aerobic methanotroph subgroups  were monitored using qPCR assays, and was supported by a t-RFLP analysis. The methanotrophic activity was resilient to recurring desiccation-rewetting, but increasing the frequency of the disturbance by twofold significantly decreased methane uptake rate. Both the qPCR and t-RFLP analyses were congruent, showing the dominance of type Ia/Ib methanotrophs prior to disturbance, and after disturbance, the recovering community was predominantly comprised of type Ia ( Episodic desiccation-rewetting events are a phenomenon occurring in natural and anthropogenic-impacted environments, changing the soil quality  and nutrient concentrations , which in turn, drives microbial turnover in soils . As suchProteobacteria and Verrucomicrobia), with the proteobacterial methanotrophs forming the vast majority of the active population in many terrestrial ecosystems  and type II (families Methylocystaceae and Beijerinkiaceae) methanotrophs. The representative methanotrophs from these subgroups seemingly show different ecological characteristics and possess distinct traits associated to their life strategies (pmoA gene which encodes for a subunit of the particulate methane monooxygenase (pMMO) is conserved, and is congruent with the 16S rRNA gene phylogeny, making the use of the pmoA gene as means to detect and quantify methanotrophs suitable in culture-independent studies of complex environments  in a rice field soil. We aim to determine the response and recovery of aerobic methanotrophs to recurring desiccation-rewetting, and whether the frequency of the recurring disturbance imposed an accumulating effect on the soil nutrient concentrations and methanotrophic activity. We monitored the recovery of the methane uptake rates, as well as the response of the methanotrophic community abundance using group-specific quantitative PCR (qPCR) assays targeting the type Ia, Ib, and II methanotrophs. To follow shifts in community composition over time, we performed a lar soil .v/v methane in air in the dark. Headspace atmosphere in the jar was replenished every 2–3 days to ensure constant air and methane availability. The microcosm was pre-incubated for 14 days to acclimatize to the incubation condition. Desiccation was induced by placing the microcosm under the laminar flow cabinet  overnight (16 h) at room temperature (∼25°C) which caused >94% gravimetric water loss. Desiccation was induced fortnightly and weekly, designated as moderate and severe disturbances, respectively. After desiccation, water loss in the microcosm was replaced by adding the corresponding amount of autoclaved de-ionized water, and methane uptake rate was determined in triplicate. Water loss (∼2–3% gravimetric water content) in the un-disturbed microcosm was also replenished. After methane uptake measurement, the three microcosms  representing independent replicates were destructively sampled. The remaining microcosms were returned to the jar, and incubation was resumed under 10%v/v methane in air in the dark. Depending on the disturbance, methane uptake was measured again after 7 or 14 days to determine the recovery of activity. Microcosm not exposed to desiccation served as a reference. The soil was homogenized before sampling, and stored in aliquots in the -20°C freezer till further analysis.Rice field soil was sampled at the CRA Agricultural Research Council, Rice Research Unit  in May 2010. Soil parameters and rice agricultural practices in the sampling field have been described previously . Soil, sThe methane uptake rate was determined as described before . BrieflyThe resilience index was derived by comparing methane uptake rates in the disturbed and un-disturbed microcosms using the following equation as proposed by 0 and Dx refers to the difference in mean methane uptake rate between the disturbed and un-disturbed microcosms at time 0 (immediately after desiccation) and x, respectively . The RL value ranges from -1 to +1, with a value of +1 indicating full recovery , and values <1 indicating slower rates of recovery. RL value of zero indicates no recovery at time x  in the soil were determined using a SEAL QuA Atro SFA autoanalyzer  as described before  as described in the manufacturer’s instruction.Total DNA was extracted from triplicate microcosms per treatment and time using the PowerSoilTable 1. Each qPCR assay  targeting the methanotrophs  consisted of 10 μl 2X SensiFAST SYBR , 3.5 μl of forward and reverse primers each, 1 μl bovine serum albumin , and 2 μl 100-fold diluted template DNA. Each EUBAC assay  consisted of 7.5 μl 2X SensiFAST SYBR (BIOLINE), 0.75 μl of forward and reverse primers each, 1.5 μl bovine serum albumin , 3 μl 100-fold diluted template DNA, and 1.5 μl DNase- and RNase-free water. Plasmid DNA isolated from pure cultures was used for the calibration curve. Previously, in an initial qPCR run using the same soil, template DNA diluted by a 100-fold gave the optimal target yield , and comparison with an internal standard  to determine the length of the t-RFs was performed with GeneScan 3.71 software (Applied Biosystems).The methodology for the t-RFLP, including the primer concentration, thermal profile, and subsequent comparative gene sequence analysis with a n detail . Brieflyp < 0.01) between treatments and time was performed using ANOVA or t-test as implemented in SigmaPlot v12.5 .The t-RFLP profiles were standardized as described previously , 2014. BFigure 1). Although methane uptake was detected immediately after desiccation-rewetting in the severely disturbed microcosms, eventually reaching values which were significantly higher  than in the un-disturbed microcosms during recovery, methane uptake became adversely affected after four consecutive cycles of desiccation-rewetting . At the final desiccation-rewetting event (cycle 6), methane uptake rate was significantly lower and activity did not recover to levels exhibited in the un-disturbed microcosm. The elevated methane uptake in response to severe disturbance in cycles two and three  is noteworthy, but remains to be fully elucidated. Previous studies showed the remarkable resilience of methanotrophic activity to distinct physical disturbances . However, increasing the frequency of the disturbance from every 14 to 7 days significantly compromise methanotrophic activity.Methane uptake was detected in the un-disturbed microcosms, but ceased after desiccation-rewetting in the moderately disturbed microcosms , showing a decrease of the RL value after four cycles of desiccation-rewetting in the severely disturbed microcosm; in the third cycle, value was negative as anticipated because the recovering methane uptake rate was significantly higher than in the un-disturbed microcosm . NH4+ and PO43- concentrations were negatively affected by the disturbance regime; NH4+ and PO43- concentrations was significantly lower in both the disturbed microcosms , but changes in the total nutrient concentrations were not pronounced over time suggesting that the nutrient pool available remained relatively constant throughout the desiccation-rewetting cycles . However, we cannot completely exclude that nutrient limitation may be a factor restricting the methanotroph population size during the recovery from disturbance. Nevertheless, considering that NH4+ and PO43- concentrations were comparable in both the moderately and severely disturbed microcosms, while the community abundance was significantly affected , suggest that the shift in the methanotroph subgroups were unlikely constrained by nutrient availability . Although the pH was significantly affected by the disturbance  as revealed by the correspondence analysis, the values shifted only within a narrow range of 0.2 and 0.1 units in the disturbed and un-disturbed microcosms, respectively. Hence, we do not anticipate major effects of pH shift on the methanotrophic activity.Desiccation and subsequent rewetting may have caused a carbon/nitrogen flush, mobilizing nutrients from the soil and/or increasing soil nutrients as a result of cell lysis . These nMethylococcaceae (type Ia and Ib) and Methylocystaceae (type II), with the type II methanotrophs (Methylocystis–Methylosinus) being numerically dominant  appears to form the predominantly active population in rice field soils , as well as the total 16S rRNA gene during the recovery from disturbances. The lower detection limit of the qPCR assays was 103–104 copies of target molecule g dry weight soil-1, depending on the assay; in all samples, the pmoA and 16S rRNA gene copies were above the detection limit . The disturbance exerted a differential response among the methanotroph subgroups . The pmoA gene abundances of type Ia and Ib methanotrophs remained relatively stable after moderate disturbance; type Ia pmoA gene abundance being the least responsive to the induced disturbances. In contrast, type II pmoA copies were reduced by approximately two orders of magnitude after both moderate and severe disturbances. In the un-disturbed microcosms, however, type II pmoA gene abundance initially increased  before reaching a stable abundance. Although not appreciably affected by the moderate disturbance, pmoA gene belonging to type Ib methanotrophs significantly decreased by 2–3 orders of magnitude after severe disturbance. The decrease was not statistically significant over time, but the trend indicates that type Ib methanotrophs were negatively affected with increasing desiccation-rewetting frequency . Hence, results showed the differential response in the methanotroph subgroups to recurring desiccation-rewetting (frequency), indicating the inherently different degrees of resilience to