Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.1383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age ; Black patients , Asian Americans and Pacific Islander patients  and Other  racial/ethnic groups; worse ECOG performance status ; pre-existing cardiovascular /pulmonary comorbidities ; diabetes mellitus ; and active and progressing cancer . Hispanic ethnicity, timing, and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.Using one of the largest registries on cancer and COVID-19, we identified patient and BC-related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to non-Hispanic White patients.This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L Warner; P30-CA046592 to Christopher R Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K Shah and Dimpy P Shah; KL2 TR002646 for Pankil Shah and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01-CCE) and P30-CA054174 for Dimpy P Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication.NCT04354701.CCC19 registry is registered on ClinicalTrials.gov,  The COVID-19 pandemic has had a devastating impact worldwide and within the United States (US) . PreviouBreast cancer (BC) is the most common cancer diagnosed in females and affects all major racial/ethnic groups . There asupplementary appendix 1)  consists of 129 member institutions capturing granular, detailed, and uniform data on demographic and clinical characteristics, treatment information, and outcomes of COVID-19. Details of CCC19 protocol, data collection, and quality assurance have been previously described . This reendix 1) . This stThe primary outcome was a five-level ordinal scale of COVID-19 severity based on each individual patient’s most severe reported disease status: none of the following complications; admitted to the hospital; admitted to an intensive care unit (ICU); mechanically ventilated at any time after COVID-19 diagnosis; or death from any cause. Other COVID-19-related complications ; 30-day mortality; and anti-COVID-19 directed interventions  are also reported.https://github.com/covidncancer/CCC19_dictionary  as recorded in the EHR, based on the Center for Disease Control and Prevention Race and Ethnicity codes ; US censctionary . The prosupplementary appendix 2). Standard descriptive statistics were used to summarize prognostic factors, rates of clinical complications, interventions during hospitalization, and rates of outcomes such as 30-day mortality, hospitalization, oxygen requirement, ICU admission, mechanical ventilation, and overall mortality among racial and ethnic groups. The primary analysis was restricted to females with BC.Covariates, outcome definitions, and statistical analysis plan were prespecified by the authors and the CCC19 Research Coordinating Center prior to analysis , and US census region of reporting institution. These covariates were identified a priori as the most clinically relevant for COVID-19 severity and were included in a single model, given a sufficient number of events and corresponding degrees of freedom. Because the ordinal outcome was assessed over a given patient’s total follow-up period, the model included an offset for (log) follow-up time. The results are presented as adjusted odds ratio (ORs) with 95% CIs. Model stability was assessed by comparing unadjusted and adjusted models and variance inflation factors. Graphical methods were used to verify the proportional odds assumption . We usedOf the total 12,034 reports on all cancers submitted to the CCC19 registry at the time of this analysis, 1383 females with BC met the eligibility criteria and were included . The medOf the 1383 female patients, 736 (53%) were NHW, 289 (21%) Black, 235 (17%) Hispanic, 45 (3%) AAPI, and 78 (6%) belonged to Other racial/ethnic group. Baseline characteristics of females stratified by race/ethnicity groups are shown in Female patients with MBC consisted of 17% of the cohort (N=233), with median age 58 years [IQR 50–68]. Racial/ethnic groups consisted of 46% NHW, 24% Black, 21% Hispanics, 4% AAPI, and 4% Other. Most patients with MBC were never smokers (70%) and non-obese (60%). The predominant tumor biology was HR+/HER2- (42%) followed by HR+/HER2+ (23%). The most common sites of metastases were bone (58%), lung (28%), and liver (26%). A high percentage (87%) had received anti-cancer treatment within 3 months prior to COVID-19 diagnosis and 32% had active and progressing cancer. The unadjusted total all-cause mortality and hospitalization rate in females with MBC was 19% and 53% respectively. Further details of baseline characteristics and unadjusted rates of COVID-19 outcomes, complications, and interventions are presented in 758 (55%) out of 1383 female patients with BC received some form of systemic treatment within 3 months prior to COVID-19 diagnosis, and specific drug information was available for 679 (90%) . Of thesresidual_ confounding above that adjusted for by including adjustment variables in the multivariable model. For example, an unmeasured confounder would need to be associated with both race and mortality with an OR of at least 1.97 to fully attenuate the observed association for Black females and the OR would need to be at least 1.47 for the null-hypothesized value (1.0) to be included in the CI. Similarly, e value estimates are noted