the disturbance.The aerobic methanotrophic composition in this rice field soil is well-characterized, comprising of methanotrophs belonging to the families dominant . Howeverld soils . Hence, 4+, PO43-, and pH) as constraints, of which NH4+, PO43-, and pH showed statistically significant correlation  together explaining 34.64% of total variance . Consistent with the qPCR analysis, the ordination revealed that the community composition in the un-disturbed and disturbed microcosms diverged. Besides the t-RFs identifiable from comparison to a pmoA clone library of the same soil . The relative abundance of t-RF indicative for type II methanotrophs (t-RF 245) increased in the un-disturbed microcosm, but the increase was more pronounced after severe disturbance, while type Ia/Ib-related t-RFs (t-RF 515 and 74) were dominant in both the disturbed microcosms . Given that the t-RFLP analysis detects the shift in the relative abundance of the community composition, the increase in type II-related t-RF (t-RF 245) in the severely disturbed microcosm may be caused by the numerical decrease in the type Ib subgroup , while the type Ia subgroup remained relatively constant. Nevertheless, type II pmoA gene abundance was significantly, if not appreciably higher after six consecutive desiccation-rewetting events . In particular, t-RF 515 indicative for Methylobacter (type Ia methanotroph) responded positively to increasing desiccation-rewetting intensity, whereas t-RF 74 indicative for Methylocaldum/Methylococcus (type Ib methanotrophs) formed the majority during the recovery from moderate disturbance, but relative abundance was reduced after severe disturbance . The compositional dynamic indicates a transition in the trajectory of community composition and abundance as the frequency of the desiccation-rewetting event increased. Overall, both the qPCR and t-RFLP analyses were congruent, showing that the recovering community was predominantly comprised of type Ia (Methylobacter), and that although type II (Methylosinus/Methylocystis) methanotrophs were initially adversely affected by desiccation-rewetting, population increased over time.Although changes in community composition may not indicate a change in activity, it can be significantly related to the shift in population size . Shifts ame soil , with thMethylococcus/Methylocaldum) were adversely affected by the frequency of the disturbance. Some Methylococcus/Methylocaldum genotypes are known to be thermotolerant, if not thermophilic, and were isolated from relatively harsh environments . Despite being able to form heat- and desiccation-resistant exospores and/or lipid cysts (Methylocystis sp.) in a rice field soil, potentially eliminating the likelihood of protozoa grazing in reducing type II methanotroph abundance. However, regardless of the increased disturbance frequency, the type II methanotrophs were no longer adversely affected after the initial (cycle 1) desiccation-rewetting event, and showed a relatively stable community with a significant increase in population size over time. This was consistent with a previous study showing recovery (relative abundance) of type II methanotrophs following two alternating dry/wet cycles over 80 days (Figure 4; Unexpectedly, type II methanotrophs were decimated even after moderate disturbance and numbers had not recovered (id cysts , type II 80 days . PossiblTaken together, this study along with previous work  suggest AH and PB conceived and designed the study. AH, AR, and EvdB performed the work, and acquired and analyzed the data. AH wrote the manuscript. EvdB, AR, SK, and PB critically revised and approved the manuscript. All authors are accountable for all aspects of the work.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.


Pan paniscus) to fusions within a zoo facility designed to simulate naturalistic fission-fusion social dynamics. We compared urinary cortisol levels and frequencies of aggression, grooming and socio-sexual interactions between female bonobos while in stable sub-groups and when one “joiner” was reunited with the “residents” of another sub-group. We hypothesized that fusions would trigger increases in aggression and cortisol levels among reunited joiners and resident females. We further predicted that females who face more uncertainty in their social interactions following fusions may use grooming and/or socio-sexual behavior to reduce social tension and aggression. The only aggression on reunion days occurred between reunited females, but frequencies of aggression remained low across non-reunion and reunion days, and there was no effect of fusions on cortisol levels. Fusions did not influence patterns of grooming, but there were increases in socio-sexual solicitations and socio-sexual interactions between joiners and resident females. Joiners who had been separated from residents for longer received the most solicitations, but were also more selective in their acceptance of solicitations and preferred to have socio-sexual interactions with higher-ranking residents. Our results suggest that socio-sexual interactions play a role in reintegrating female bonobos into social groups following fusions. In addition, females who receive a high number of solicitations are able to gain more control over their socio-sexual interactions and may use socio-sexual interactions for other purposes, such as to enhance their social standing.In species with a high degree of fission-fusion social dynamics, fusions may trigger social conflict and thus provide an opportunity to identify sources of social tension and mechanisms related to its alleviation. We characterized behavioral and endocrine responses of captive female bonobos ( Pan paniscus) live in patrilineal social groups characterized by male life-long residency and female dispersal at sexual maturity, typically into groups without other relatives present . W. WAtelescrocuta) , includicrocuta) . Circulacrocuta) .Investigations of fission-fusion social dynamics in bonobos are useful for characterizing the extent of social tension among females, and for exploring how females may reduce or resolve social conflicts. However research on responses of bonobos to fusions is lacking, likely due to difficulties in monitoring changes in group composition in the wild and observing post-fusion events that may involve simultaneous, widely-dispersed social interactions among group members. Several sanctuaries and zoos have facilities designed to incorporate naturalistic fission-fusion social dynamics into ape husbandry (e.g. ), providWe characterized behavioral and endocrine responses of captive female bonobos to fusions within subgroups of varied composition at the Frankfurt Zoo Ape Facility, which was designed to simulate natural fission-fusion social dynamics. In each fusion event, one female subject transferred from one sub-group to another, whose members she had been separated from for varying periods of time. Through this design we were able to examine individual responses to fluctuating social environments. We predicted that fusions may trigger increased social tension among female bonobos, which is likely to be expressed through increases in aggression and cortisol levels. Alternatively, in a species characterized by high levels of female gregariousness and cooperation, fluctuations in female sub-group membership may pose little threat to females. If this is the case, then rates of aggression and cortisol levels should remain similar to baseline conditions before fusions, and should not be influenced by changes in the social environment.Female bonobos may also have behavioral strategies to reduce or avoid the escalation of social conflict following fusions. This hypothesis is consistent with evidence in other species with a high degree of fission-fusion social dynamics that fusions are associated with increases in ritualized social interactions, including embraces among spider monkeys  and chimth, June 2011). The bonobo colony consisted of six mature females (five parous and one nulliparous), three mature males and five immatures. One female (MI) and one male had been transferred into the group one-month prior to the beginning of the study. Two of the mature females (KA and KU) were siblings, but they had been reared in different zoos without contact prior to adulthood. Females were at different reproductive stages during the study  and also had access to several off-exhibit enclosures (from 90–170 cubic meters). The off-exhibit enclosures had fencing on one side, facilitating urine sample collection for hormone analyses. The viewing exhibits and off-exhibit enclosures were connected via remotely controlled sliding gates. Viewing exhibits contained naturalistic climbing structures and were regularly enriched with novel objects and foraging tasks. As another form of environmental enrichment and for management purposes, the colony was sporadically separated into sub-groups in different viewing exhibits for varying periods of time before being reunited, in a process simulating the fission-fusion dynamics of wild bonobos. The colony was fed an assortment of fruits and vegetables twice daily, at 9:30 and 14:00, and also received supplemental snacks throughout the day. To insure that feeding interactions did not influence behavior, all observations occurred outside of feeding times.After initially remaining together for 48 hours, colony members were separated into two sub-groups, each consisting of three adult females with their associated offspring and one to two adult males. Division of individuals into sub-groups typically occurred during feeding times, when individuals could choose to feed in either of the two indoor viewing exhibits. This approach was chosen to approximate fissions among wild bonobos, which often occur when some individuals initiate independent travel to forage in a different location. In order to insure that each sub-group included equal numbers of females representing a range of reproductive states, and also to insure that reunions involved as many different dyadic combinations as possible, bonobos were sometimes assigned to a specific sub-group, which was facilitated by limiting access to various enclosures other than the one containing the designated sub-group. While this additional strategy meant that individuals did not always freely choose their sub-group associations, this strategy was used infrequently during this study and was familiar to the bonobo colony, since the zoo keepers used the same strategy to move individuals between sub-groups and enclosures periodically for management purposes and for cage cleaning.non-reunion days, a focal female was observed in her sub-group without changes in sub-group composition. On reunion days, which occurred within two days of non-reunion days, a focal female (the joiner) was reunited with the members of the other sub-group (the residents) at 8:00, after being separated from them for between 2–15 days (median = 7). In the wild, bonobos can remain in separate parties for hours to weeks following fissions [Each sub-group was housed in one of the indoor viewing exhibits and also had daily access to two off-exhibit enclosures. During separations, sub-groups had limited visual, auditory and olfactory, but no physical contact. We conducted one-hour continuous focal observations daily at 8:00, 10:30 and 12:00. On fissions .As part of their daily husbandry, sub-groups spent between one to two hours each morning in their off-exhibit enclosures while the viewing exhibits were cleaned. As a result, across non-reunion and reunion days the first behavioral observation occurred in the off-exhibit enclosures, while the second and third observations occurred in the viewing exhibits. Reunions occurred in the off-exhibit enclosures, facilitated by a 30 cubic meter passageway connecting the enclosures of the two sub-groups. Reunions only occurred when a joiner voluntarily entered this passageway, from which she could enter the enclosure of the other sub-group. Following the last daily behavioral observation, the joiner was moved back to her original sub-group, restoring the non-reunion sub-group composition. After every female member of one sub-group had been individually reunited with the members of the other sub-group, two new sub-groups were formed using the same procedure described above and the process was repeated until each focal female had been observed on a minimum of two non-reunion and two reunion days.During focal observations we recorded the initiation and direction of grooming and the frequency, direction and outcome of socio-sexual solicitations involving the focal female and any sub-group members. Intra-sexual solicitations were scored when one female faced another and squatted with open legs, presenting her genitals ventrally to the intended target. Solicitations sometimes involved additional behaviors including vocalizations, head movements or thrusting of hips, but these behaviors were rarely performed without ventral genital presentations, and this behavior was used as the decisive measure of a solicitation. Inter-sexual solicitations were identified by: 1) Dorsal or ventral presentation of genitals by females to a male target or 2) Penile displays directed at a female target. The outcome of each solicitation was recorded as: Accepted  or rejected (target ignores the solicitation and often moves away from the solicitor). Following a rejection, if individuals renewed their solicitations this was scored as a new solicitation event. Socio-sexual interactions that were not preceded by a clear solicitation  were excluded from analyses.As a behavioral measure of social tension, we used all occurrence sampling  to recorTo obtain a physiological index of social tension, we measured cortisol levels in urine samples collected non-invasively from focal females and their sub-group members following each focal observation. For husbandry and research purposes, all bonobos had been previously trained to urinate into plastic dishes held by zookeepers outside the fenced section of the off-exhibit enclosures . Providiß-glucuronidase from Escherichia coli . Extracts were purified via solid phase extraction . Steroids were extracted with tert. butyl methyl ether, evaporated and reconstituted in 70% ethanol. Samples were diluted between 1:40–1:240 and run in duplicate in an Enzyme Immunoassay provided by Coralie Munro . Serial dilutions of a pooled urine sample and cortisol standards gave parallel displacement curves. Inter-assay cvs for high and low concentration controls were 3.9% and 8.7%. Intra-assay cvs for high and low concentration controls were 5.2% and 12.0%. To control for variation in fluid intake and output, hormone concentrations were expressed as ng per mg Creatinine (Cr). Creatinine was measured via microtiter plate analysis based on the Jaffé reaction [Samples were stored at -20°C at the Frankfurt Zoo until shipment on dry ice to the Max Planck Institute for Evolutionary Anthropology, Leipzig. Samples were then stored at -20°C until the time of analysis. Samples first went through hydrolysis and solid-phase-extraction in a modification of techniques used by Hauser and colleagues . In brieStatistical analyses were performed in R 3.1.1  using thFor N = 28 joiner and resident pairs (representing N = 14 dyads) that were tested on 3.1 (± 1.3) reunion days, we used GLMMs with binomial error structure to test whether receiving grooming or socio-sexual solicitations from a partner on reunion days (response variables) was associated with the likelihood of directing aggression against the partner, the dominance rank category of the partner (higher/same vs. lower rank category), the number of days that the target had been separated from the partner or whether the partner was the joiner or the resident (test predictors). We also used a GLMM to test whether the likelihood of accepting a socio-sexual solicitation (response variable) was influenced by these same test predictors.In all models, response and predictor variables were transformed when necessary to achieve approximate normality. Individuals, dyads and observation days were included as random effects. In addition, to reduce the possibility of inflated type I error rates, we included in each model random slopes of all fixed effect predictors that varied within individuals and dyads . In thisDuring 96 hours of focal observations (N = 54 non-reunion and N = 42 reunion hours), there were N = 14 aggressive interactions between focal females and sub- group members. (0.10 (± 0.22) per hour on non-reunion and 0.38 (± 0.48) per hour on reunion days). Aggression consisted of non-contact directed displays or charges. On reunion days, all aggression (N = 11 events) occurred between joiners and resident females. However, dyadic aggression did not increase between non-reunion and reunion days  ng/mg Cr vs. 164.82 (± 60.10) ng/mg Cr, likelihood ratio test, Chisq = 2.82, df = 2, P = 0.244, There were N = 159 socio-sexual solicitations involving focal females and other female sub-group members across observation days (0.64 (± 0.48) per hour on non-reunion and 1.41 (± 0.34) per hour on reunion days). The majority of female intra-sexual solicitations  occurred on reunion days, and of those, 75.9% (N = 88) occurred within the first fifteen minutes following reunions. Within pairs, females were more likely to solicit partners on reunion days (57.9 (± 33.1)% of reunion vs. 27.1 (± 21.3)% of non-reunion days, GLMM, estimate ± SE = 1.95 ± 0.54, P < 0.001, On reunion days, patterns of grooming were not explained by any of the test predictors , but patterns of socio-sexual behavior were influenced by the test predictors. Females were more likely to be solicited by partners when they had been separated for longer  of solicitations that they received from joiners, while joiners rejected 42.7% (N = 32) of solicitations from residents  of all possible joiner-resident dyads had at least one socio-sexual interaction. By rejecting a proportion of solicitations, joiners and higher-ranking females received more solicitations for each socio-sexual interaction that they took part in and were able to have more control over the context in which their socio-sexual interactions occurred.Rejections of socio-sexual solicitations by bonobos occur in other captive and field settings , althougIn addition to the established role of female socio-sexual behavior in the gradual acceptance of immigrant females into social groups, this study suggests that socio-sexual behavior continues to play a role in helping to reintegrate resident females into social groups following fusions. Additional studies at other captive facilities designed to simulate fission-fusion social dynamics, along with improved methods for observing fusions in field settings, are critical for determining whether the patterns of post-fusion socio-sexual behavior observed here are widespread across different bonobo groups. A combination of captive and field studies would also be useful for investigating whether variation in behavioral and physiological responses to fusions may reflect variation in the quality of social relationships and correspond with differences in the extent of behavioral coordination and cooperation achieved among females following fusion events.