for AAPI and Other groups. The unmeasured confounding for other races based on the e value is larger than most documented associations in the CCC19 cohort ; Black , AAPI , and Other  racial/ethnic group; cardiovascular  and pulmonary  comorbidities; diabetes mellitus ; worse ECOG PS ; and active and progressing cancer status . Association between Hispanic ethnicity, obesity, pre-existing renal disease, anti-cancer treatment modalities including all forms of systemic therapy and locoregional therapy, month/year, and geographic region of COVID-19 diagnosis and COVID-19 severity did not reach statistical significance . The e v9 cohort .Male patients with BC were evaluated separately as part of exploratory analysis. The median age for male BC cohort (N=25) was 67 years [IQR 60–75]. Racial/ethnic composition consisted of NHW (52%) followed by Black (32%) males. Most males with BC were non-smokers (72%) and diabetes mellitus was the predominant comorbidity (44%). The hospitalization rate was 60% and all-cause mortality was 20%. Additional clinical characteristics, complications, interventions, and unadjusted outcomes among males with BC in the CCC19 registry are provided in In this large, multi-institutional and racially diverse cohort of females with BC and COVID-19 from CCC19 registry, we assessed the clinical impact of COVID-19. The all-cause mortality from COVID-19 was 9% and hospitalization rate was 37%, which is numerically lower than in the entire CCC19 cohort at 14% and 58%, and other previously reported studies of COVID-19 in patients with cancer . These dWe observed older age, pre-existing cardiovascular and pulmonary comorbidities, diabetes mellitus, worse ECOG PS, and active and progressing cancer status were associated with adverse COVID-19 outcomes in females with BC. Prior studies have reported similar factors to be associated with adverse COVID-19 outcomes in patients with all cancer types. The majority of these studies have reported older age to be an important prognostic factor for adverse outcomes from COVID-19, including mortality, which is consistent with data presented here . Non-canWe also report important findings related to the impact of racial/ethnic inequities in females with BC and COVID-19, which adds to the growing body of literature on COVID-19-related racial/ethnic disparities. In our study, Black females with BC had significantly worse COVID-19 outcomes compared to NHW females. Multiple studies have similarly reported Black patients in US with and without cancer diagnosis having significantly worse COVID-19 outcomes ; howeverIn summary, this is one of the largest cohort studies to evaluate the clinical impact of COVID-19 on females with BC. Strengths of our study include standardized data collection on the most common cancer in females in the US and large sample size to evaluate the effect of major clinical and demographic factors. The study had representative population by race and ethnicity from geographically diverse areas and variable time/period of COVID-19 diagnosis. In addition, our study has detailed manually collected information on both cancer status and treatment modalities which contrasts with other studies that have utilized either of these variables as surrogate. Limitations of this study include the retrospective nature of data and inherent potential for confounding because of its observational nature. It’s possible that ascertainment bias could have led to some of the high values observed in specific groups such as females with MBC and those with active and progressing cancer. Additional information on drivers for inequity such as socio-economic status, occupation, income, residence, education, and insurance status may have provided added insights on the root causes for disparities; however, unavailability of these factors does not nullify our current findings of existing racial disparities in COVID-19 outcomes in females with BC. Vaccination status was not part of this study as vaccines were not available during the predominant time frame for this cohort. Data presented here including the risk of hospitalization and death applies to the specific COVID-19 variants prevalent during the study period. Despite these limitations, the study reports important sociodemographic and clinical factors that aid in identifying females with BC who are at increased risk for severe COVID-19 outcomes. Given the largely unknown long-term impact of this novel virus, systematic examination of the post-acute sequelae of COVID-19 in patients with breast and other cancer subtypes is warranted.Our study addresses an important knowledge gap in patients with BC diagnosed with COVID-19 using the CCC19 registry. In addition to clinical and demographic factors associated with adverse COVID-19 outcomes, racial/ethnic disparities reported here significantly contribute to the growing literature. At this stage, it is irrefutable that one of the principal far-reaching messages the pandemic has conveyed is that any such major stressors on the health care system increases risk of detrimental outcomes to the most vulnerable patient population, including the underrepresented and the underserved. These are important considerations for future resource allocation strategies and policy interventions. We also report an