Based on miRNA and annotated gene expression profiles, the term “coTFBS” was introduced to detect common transcription factors and the corresponding binding sites within the promoter regions of each miRNA and its coexpressed annotated genes. The computational pipeline was successfully established to filter redundancy due to short sequence motifs for TFBS pattern search. Eventually, we identified more convinced TF-miRNA regulatory relations for 225 human miRNAs. This valuable information is helpful in understanding miRNA functions and provides knowledge to evaluate the therapeutic potential in clinical research. Once most expression profiles of miRNAs in the latest database are completed, TF candidates of more miRNAs can be explored by this filtering approach in the future.Noncoding, endogenous microRNAs (miRNAs) are fairly well known for regulating gene expression rather than protein coding. Dysregulation of miRNA gene, either upregulated or downregulated, may lead to severe diseases or oncogenesis, especially when the miRNA disorder involves significant bioreactions or pathways. Thus, how miRNA genes are transcriptionally regulated has been highlighted as well as target recognition in recent years. In this study, a large-scale investigation of novel  Among functional noncoding RNAs (ncRNAs), microRNAs (miRNAs) are tiny molecules ~21–23 nt) with giant roles. miRNAs participate in gene regulation by targeting messenger RNAs (mRNAs) and influencing their stability and the initiation of translation. It is implied that if the expression of miRNA is aberrant, miRNA-mediated gene circuitries will be disordered, resulting in homeostatic imbalance, pathogenesis, and oncogenesis –23 nt wi. High-th cis- and trans-elements is necessary to fulfill the unmet need for locating transcription factor binding sites (TFBSs) within miRNA promoter regions.To further understand upstream regulatory elements controlling miRNA expression, transcription factors (TFs) and their binding sites of miRNA promoters were deciphered by either literature survey or computational prediction –13. By i cis-regulatory analysis of coregulated gene sets was executed to determine overrepresented TFBSs [Since sequence-specific TFs possess DNA-binding domains (DBDs) to recognize specific motifs in miRNA promoter sequences, potential binding sites can be detected by sequence-based computational approaches, for example, position weight matrix (PWM). A position weight matrix  infers a pattern of DNA segment and is widely applied in searching TFBSs –21. Two ed TFBSs , 25. Alted TFBSs  and oPOSed TFBSs  can sear cis- and trans-elements for human miRNA genes based on coexpression strategy. First, we constructed 255 coexpressed gene groups of human miRNAs. Moreover, instead of grapping the upstream regions of pre-miRNAs as promoter sequences, we exploited more concrete human miRNA promoters by following the processes as previously described [Therefore, the purpose of this study is to create a computational pipeline to undertake large-scale investigation of novelescribed . Throughhttp://dx.doi.org/10.1155/2014/623078) in additional file for reference.The latest genomic coordinates of human miRNAs were retrieved from miRBase release 19 . Human mZ-score transformed [In order to determine human genes that are coexpressed with specific miRNA genes, GDS596 record, the Affymetrix gene expression profiles from 79 physiologically human normal tissues, was downloaded from Gene Expression Omnibus (GEO) , 31. Amonsformed .r) is as follows:Xi and Yi denote the expression level of i condition (tissue) of two genes x and y that are calculated for  r, whereas n conditions. Since the value of Pearson's correlation coefficient ranges from +1 (positively correlated) to −1 (negatively correlated), we defined that two genes of interest are coexpressed if their Pearson's correlation coefficient is more than 0.8. Subsequently, coexpressed genes of human miRNAs were determined, and their promoter sequences (1 kb upstream from TSS) were obtained from BioMart of Ensembl release 69 [After the transformation process between two expression datasets, Pearson's correlation coefficient (PCC) was calculated to estimate which annotated genes are coexpressed with specific miRNAs. The formula of Pearson's correlation coefficient .Among them, however, only 255 human miRNAs have more than one coexpressed genes (PCC > 0.8). Moreover, 25 out of 255 human miRNAs have no identified TSSs by following the previous strategy  and haveTheoretically, a group of genes that are coexpressed may be regulated by common transcription factors. Based on this concept, a specific transcription factor binding site located in the promoter regions of most genes in each coexpressed group implies that its corresponding TF is the most possible one controlling the expression of these genes. Here, we introduce the term “coTFBS” which represents the common TFBS of a coexpressed gene group to filter redundant TF candidate of miRNA genes. For example, the “pink rectangle” binding motifs were detected in the proposed miRNA and other four gene promoters in hsa-miR-122 is one of the intergenic miRNAs whose TSS and promoter have been experimentally characterized . Previou trans-activation effect of HNF-4alpha in miR-122 promoter but also the ChIP and EMSA assays to determine HNF-4alpha binding of miR-122 promoter in vitro and in vivo. Moreover, other liver-enriched transcription factors including HNF-1alpha, HNF-3alpha, HNF-3beta, and HNF-6 showed a strong positive correlation with miR-122. The knockout of HNF1A, FOXA1, and FOXA2 by RNAi assay reduces the expression of miR-122, suggesting that these transcription factors may bind to miR-122 promoter and transcriptionally regulate miR-122 [Then, the promoter sequences (1 kb upstream from TSS) of hsa-miR-122 gene and 261 coexpressed genes were collected to identify coTFBSs using Match. The occurrence of putative transcription factors of miR-122 is listed in  miR-122 . ImportaIn addition, the TF binding site of NR1B2 can be found in 226 coexpressed gene promoters. A previous research article published in 1987 indicated that the inappropriate expression of HAP gene  may relate to the hepatocellular carcinogenesis, and hap protein may directly participate in the hepatocellular transformation . It is i cis- and trans-elements if the lower PCC cut-off was used, it may cause the trade-off of specificity when determining miRNA coexpressed genes. For example, hsa-let-7a-1 has no coexpressed gene when using 0.8 PCC value but has 29 coexpressed genes if 0.6 PCC value was applied.For large-scale investigation of human TF-miRNA relations in this study, the expression profiles of human miRNAs and over ten thousands genes from normal human tissues facilitate the acquirement of miRNA coexpressed gene groups. However, the latest usable RT-qPCR miRNA expression data for human normal tissues were published in 2007 . The curZ-score transformed, without using log10 transformation before Z-score standardization. According to the definition of formula, Pearson's correlation coefficient calculates linear correlation between two variables and has an invariant property in statistics. In fact, the log10 transformation tends to alter the original expression patterns and sharply reduces the scale of raw intensity, resulting in unexpected affection of PCC values. Figure S2 illustrates an example of hsa-miR-122 expression patterns with and without log10 transformation. In addition to the high expression level in liver, two obvious peaks of brain and thymus appear in the log10 transformed expression profile of hsa-miR-122. The members of hsa-miR-122 coexpression group also reflect the variation. Unlike more than two hundred coexpression genes by using Z-score transformed expression data, merely five coexpressed genes left based on the cut-off 0.8 PCC value by Z-score and log10 transformed data.It is noteworthy that the normalization process between two raw expression datasets was only Another limitation of TFBS/TF detection depends on present transcription factor binding matrices collected in TRANSFAC. As is well known, sequence motif search of transcription factor binding sites is executed by the Match program according to the matrix information in TRANSFAC library. A specific TFBS in miRNA promoter will not be detected if the corresponding matrix has not been obtained by in vitro selection studies. Here is an example. Unlike hsa-miR-122, miR-224 is upregulated in HCC through epigenetic mechanisms and controls several crucial cellular processes . Wang et cis-elements in promoter regions, the coTFBS strategy was developed to determine more confident TFBSs for human miRNAs. The investigation was restricted by the incomplete expression profiles of present human miRNAs. Once most expression profiles of miRNAs in the latest database are available, TF candidates of more miRNAs can be explored in the future. Furthermore, although more and more ChIP-seq data were generated and were useful to identify transcription factor binding sites [In conclusion, rather than traditional PWM search characterizing putativeng sites –43, the In organisms, not all of ribonucleic acids (RNAs) are translated to proteins. miRNAs are such noncoding RNAs which play critical roles in gene regulation, even if it is generally believed that proteins convey vital information from genes and execute biological functions to maintain life processes. Although target prediction has been the mainstream when studying miRNA functions for a while, researchers start to explore TF-miRNA interactions and study the transcriptional regulation of miRNAs, which are necessary to depict how miRNAs participate in diverse biological processes. To determine putative TFs and TFBSs located in human miRNA promoters, we created a computational pipeline which not only allows large-scale investigation as long as the expression profiles of miRNAs are available, but also filters the redundancy when searching short sequence. This valuable information is helpful in understanding miRNA functions and provides knowledge to evaluate the therapeutic potential in clinical research.The additional file provides the expression profile of hsa-miR-122 and its 261 co-expressed genes among 17 human normal tissues , and full list of TSSs, the number of co-expressed gene groups, and putative TFs of human miRNAs (Table S1-S3).


Toevaluate whether a 2-day International Liaison Committee on Resuscitation(ILCOR) Universal Algorithm-based curriculum taught in a tertiary care hospitalin Liberia increases local health care provider knowledge and skill comfortlevel.Acombined basic and advanced cardiopulmonary resuscitation (CPR) curriculum wasdeveloped for low-resource settings that included lectures and low-fidelitymanikin-based simulations. In March 2014, the curriculum was taught tohealthcare providers in a tertiary care hospital in Liberia. In a qualityassurance review, participants were evaluated for knowledge and comfort levelswith resuscitation before and after the workshop. They were also videotapedduring simulation sessions and evaluated on standardized performance metrics.Fifty-twohospital staff completed both pre- and post-curriculum surveys. The medianscore was 45% pre-curriculum and 82% post-curriculum (p<0.00001). The medianprovider comfort level score was 4 of 5 pre-curriculum and 5 of 5post-curriculum (p<0.00001). During simulations, 93.2% of participantsperformed the pulse check within 10 seconds, and 97.7% performed defibrillationwithin 180 seconds.Clinician knowledge of and comfort level with CPR increased significantly afterparticipating in our curriculum. A CPR curriculum based on lectures andlow-fidelity manikin simulations may be an effective way to teach resuscitationin this low-resource setting. A Nigerian hospital evaluated 366 nurses and confirmed that CPR skills deteriorate rapidly 1 year after training.Sustaining the healthcare system for Liberians is dependent on competent, trained providers. Performing basic and advanced life support is an essential part of a healthcare provider’s scope of practice. Our goal is for BLS at minimum to be an essential skill among Liberian healthcare providers. Our team was invited by a rural, tertiary care hospital in Liberia to educate healthcare providers on resuscitation practices. In this study, we evaluated whether local health care providers had an increase in knowledge and skill comfort level after participating in our educational resuscitation workshop designed for low-resource environments.th.Liberia is a West African country with an estimated population of 4,092,310 in 2014.The curriculum was taught to 75 staff members, 52 of whom completed both the pre-curriculum and post-curriculum surveys and 3 did not fill out either survey. In March 2014, a 2-day resuscitation curriculum based on the International Liaison Committee on Resuscitation(ILCOR) Universal Cardiac Arrest AlgorithmLectures covered basic life support (BLS) and advanced cardiac life support. Terminology was consistent with that of the international Utstein consensus conferences, which has published several recommendations on standardizing CPR educational material content, quality, documentation, and quality control.Students practiced chest compressions on low-fidelity manikins after the BLS lecture. The manikins produce a "click" when a chest compression of adequate depth is delivered. During the afternoons, they practiced megacode scenarios in groups to demonstrate resuscitation knowledge and skills. Simulation scenarios included ventricular fibrillation, respiratory arrest, and pulseless ventricular tachycardia.Participants were surveyed on medical knowledge and comfort levels with skills before and after teaching the curriculum. The written survey contained questions that queried demographic factors, prior resuscitation training, level of medical training, current level of comfort delivering CPR to specific age groups, and knowledge regarding CPR skills. The questions on participants' comfort with performing CPR and knowledge to teach CPR were rated on a Likert scale from 1 to 5. Knowledge questions were multiple choice. Participants were given the same survey at the end of the 2-day workshop to assess improvement in comfort level and resuscitation knowledge.,For the skills component, participants were video recorded during simulation sessions for evaluation of quality metrics, including chest compression fraction (CCF), compression rate, time to chest compression, and time to defibrillation. An instructor present during the simulation provided real-time feedback. The video metrics were later recorded by one team member for analysis. The goal for the time from pulse check to chest compressions is 10 seconds and for pulse check to defibrillation is 3 minutes.. Descriptive statistics for demographics were calculated. Provider comfort level questions were based on a Likert scale of 1 to 5 and were calculated as ordinal data. We used ordered logistic regression to compare the post-curriculum provider comfort level score with the pre-curriculum score of the same individual. Knowledge scores were calculated as a percentage, and overall averages for pre-curriculum and post-curriculum were analyzed with the proportions test. We used logistic regression to evaluate the post-curriculum knowledge score with possible confounders such as the pre-curriculum score, sex, prior CPR education, age, and occupation. Age and pre-curriculum score were calculated as continuous variables. Sex and prior CPR education were classified as dichotomous variables. Occupations were converted to numbers  and calculated as ordinal values. We used a paired t-test to determine if the change between each pre- and post-curriculum knowledge score was statistically significant. A Wilcoxon signed-rank test was used to evaluate comfort level scores pre- and post-intervention. For the video analysis, we used logistic regression to evaluate whether prior knowledge, prior CPR experience, post-training comfort level, age, occupation, or post-training test score had any effect on their ability to pass the competency. One team member reviewed the videos. Any hospital staff member who provided written consent was included in this research. The Johns Hopkins School of Medicine Institutional Review Board gave approval for this study.We used Microsoft Excel for data collection and STATA 12  for statistical analysis. Statistical significance was set as p < 0.05The aggregate median pre-curriculum score was 45%, and median post-curriculum score was 82%. A comparison of pre- and post-curriculum scores by paired t-test showed a 32% increase in scores (p<0.00001). Linear regression analysis of post-curriculum scores suggested that sex, prior CPR education (yes/no), age, and occupation had minimal effects on the post-curriculum scores; none were significant.The aggregate median provider comfort level score was 4 pre-curriculum and 5 post-curriculum. A Wilcoxon rank test showed that the increase in provider comfort level after the curriculum was statistically significant (p<0.00001). Ordered logistic regression analysis showed that prior CPR education, age, sex, occupation, and post-curriculum scores did not have a significant effect on CPR performance comfort level.Forty-four participants were video recorded during simulation sessions. Group size ranged from 3 to 8 participants. Three participants did not perform the pulse check. Forty-one participants performed the pulse check within 10 seconds. All but one participant defibrillated the manikin within 180 seconds. Logistic regression evaluation of the pulse-check-to-chest-compression time (n = 41) indicated that answering the question correctly on the post-curriculum survey suggested correct performance in a megacode scenario (p = 0.003). Prior CPR experience, post-curriculum comfort level, age, occupation, and post-curriculum test score did not affect whether the participant could perform pulse-check-to-chest-compression in less than 10 seconds . The pulForty-seven simulation sessions were recorded on videotape, with some participants participating in more than one session. CCF was >80% in five sessions (10.6%) and >70% in 33 sessions (70.2%). During simulations, 21 individuals (41.2%) performed chest compressions at 100–120 compressions/minute, 14 individuals (27.5%) were slower than 100 compressions/minute, and 16 individuals (31.4%) were faster than 120 compressions/minute. Logistic regression determined that providing adequate chest compressions per minute (100–120) was not statistically influenced by answering the question correctly on the post-course survey, prior CPR experience, occupation, sex, age, or post-course survey score . HoweverMedical education in any setting should be evaluated for efficacy and quality per the Utstein Education in Resuscitation 2001 consensus recommendations. The international Utstein conferences are held to discuss uniform cardiac arrest reporting, but this symposium targeted improving the teaching of CPR.Our participants had a statistically significant increase in knowledge scores after participating in our resuscitation