important finding that cancers that are active and progressing are associated with severe COVID-19 outcomes. During the ongoing pandemic, this has significant implications for shared decision-making between patients and physicians. These data offer novel and compelling information that could impact treatment decision-making for breast cancer patients, and the development of this registry contributes a valuable resource for future research, including and beyond breast cancer. It is anticipated that this study is the first of multiple publications that leverage this important data infrastructure. In the interests of transparency, eLife publishes the most substantive revision requests and the accompanying author responses.Decision letter after peer review:eLife. Your article has been reviewed by one peer reviewer who is a member of our Board of Reviewing Editors, and the evaluation has been overseen by a Senior Editor. The reviewer has opted to remain anonymous.Thank you for submitting your article "Clinical Characteristics, Racial Inequities, and Outcomes in Patients with Breast Cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) Cohort Study" for consideration by The reviewer and the editors have discussed the critique, and the Reviewing Editor has drafted this to help you prepare a revised submission.Essential revisions:1) Please address the impact that "long COVID" might have on study findings and implications.2) Please discuss how this registry will be used to continue to monitor the long-term impact of COVID-19 infection on cancer outcomes, including but not limited to breast cancer.Reviewer #1 (Recommendations for the authors):The current study leverages a unique and powerful consortium resource--the "COVID-19 and Cancer Consortium (CCC19)" registry. This retrospective cohort study is a key study strength and has over 120 member institutions allowed researchers to examine the impact of cancer factors on COVID-19 infection severity.The data provided are among the most robust data available to determine the associations between factors including prognostic factors, racial disparities, interventions, complications, and cancer treatment on COVID-19 severity. This study specifically focuses on adult women with either current breast cancer (BC) or a history of BC, as well as a confirmed diagnosis of COVID-19 from this CCC19 registry .The authors reveal several key findings, including that obesity was not observed to impact COVID-19 among these women. The study also provides compelling data in showing no association between anti-cancer treatments on COVID-19 severity. These findings have clear implications for treatment counseling and decision making for women with breast cancer who become COVID-19 infected.Among study weaknesses and areas for alternative considerations, the follow-up period is still relatively short, given the recency of the pandemic. The authors should consider the possibility of "long COVID" in these patients and treatment effectivenessOverall the study contributes confirmatory and novel information, utilizing a critical national registry effort. This registry can and should be used to continue to monitor the long term impact of COVID-19 infection on cancer outcomes, including but not limited to breast cancer.These initial findings are quite compelling though the investigators should consider examining vaccination status and timing, booster status and timing, and longer-term follow up in the cohort. This is especially important in light of the possibility of "long COVID" for cancer patients. Essential revisions:1) Please address the impact that "long COVID" might have on study findings and implications.We agree with the reviewer that long COVID or post-acute sequelae of COVID (PASC) in patients with cancer is a highly relevant public health problem and needs to be studied further. Long COVID was beyond the scope of our study aims since we focused only on outcomes of acute infection and presented these findings in the manuscript. While this study did not specifically look into long COVID, we conducted a separate preliminary analysis to examine PASC in patients with cancer using data from CCC19.* Patients with underlying comorbidities, worse ECOG PS, and more severe acute SARS-CoV-2 infection had higher rates of PASC and suffered more severe complications, and incurred worse outcomes; however, long-term follow-up with granular data in a larger sample are needed to make a conclusive statement about the impact of long COVID in patients with any type of cancer.Reference: ASCO abstract for LongCOVID: DOI: 10.1200/JCO.2022.40.16_suppl.e18746 Journal of Clinical Oncology 40, no. 16_suppl  e18746-e18746.We have added the following sentence in the discussion/limitation section, “Given the largely unknown long-term impact of this novel virus, systematic examination of the post-acute sequelae of COVID-19 in patients with breast and other cancer subtypes is warranted.”2) Please discuss how this registry will be used to continue to monitor the long-term impact of COVID-19 infection on cancer outcomes, including but not limited to breast cancer.We are still collecting follow-up data on existing cases and will continue to monitor the long-term impact of COVID-19 infection on cancer outcomes, including breast cancer. We