curriculum. The analysis of participants’ knowledge base indicated that variables such as age, sex, pre-curriculum score, prior CPR education, and occupation did not have a significant effect on post-curriculum score. Prior CPR experience did not improve a participant’s score on the post-curriculum survey, which was noted to be positive in a South African study.Comfort level of the participants was higher after the workshop. The participants ranked their skill comfort levels prior to the curriculum was high, but correlated poorly with knowledge scores. This could be that providers felt they could perform compressions, but did not have the knowledge base to lead a resuscitation effort. Learning or relearning the material is an important way for providers to feel comfortable with performing or teaching resuscitation. A systematic review of advanced life support knowledge and skill retention rates by Yang and colleagues suggested that both deteriorate between 6 and 12 months after training, with skills deteriorating faster than knowledge.The video analysis of resuscitation quality indicated that answering questions correctly on the post-tests could lead to better clinical performance. The participants’ ability to carry out defibrillation within 180 seconds of pulse check was not affected by prior CPR experience, post-curriculum comfort level, age, occupation, or post-curriculum test score. This finding suggests that practicing megacode simulations is as importance as knowing the guidelines.The low rate of participants' ability to sustain CCF > 80% indicates that more practice is needed. The trainees practiced chest compressions on manikins individually before simulations, but the recorded sessions were their first experience working as a team. In future trainings, individuals should participate in several simulations to improve the time the patient receives chest compressions during cardiac arrest. More emphasis will be placed on “choreographing” the drills so that people performing chest compressions will switch only during pulse checks. Quality chest compressions are key to delivering effective CPR, and our results show that the 2-day workshop should dedicate more time to practicing simulations.In a low-resource setting with a suboptimal number of medical providers, requesting staff to take time off is a difficult logistical task that requires advanced planning. Taking this into account, we would advocate restricting the workshop to 2 days, but scheduling more skills time.During the curriculum implementation, super-users were selected and given one-on-one training and practice during the following week. The manikins were donated to the hospital so that super-users could teach new hospital staff on a regular basis, creating a sustainable education model.Limitations Study limitations include a small sample size of 41 for skills analysis. Larger studies are needed to confirm our findings, although it could be difficult given the settings. Also, because of the Ebola outbreak shortly after the workshop, we were unable to complete the Utsein objective of reevaluating participants 6 months after the training course. However, during our visit, two participants demonstrated satisfactory advanced cardiac life support in a patient with real cardiac arrest.Analysis of cardiac arrest events in the hospital would be warranted in the future to measure educational program success. We plan to measure knowledge retention, refresh the knowledge of trainees, and build their resuscitation knowledge with other critical care education after the Ebola epidemic has resolved.After the 2-day CPR curriculum was presented at the JFD Regional Referral Center in Liberia, we measured a statistically significant increase in knowledge scores and participant comfort level with CPR. A CPR resuscitation curriculum based on lectures and low-fidelity manikin simulations may be an effective way to teach resuscitation in low-resource settings such as this. Additional research on education quality and retention rates of medical providers in low-resource settings is needed.Special thanks to Laerdal Medical  for donating the simulation manikins. Our gratitude to Claire Levine who provided final edits to the manuscript.The authors declare that they have no conflict of interest.


Interferon (IFN)-based therapy, the cornerstone for treatment of hepatitis C virus (HCV) infection, is generally considered to be the single most effective treatment strategy for this infection. Although most adverse effects of IFN therapy respond very well to the cessation of this drug, there are reports of serious irreversible adverse effects. This review article evaluates the adverse effects of IFN therapy in HCV-infected patients. We have undertaken an extensive search for articles regarding IFN and pegylated-IFN (PEG-IFN) therapy and their vascular complications using multiple sources that include PubMed, publishers’ websites, and Google Scholar. The prevalence of ocular disorders in the early period (first 8 weeks) after IFN administration was high with over half of the patients experiencing these adverse effects. Several authors strongly propose screening programs for retinopathy in the early period after IFN administration. Pulmonary hypertension due to IFN therapy is a serious side effect due to its irreversible nature in most patients. Patients who develop signs of acute abdomen up to months after IFN administration should be rapidly assessed for potential adverse effects of IFN. The literature suggests a broad spectrum of vascular injuries to different organs in humans as adverse effects of IFN therapy in HCV-infected patients. In the context of gastroenterology, the significance of IFN is mainly due to its prominent role in the treatment of chronic active hepatitis in patients infected with hepatitis C virus (HCV) and/or hepatitis B virus. IFN-based therapy is the cornerstone and one of the most effective treatment strategies for HCV infection. However, despite the mentioned advantages, IFN administration is accompanied by complications that affect various organs and systems, necessitating serious consideration prior to its administration. The relevance of this issue is underscored when one considers that IFN-associated adverse effects can result in the discontinuation of treatment.4 A recent series has reported the discontinuation of IFN in 17% of HCV-infected patients, mainly due to cardiovascular complications.5 Apart from one report from a large population, much lower frequencies of cardiovascular complications of IFN [7 out of 11241 (0.06%)] in patients with chronic hepatitis have been reported.6Interferon (IFN) is a cytokine broadly used to treat viral infections, malignancies, and disorders of the immune system. IFN is highly effective in the treatment of tumors that affect the vascular system, including hypernephroma,The cardiovascular complications of IFN therapy include pericarditis, rhythm disturbances, myocarditis, cardiomyopathy, congestive heart failure, vasospastic angina pectoris, microvascular angina, peripheral vascular disorders, stroke, and myocardial infarction. These complications have been reported as case reports and series from different centers; however, to the best of our knowledge there is no article that has comprehensively reviewed the existing data to provide clinicians with an inclusive view on this subject. HCV-infected patients are mostly complicated with several other disorders, and a cardiovascular complication may not be considered a side effect to IFN therapy. Therefore, this review article aims to categorize different cardiovascular complications associated with IFN therapy in HCV-infected patients and to provide sufficient information for future planning in order to ensure higher safety for HCV-infected patients who undergo IFN therapy.We undertook an extensive search for articles that concerned IFN and PEG-IFN therapy and their vascular complications by using multiple sources including PubMed, publishers’ websites, and Google Scholar. We assessed all articles for the levels of evidence and employed the following keywords or combinations thereof: interferon; pegylated interferon; hepatitis C virus; HCV; cardiovascular complication; heart; coronary artery; cardiomyopathy; pericarditis; myocarditis; retina; retinopathy; nephropathy; pulmonary; lung disease; gastrointestinal; intestinal injury; myopathy; myositis; myopathy; ischemia; thyroiditis; etc. 7,8 Takase et al.,9 followed 9 HCV-infected patients undergoing a course of recombinant IFN therapy. These authors reported that INF treatment resulted in decreased exercise tolerance time from 449±94 s to 329±67 s (P<0.05) and decreases in several heart rate variability parameters . Several reports indicated an association between IFN