are continually encouraging sites to keep contributing follow-up details, so that the long-term impact of COVID-19 infection on cancer outcomes can be systematically monitored.Reviewer #1 (Recommendations for the authors):The current study leverages a unique and powerful consortium resource--the "COVID-19 and Cancer Consortium (CCC19)" registry. This retrospective cohort study is a key study strength and has over 120 member institutions allowed researchers to examine the impact of cancer factors on COVID-19 infection severity.The data provided are among the most robust data available to determine the associations between factors including prognostic factors, racial disparities, interventions, complications, and cancer treatment on COVID-19 severity. This study specifically focuses on adult women with either current breast cancer (BC) or a history of BC, as well as a confirmed diagnosis of COVID-19 from this CCC19 registry .The authors reveal several key findings, including that obesity was not observed to impact COVID-19 among these women. The study also provides compelling data in showing no association between anti-cancer treatments on COVID-19 severity. These findings have clear implications for treatment counseling and decision making for women with breast cancer who become COVID-19 infected.We are grateful for the encouraging response by the reviewer. We agree that this is an important study with regards to its unique and vulnerable patient population facing an unprecedented crisis.Among study weaknesses and areas for alternative considerations, the follow-up period is still relatively short, given the recency of the pandemic. The authors should consider the possibility of "long COVID" in these patients and treatment effectivenessOverall the study contributes confirmatory and novel information, utilizing a critical national registry effort. This registry can and should be used to continue to monitor the long term impact of COVID-19 infection on cancer outcomes, including but not limited to breast cancer.We agree with the reviewer. Due to the complete lack of information on the impact of acute infection in patients with Breast cancer, this study was urgently warranted. However, although out of scope for the current study, we acknowledge that the long-term impact of this novel virus in patients with cancer is largely unknown and this national registry should continue to follow-up with this cohort of patients.These initial findings are quite compelling though the investigators should consider examining vaccination status and timing, booster status and timing, and longer-term follow up in the cohort. This is especially important in light of the possibility of "long COVID" for cancer patients.Thank you for the thoughtful recommendation, and we agree with the reviewer. Vaccination status was not part of this study as vaccines were not available during the predominant time frame for this cohort and we have mentioned this in the Discussion section as a limitation. We also added a sentence mentioning the importance of studying long COVID in patients with cancer. “Given the largely unknown long-term impact of this novel virus, systematic examination of the post-acute sequelae of COVID-19 in patients with breast and other cancer subtypes is warranted.”


The purpose of this study was to compare pre- and post-surgical healthcare costs in commercially insured total joint arthroplasty (TJA) patients with osteoarthritis (OA) in the United States (U.S.).Using a large healthcare claims database, we identified patients over age 39 with hip or knee OA who underwent unilateral primary TJA (hip or knee) between 1/1/2006 and 9/30/2007. Utilization of healthcare services and costs were aggregated into three periods: 12 months "pre-surgery," 91 days "peri-operative," and 3 to 15 month "follow-up," Mean total pre-surgery costs were compared with follow-up costs using Wilcoxon signed-rank test.p < 0.01). Mean total costs during the follow-up period were 18% higher than during pre-surgery , largely due to an increase in the costs of inpatient care associated with hospital readmissions . Pharmacotherapy costs were similar for both periods ; outpatient care costs were slightly lower in the follow-up period . Mean total costs for the peri-operative period were $36,553.14,912 patients met inclusion criteria for the study. The mean total number of outpatient visits declined from pre-surgery to follow-up (18.0 visits vs 17.1), while the percentage of patients hospitalized increased (from 7.5% to 9.8%) , while mean total healthcare costs increased during the same time period, largely due to increased costs associated with hospital readmissions. Further study is necessary to determine whether healthcare costs decrease in subsequent years. Advanced osteoarthritis (OA) of the hip and knee is associated with severe pain, limitation in function, and impaired quality of life ,2. PatieData were obtained from the PharMetrics Patient-Centric Database, which is comprised of facility, professional-service, and retail  pharmacy claims from over 85 health plans throughout the United States. These plans provide health insurance to approximately 14 million people annually . All patient identifiers in the database are encrypted, and the database is fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As no patient or provider contact was made and patient information was de-identified, Institutional Review Board (IRB) approval was not required.th Revision, Clinical Modification [ICD-9-CM] format), procedures , provider specialty, and charged and paid amounts. Data available for each retail pharmacy claim include the drug dispensed , the dispensing date, and the quantity dispensed and number of days of therapy supplied (selected plans only). All claims include a charged amount; the database also provides paid  amounts.Information available for each facility and professional-service claim includes date and place of service, diagnoses , which represented the most recent period for which complete data were available at the point of study initiation.The source population for this study consisted of all patients with any claims for unilateral primary TKR (CPT-4 code 27447 or ICD-9-CM procedure code 81.54) or unilateral primary THR (CPT-4 code 27130 or ICD-9-CM procedure code 81.51) between January 1, 2006 and September 30, 2007. . Among these patients, the date of the first-noted claim for TKR or THR was designated the "index procedure date", and patients not continuously enrolled in the database for the 12 month period prior to this date ("pre-surgery period") and the 15-month period subsequent to this date ("post-operative period") were excluded from the study sample.a. All pharmacy, professional service, and facility claims were then compiled for all patients in the study sample over the one-year pre-surgery period and the 15-month post-operative period.Patients without diagnoses of OA  in the three-month period preceding surgery were excluded from the study sample, as were those aged less than 40 years as of the time of their index procedure, those enrolled in Medicaid, and persons aged 65 years and older as of the time of their index procedure who were enrolled in a Medicare Advantage plan (because their claims histories are incomplete in the study database). Additional exclusions from the study sample included persons with evidence of any of the following during the one-year pre-surgery period: (1) prior TKR or THR; (2) joint fusion ; (3) procedures suggestive of a prior TKR/THR ; (4) knee or hip fracture  (in 30-day period prior to index procedure date only); (5) other conditions associated with TKR/THR , post-traumatic arthritis , avascular necrosis  benign/malignant bone tumors , or Paget's disease (731.0) during the pre-surgery period, and (6) patients who underwent a second primary TKA or THA during the 15-month period subsequent to the index procedure dateThe demographic and clinical characteristics of study subjects were examined, including prevalence of selected comorbidities, on the basis of information prior to the index procedure date. Patients were assumed to have a particular comorbidity if they had either one or more hospitalizations, or two or more outpatient claims at least 30 days apart, during the pre-surgery period with a corresponding diagnosis code/prescription.Total healthcare costs were aggregated into three distinct periods: pre-surgery period (12-months prior to TJA); "peri-operative" (91-day period including and immediately following TJA); and "follow-up" (12-month period following the peri-operative period). Healthcare costs over each period were subcategorized into (1) pharmacotherapy ; (2) outpatient care , Emergency Department (ED) visits, and diagnostic imaging)]; (3) inpatient care; and (4) all other costs. Pharmacotherapy was further subcategorized as: (1) nonsteroidal anti-inflammatory drugs (NSAIDs), including cyclo-oxygenase (COX)-2 selective NSAIDs; (2) opioids, including tramadol; (3) antidepressants; (4) intra-articular corticosteroid and hyaluronic acid injections; and (5) all other medications.Reimbursed amounts  were used in all analyses of healthcare costs. All costs were expressed on an "as-is" basis . Non-parametric bootstrapping (using sampling [with replacement] from the source population) was used to generate 95% confidence intervals (CIs) for all estimates of healthcare costs . All estMean total pre-surgery costs—for each sub-category and in aggregate—were compared with follow-up costs using Wilcoxon signed-rank tests; the percentages of patients with ≥1 hospitalizations during the pre-surgery versus follow-up periods were compared using McNemar's test. Utilization of healthcare services and costs occurring during the 90-day peri-operative period were excluded from analyses comparing pre-surgery with follow-up so as to compare healthcare costs and healthcare services utilization during the 1-year period prior to TJA with those of the 1-year period following recovery from TJA. A total of 14,912 met the inclusion criteria for the study. The mean age of patients included in the study was 57.3 years, and 57% were women; approximately 17% of patients in our sample were 65 years of age or older (Table p < 0.01]) (Table p = 0.61)., Importantly, the percentage of patients with ≥1 hospitalizations increased .Prescriptions for NSAIDs and opioids declined slightly during the follow-up period relative to the pre-surgery period  (Table p = 0.33).Mean total per-patient healthcare costs during the follow-up period were 18% higher than during the