therapy in HCV-infected patients to arrhythmias, either directly or secondary to endocrine or pulmonary system disturbances. Hiramatsu et al.,10 in a cohort of 22 patients, suggested that arrhythmias which developed as a consequence of IFN therapy in patients with active hepatitis were reversible and subclinical with no sustained ventricular arrhythmia detected throughout the follow-up period. However, their cohort consisted of a limited number of patients and serious arrhythmias could occur occasionally. Teragawa et al.11 studied 295 HCV-infected patients during their treatment course of IFN therapy and after one year. They found that 4 (1.4%) patients developed arrhythmias; this was only 40% of the overall cardiovascular complications of HCV treatment. Fujiwara et al.12 reported the case of a 64-year-old man infected with HCV. Seven days after starting IFN, the patient developed a giant T wave inversion visualized on a check-up electrocardiogram (ECG). In addition, ten days after IFN administration the patient’s clinical symptoms included fatigue, palpitations, a depressive feeling, tachycardia of 100 beats/min, supraventricular premature beats, atrial fibrillation, and septal and apical hypertrophy. At four days after cessation of IFN therapy the patient’s subjective symptoms improved and atrial fibrillation disappeared, however his giant T wave inversion and apical hypertrophy remained detectable several months after the discontinuation of the drug. Another case report from Poland indicated atrioventricular (AV) conduction disturbances in the form of a second-degree AV block in a 55-year-old woman with no known cardiac disorders prior to treatment with pegylated IFN (PEG-IFN) therapy for an HCV infection.13 Drug cessation resulted in a significant drop in the electrocardiographic disturbances. These cases have shown that although the discontinuation of PEG-IFN can revert some arrhythmic changes, however others are likely to remain. In hemophilic patients simultaneously infected with HCV and HIV, therapy with IFN-alpha-2a has been associated with a 14% incident rate of tachycardia, leading to a decrease in the administered IFN dose.14IFN therapy for HCV infection has been associated with myocardial function disorders.15 sinus bradycardia,16,17 transient sinus tachycardia and premature ventricular beats18 have been observed in HCV-infected patients undergoing IFN therapy. They have occasionally resulted in the cessation or dose reduction of the drug. There are also reports indicative of thyroiditis and associated arrhythmias, especially tachycardia, after the administration of IFN-alpha in HCV-infected patients; this issue has been very well reviewed by Menconi et al.19Torsades de pointes,11 reported a case of pericarditis that developed in an HCV-infected individual on IFN therapy. Since then, several other studies have reported similar cases.20,21 Boonen et al.22 reported a 24-year-old woman that underwent IFN-alpha therapy for HCV infection and subsequently developed pericarditis; later tests showed that she all criteria necessary for the diagnosis of systemic lupus erythematosus (SLE). The authors concluded that IFN-alpha therapy could result in the provocation of autoimmunity and they supported their hypothesis by citing several reports of other autoimmune disorders which occurred after IFN therapy in HCV-infected patients (including Grave’s disease and sarcoidosis). Another case-report study reported similar adverse effects for PEG-IFN-2a in a 67-year-old male, in whom discontinuation of the drug plus Prednisolone therapy cured pericardial effusion within 16 days.23 An immune reaction might partially explain the rationale behind the pericardial effusion and pericarditis that developed after IFN therapy in HCV-infected patients.22 In these cases corticosteroid therapy has been highly recommended.23Teragawa et al.24 In hemodialysis patients with HCV infection PEG-IFN resulted in pericarditis two weeks after administration, which necessitated discontinuation of treatment.25 On the other hand, HCV infection itself has been a known factor for the development of pericarditis and PEG-IFN therapy has been used to treat the associated pericarditis.26 Myocarditis is a more serious side effect of IFN therapy that can result in cardiogenic shock11 and/or fatal consequences in HCV-infected patients.27 As is the case in pericarditis, HCV infection can also give rise to myocarditis and for its treatment, IFN therapy has been successfully employed.28,29 This controversy is of utmost importance. Physicians should determine whether the injury is due to an HCV infection or IFN therapy-this will have a decisive effect on the therapeutic approach. If the problem is due to an HCV infection, IFN should be administered or the dose augmented. However if it is an adverse effect of IFN, drug administration should be discontinued. Some authors have proposed that in cases where pericarditis is considered as a manifestation of HCV-induced autoimmunity, administration of IFN is contraindicated because it can exacerbate the disease.30,31PEG-IFN has been reported as a precursor for acute pericarditis that developed in HCV-infected patients seven months after starting PEG-IFN, which resolved following complete cessation of the drug.32 that are probably attributed to IFN-induced vasospasms.33 The most notorious side effect of Ribavirin is hemolysis; the stress of a sudden onset of anemia due to hemolysis can induce myocardial infarction in persons with pre-existing coronary artery disease or stroke in those with cerebrovascular disease. This is the only cardiovascular side effect usually attributed to Ribavirin, one of the key agents in HCV combination therapy.32 Shakil et al.,34 in a follow-up of 38 HCV-infected liver transplant patients, introduced 2 patients who experienced myocardial infarctions after starting IFN plus Ribavirin therapy, both had normal cardiovascular evaluations prior to the study onset. The first patient was a 53-year-old man who developed myocardial infarction at week 28 and died with normal hemoglobin levels. The second, a 39-year-old woman, developed a myocardial infarction at week 48 concomitant with a sharp decline in the hemoglobin level from 13.1 g/dl to 8.7 g/dl; she survived the myocardial infarction after a reduction in the drug dose.34 IFN alone has been shown to cause myocardial infarctions in HCV-infected patients.35,36 IFN cardiotoxicity may be related to the febrile reaction induced by exposure to IFN therapy, inducing an increase in oxygen demand and resulting in an acute coronary syndrome attack such as a myocardial infarction.37 Therefore, any acute coronary event after the initiation of IFN and Ribavirin in an HCV-infected patient should alert physicians and modifications in IFN and Ribavirin dosage administration should be seriously considered.Acute coronary syndromes are among the rare adverse effects of HCV infection therapy29 One study reported improved serum levels of creatine kinase (CK), CK-MB, and cardiac troponin T during treatment with IFN whereas the conventional treatment for heart failure was not effective.38 On the other hand, some authors, including Dalekos et al.39 and Kuethe et al.,40 found no association between cardiomyopathy and HCV infection.HCV infection has been reportedly associated with the development of cardiomyopathy. IFN therapy has been suggested for the treatment of HCV-related cardiomyopathy.41The development of cardiomyopathy in HCV-infected patients, due to the above-mentioned evidence, may inevitably lead to a diagnosis of HCV-related cardiomyopathy, whereas none of the above mentioned articles have discussed a history of IFN therapy. As a result, one may assume that at least some of those cases might have developed cardiomyopathy as an adverse effect of anti-HCV therapy rather than the HCV infection itself.42 There is a report of the development of fatal cardiomyopathy due to IFN therapy in an HCV-infected patient.43IFN therapy has been reported to induce hypertrophy of the septal and posterior wall of the left ventricle days after the onset of treatment.44 reported a male liver transplant recipient who underwent IFN therapy for allograft dysfunction due to HCV reactivation. At the commencement of treatment, the patient developed weakness and malaise that necessitated a reduction in drug dosage. The patient, 11 days after discharge and following a transfusion of packed red blood cells became critically ill with a T-wave inversion in his ECG; ejection fraction of 28%; and dilated cardiomyopathy in the thoracic ECG. Discontinuation of IFN improved his symptoms, and subsequently IFN was readministered with a gradual increase in dosage. Not only does this interesting case show the reversibility of IFN-induced