pre-surgery period  and injectable agents , but higher for opioids , antidepressants , and all other medications . On a per-patient basis, outpatient care costs were slightly lower in the follow-up period than in the pre-surgery period , whereas mean per-patient inpatient costs were substantially higher in the follow-up period when compared with the pre-surgery period . All other per-patient healthcare costs were also slightly higher in the follow-up period .However, within pharmacotherapy, mean total per-patient follow-up costs were lower than mean total pre-surgery costs for NSAIDs  ,8. At thWhile previous authors have reported that OA is associated with substantial direct and indirect medical expenditures ,16,17, rOur results indicate that although utilization of healthcare services decreased for most services during the first year following TJA (exclusive of the peri-operative period) in commercially insured patients with OA of the hip or knee, mean total healthcare costs increased, largely due to increased costs associated with inpatient care. Given that the mean length of stay during the peri-operative period  was only 6.9 days, and that 75% of patients spent no more than 8 days in hospital during this time, our findings are most likely associated with readmissions, rather than stays in hospital for the initial TJA of > 91 days. Hospital readmissions following elective surgical procedures such as TJA have become the focus of great debate and concern among healthcare policymakers , and havDespite the interesting findings, our study has several limitations. First, our database consisted of administrative claims for patients enrolled in private insurance plans, who tend on average to be younger than the "typical" cohort who undergoes TJA for OA. Specifically, while patients aged ≥65 years comprise approximately two-thirds of all patients who undergo TJA in the US , they onSecond, our analysis relied upon administrative claims data, which have been shown to have an imperfect correlation with the clinical record . It is pThird, and somewhat related to the second, we did not attempt to adjust for price inflation by expressing costs in terms of a particular "base year". The principal reason that we did not undertake such an adjustment was that we thought it important to examine (and report) actual amounts paid in "real-word" clinical practice during the periods before and after joint replacement. Were we to have expressed all costs in terms of a "base year", such information would not be available. We also note that identification of an appropriate "price index" to adjust healthcare costs is not straightforward. In most instances where this method is employed, a single index  is used to adjust values; implicit in use of this single index, however, is the assumption that all goods and services  experience the same relative change in pricing in a given year. The degree to which that assumption is valid within any given year is unknown. Regardless, to the extent that differences between pretreatment and follow-up costs reflect price inflation, our findings may overestimate differences in healthcare costs between these two periods.Fourth, although recovery from TJA surgery is variable, it is possible that some patients were not fully recovered from surgery by 90 days , and theIn summary, despite slightly lower outpatient care costs and similar costs associated with pharmacotherapy, we found that mean total direct health care costs increased during the 12-month period following recovery from TJA when compared with the 12-month period prior to surgery in commercially insured patients with OA, in large part due to increased costs associated with hospital readmissions. Further study is necessary to determine whether healthcare costs decrease in subsequent years.aPatients who underwent a second primary TKA or THA during the 15-month period subsequent to the index procedure were excluded, as these procedures are often scheduled electively following recovery from the index procedure, they are not indicative or reflective of the condition of the index joint, and they substantially impact the cost and utilization of healthcare services during the time period under study.This study was funded by Pfizer Inc. Alesia Sadosky is a full-time employee of Pfizer Inc. and owns stock in the company. The analyses were conducted by Ariel Berger and Gerry Oster, employees of Policy Analysis, Inc. Policy Analysis, Inc. received financial support from Pfizer, Inc. for the conduct of this analysis and development of this manuscript. Drs. Kevin Bozic and Brett Stacey did not receive any financial support from Pfizer. The funding source did not play a role in the investigation or the interpretation of the results.KB, BS, AB, AS, GO designed the study. AB and AS gathered the data. KB, AB, AS, analyzed the data. KB, BS, AB, AS, GO wrote the initial draft. KB, BS, AB, AS, GO ensured the accuracy of the data and analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/73/prepub


The development of a technique to induce the transformation of somatic cells to a pluripotent state via the ectopic expression of defined transcription factors was a transformational event in the field of regenerative medicine. The development of this technique also impacted ophthalmology, as patient-specific induced pluripotent stemcells (iPSCs) may be useful resources for some ophthalmological diseases. The lens is a key refractive element in the eye that focuses images of the visual world onto the retina. To establish a new model for drug screening to treat lens diseases and investigating lens aging and development, we examined whether human lens epithelial cells (HLECs) could be induced into iPSCs and if lens-specific differentiation of these cells could be achieved under defined chemical conditions. We first efficiently reprogrammed HLECs from age-related cataract patients to iPSCs with OCT-4, SOX-2, and KLF-4. The resulting HLEC-derived iPS (HLE-iPS) colonies were indistinguishable from human ES cells with respect to morphology, gene expression, pluripotent marker expression and their ability to generate all embryonic germ-cell layers. Next, we performed a 3-step induction procedure: HLE-iPS cells were differentiated into large numbers of lens progenitor-like cells with defined factors , and we determined that these cells expressed lens-specific markers . In addition, HLE-iPS-derived lens cells exhibited reduced expression of epithelial mesenchymal transition (EMT) markers compared with human embryonic stem cells (hESCs) and fibroblast-derived iPSCs. Our study describes a highly efficient procedure for generating lens progenitor cells from cataract patient HLEC-derived iPSCs. These patient-derived pluripotent cells provide a valuable model for studying the developmental and molecular biological mechanisms that underlie cell determination in lens development and cataract pathophysiology. Age-related cataracts are one of the most prevalent ocular conditions and are responsible for nearly half of the cases of blindness worldwide However, a systematic approach for studying human cataracts has been hampered by the lack of appropriate human-derived models and limitations of human primary lens culture There are currently no patient-specific models for the mechanistic exploration of lens development and cataract formation. Furthermore, no research has been conducted to determine whether human lens epithelial cells (HLECs) from cataract patients may be induced into iPS cells or whether these iPSCs may subsequently be differentiated into lens progenitor cells under defined chemical conditions. To address these questions, we generated patient-specific iPS cells from lens epithelial cells. Next, we differentiated these iPSCs and ESCs into lens progenitor cells using a 3-stage procedure of sequential inhibition and activation of the FGF, TGF-β and Wnt signaling pathways. Additionally, we analyzed the expression of epithelial mesenchymal transition (EMT) markers, key lens regulatory genes and structural genes during lens development from iPS and ES cells. Our results demonstrate that patient–specific iPSCs can be used to generate lens cells efficiently.Human lens epithelial cells were isolated from age-related cataract patients at the Eye and ENT Hospital of Fudan University. We thoroughly reviewed the patients' onset age, symptoms and family history. No evidence suggested that their cataracts were caused by congenital, traumatic or metabolic factors. The circular piece of the anterior capsule with the LECs attached was obtained by capsulotomy during cataract surgery and cultured directly without dispersion of the cells. After circular capsulorhexis, a section of the anterior capsule measuring approximately 5 mm in diameter was touched with an irrigation/aspiration tip and withdrawn from the eye by aspiration. The cells were cultured in Dulbecco's modified Eagle's medium (DMEM)  containing 15% fetal bovine serum (FBS) . Skin biopsy samples were also obtained from these patients, digested with trypsin for 30 minutes and plated in a dish with DMEM+10% FBS Medium. 293T cells  were cultured in DMEM containing 10% fetal calf serum (FCS) The lentiviral vectors obtained from Addgene were as follows: plenti-hOCT4, plenti-hSOX2 and plenti-hKLF4. The packaging plasmids (pCMV-gag-pol-PA and pCMV-VSVg) were generously provided by Dr. Trono of Geneva University. Lentivirus was collected 48 hours following cotransfection of the plasmids in 293T cells. Transfections were performed using Lipofectamine  in accordance with the manufacturer's recommendations.6 HLECs and fibroblast cells were seeded on 60 mm gelatin-coated dishes. After the cells had spread evenly on the culture dishes, a solution of the three viruses was added to the medium with polybrene  for 48 hours. On the fifth day, the infected fibroblast cells were replated onto irradiated mouse embryonic fibroblasts (MEFs). After seven days, the DMEM medium was replaced with the standard human ES cell culture medium , and small colonies emerged in the culture dish. Single colonies were picked two days later and cultured until they grew into large colonies.HLECs and human fibroblast cells were infected at passage 2. For viral transduction, 1×10H9 human ES cells were cultured on MEFs in DMEM/F-12  supplemented with ES medium. The culture medium was refreshed every two days, and the cells were passaged once a week. Cell differentiation was induced by the sequential administration of individual or specific combinations of growth factors using a 3-step induction procedure