cardiomyopathy but it has demonstrated that after cessation of IFN therapy and treatment of the primary reaction, with caution IFN can be safely re-administered. There are reports that the cardiotoxicity of IFN therapy can be irreversible. Dhillon et al.45 have reported irreversible cases of pulmonary hypertension induced by IFN therapy in HCV-infected patients. The next section presents an in-depth discussion on such cases.Mateo et al.46 have reported that IFN-alpha-2b therapy in mice could lead to a significant increase in the thickness of the endothelial processes of the myocardial capillary walls, with a subsequent decrease in the size of the capillary lumen. This might explain the augmented rate of cardiomyopathies, especially dilated cardiomyopathy, in HCV-infected patients who undergo IFN therapy.It has been demonstrated that IFN can aggregate leukocytes within the capillaries, resulting in vascular damage and micro-infarctions. This can affect a number of organs, particularly the heart and eyes. In a mouse model, Salman et al.47 reported that over 57% of the patients developed retinopathies, including 25 (40%) cases of retinal hemorrhage and 28 (44%) cases of cotton wool spots. Interestingly, 86% of the lesions were diagnosed within 8 weeks after onset of IFN administration. In a similar study by Sugano et al.,48 24% of the HCV-infected patients who started IFN therapy developed retinal hemorrhage, with two-thirds of them developing cotton wool spots and half having visual symptoms. Consistent with the previous study, approximately 85% of the patients developed their retinal signs just within the first 8 weeks post-IFN administration. In a larger recently published study, Vujosevic et al.49 demonstrated that 31% of the HCV-infected patients undergoing PEG-IFN and Ribavirin developed retinopathy. Hypertension was defined as the only independent factor associated with IFN-induced retinopathy . Only one (1.1%) patient needed therapy cessation due to bilateral branch retinal vein occlusion. The authors conducted a cost-effective study and showed that screening for PEG-IFN induced retinopathy was cost-effective.Cardiomyopathy is not the only IFN-induced complication as an adverse effect for IFN therapy in HCV-infected patients. Retinopathy is one of the most frequently reported microvascular complications of IFN in HCV-infected individuals. Both arterial and venous origins have been proposed as culprits. In some cases, the retinopathy is irreversible. In a prospective cohort of 63 patients with chronic HCV infection and no retinal lesions before IFN-alpha therapy, Kawano et al.50 reported dyspnea after PEG-IFN therapy in HCV patients with advanced liver disease. Spirometric changes in FEV1 and FEV1/FVC were also observed. Kumar et al.51 introduced 4 patients who developed significant pulmonary signs and symptoms while they were on therapy with IFN-alpha and Ribavirin for chronic HCV; final diagnosis was bronchiolitis obliterans organizing pneumonia in 2 patients, and interstitial pneumonitis in 2 others. In all patients, pulmonary symptoms resolved after cessation of the drug.Pulmonary dysfunction due to IFN therapy in HCV-infected individuals has been reported. Garib et al.45 reported 4 cases of irreversible pulmonary hypertension that developed after IFN therapy in HCV-infected patients. One of the patients was a 35-year-old male liver transplant recipient who developed pulmonary hypertension after IFN therapy for HCV and died about 2.5 years later, with no response to treatments. The second was a 40-year-old female HCV-infected individual who developed pulmonary hypertension 32 months after IFN therapy. Although the treatments failed to reverse her hypertension, she was stabilized. The third patient was a 50-year-old male liver transplant recipient who developed pulmonary hypertension after 10 months of IFN therapy. Although his hypertension did not respond to therapy, his clinical condition stabilized. The fourth patient was a 49-year-old male HCV-infected person who developed pulmonary hypertension 8 months after IFN initiation. The therapy was not successful in treating the hypertension, however the patient was stabilized.Pulmonary hypertension is another adverse effect of IFN therapy in HCV-infected patients and has been repeatedly reported by different authors. Dhillon et al.52 Leung et al.53 have reported an interesting case of ischemic colitis that developed 34 weeks after PEG-IFN-alpha; the patient’s symptoms rapidly resolved with the cessation of therapy. Similar observations were reported by Tada et al.,54 who presented 2 cases of IFN-alpha-induced ischemic colitis that developed 2 and 6 months after IFN administration. Both cases had complete resolution two weeks after cessation of IFN therapy. A recent case report by Baik et al.55 showed the development of ischemic colitis 19 weeks after the commencement of PEG-IFN-alpha-2a and Ribavirin therapy; the case was thoroughly cured only with cessation of the drug. However, not all cases of ischemia in the gastrointestinal tract had benign courses. Pompili et al.56 introduced a 53-year-old male with HCV infection who developed jejunal ischemia 3 months after the initiation of therapy with PEG-IFN. Although the patient underwent emergent jejuna resection, he died 6 months after surgery due to preoperative complications. A case of phlegmonous colitis that developed in a chronic HCV-infected patient who received combined therapy of PEG-IFN and Ribavirin also had a lethal consequence.57 A case of neutropenic enterocolitis that developed 22 weeks after the initiation of PEG-IFN-alpha-2a and Ribavirin had a fatal outcome.58Ischemia in the gastrointestinal tract is another peripheral vascular disorder associated with IFN therapy in HCV-infected patients.59 reported a case of acute heart allograft failure induced by PEG-IFN-alpha-2b therapy due to HCV infection in a 50-year-old male which proved fatal. Postmortem autopsy showed no evidence of cellular or humoral rejection, which confirmed that the case was a fatal cardiotoxicity adverse effect due to Peg-IFN-alpha-2b.Wang et al.60 have reported a case of acute myositis after PEG-IFN-alpha-2b therapy for an HCV infection and suggested that a rapid discontinuation of IFN could resolve the problem in such cases. Golstein et al.61 reported a reversible case of myopathy that developed as a side effect of the same agent, which improved after drug cessation.Myopathy and acute myositis have also been reported as adverse effects of PEG-IFN-alpha-2b therapy in HCV-infected patients. This may contribute, in part, to the cardiovascular disorders that are seen in these patients. Venezia et al.62 SLE has also been reported as an adverse effect of IFN therapy in HCV-infected patients.63 Cryoglobulinemia is another immune disorder that has been reportedly associated with IFN therapy.64 Type I diabetes mellitus, another autoimmune disorder, has been repeatedly suggested to develop as an adverse effect of IFN therapy.65 Grave’s disease and thyroiditis are other disorders attributed to IFN therapy in HCV-infected patients.66,67Disorders of the immune system have also been reported as a consequence of IFN therapy in HCV-infected patients. The importance of these diseases is attributed to their direct or indirect effects on the cardiovascular system. Sarcoidosis is one of the most prevalently reported immune system disorders.IFN-based regimens are a cornerstone for the treatment of HCV infection and generally considered effective as treatment for this infection. Although most adverse effects of IFN therapy respond very well to cessation of the drug, this review article shows that there are serious adverse effects associated with IFN therapy in HCV-infected patients, which might affect sensitive organs such as the eyes, heart, and lungs. The prevalence of ocular disorders in the early period (first 8 weeks) after IFN administration can amount to 57% and result in irreversible, significant damage to visual acuity. Pulmonary hypertension secondary to IFN therapy is a serious side effect due to its irreversible nature in most patients and as such necessitates prompt evaluation. After mentioning these adverse effects of IFN therapy in HCV patients, it should be mentioned that HCV infection itself may produce cardiovascular injuries. Only a few of the articles we have reviewed were case-controls, thus we cannot separate the potential effects of HCV from IFN therapy adverse effects. More prospective studies should be conducted for this purpose. To the best of our knowledge, there is no study in the current literature that concerns prevention strategies for the vascular effects of IFN therapy on different organs. We suggest that prospective studies be undertaken to address this critical issue.