Total RNA was isolated using the Trizol Reagent  and reverse-transcriped using the SuperScript II Reverse Transcriptase kit  according to the manufacturer's recommendations. Real-time PCR analysis was performed using the SYBR-Green PCR Master Mix . The expression levels of individual genes were normalized to ß-actin levels and are shown relative to the control samples as indicated. The primer sequences used in the real-time PCR assays are listed in The cultured cells were fixed in situ in 4% paraformaldehyde (PFA) for 30 min. Following 3 washes with PBS, the cells were permeabilized in 0.2% Triton X-100 for 30 min, blocked for 1 hour in 10% FCS and 1% BSA in PBS and incubated overnight at 4°C with primary antibodies against NANOG, OCT-4, SSEA-3, SSEA-4, TRA-60, TRA-81, PAX6, α-crystallin andβ-crystallin  in 1% BSA in PBS. On the following day, the cells were washed 3 times with PBS and incubated with fluorescence-conjugated secondary antibodies  and DAPI in 1% BSA in PBS for 1 h at room temperature. Images were obtained with an inverted Olympus IX81 microscope .Lenses from a 22-yr-old male, 44-yr-old male and 65-yr-old male were thawed on ice and homogenized in PBS, pH 7.2. The homogenates were centrifuged at 5000 rpm for 5 min, and the soluble portion of the lens was retained. Cells were harvested into 1 ml of lysis buffer  Triton X-100 , 0.1% (w/v) SDS supplemented with a cocktail of protease inhibitors . Each lane was loaded with 20 mg of total protein. The gels were blotted onto a nitrocellulose membrane (Bio-Rad) and incubated with the following antibodies overnight at 4°C: anti-human PAX6 , anti-connexin-43 , anti-fibronectin , anti-CRYAB , anti-CRYAA  and anti-β-actin . The blots were then incubated for 1 hour with secondary anti-rabbit antibody conjugated to HRP . The membranes were developed using the ECL western blotting detection system  according to the manufacturer's protocol.A total cDNA microarray was performed using a HG-U133-2 array (Affymetrix) at the Shanghai microarray core. Invariant set normalization was used to normalize arrays at the probe level, and the model-based method was used to calculate expression values. A 20% presence call was used to filter the genes for clustering, resulting in 20,001 probe sets representing individual genes. A hierarchical clustering analysis was performed to distinguish arrays with similar expression patterns.6 iPS cells in 50 µL of ES cell medium were intradermally injected into the mice. The mice were subsequently monitored for teratoma formation and euthanized 6–12 weeks following the injection. The collected teratomas were analyzed using hematoxylin and eosin staining.To test for teratoma formation, iPS cell lines were injected into nude mice. Ethical approval was obtained prior to the commencement of the study from the Council on Animal Care and the Animal Use Subcommittee at the Eye and ENT Hospital of Fudan University (ID: KY2010-68). The “Principles of Laboratory Animal Care” were followed, and every effort was made to minimize the suffering and number of animals used. Briefly, 1×10All statistical analyses were performed with SPSS for Windows . The results are shown as the mean±standard deviation (SD) or the standard error of the mean (SEM), as indicated. The values obtained from the stem cell array were analyzed using the Pearson correlation coefficient as a measure of similarity. The remaining statistical analyses were performed using an unpaired two-tailed Student's t-tests. P-values<0.05 were considered to be statistically significant.6 HLEC cells and approximately 15 clones formed from 1×106 human fibroblast cells . This was a 56-year-old male patient diagnosed as age-related cataract and there is no role of traumatic, metabolic or genetic factors influencing the generation and differentiation of this patient's iPSCs. A schematic representation of the experimental strategy used to reprogram the HLECs is shown in st cells .These results demonstrate that iPS clones were successfully induced from the HLECs of the cataract patient with high reprogramming efficiencies. HLEC-derived iPSCs colonies were AP-positive and similar to human ES cells in terms of morphology.We randomly selected four clones from the induced cells  origining from the 56-year-old age-related cataract patient and compared the expression of key markers and morphology between the HLEC-iPS clones and H9 human ES cell lines. The expression of ES cell markers was examined in iPS and H9 ES clones using real-time PCR analysis with primers targeting endogenous HESC-specific genes in the iPS clones  and vimentin, which is an HLEC-specific gene. The RT-PCR results revealed that the gene expression patterns of the iPS1 clone were largely similar to those of hESCs . A genomWe next assessed the pluripotency of iPSCs and their ability to generate all embryonic germ layers. Real-time RT-PCR analysis was performed to assess the expression of pluripotency genes in HLEC-iPSCs clones (iPS1) and ESCs induced to differentiate through embryoid body (EB)formation and subsequent plating under the indicated conditions ). The expression of these genes was determined relative to GAPDH expression . EB diffOur next goal was to determine whether these HLEC-derived iPSCs could be further differentiated into lens progenitor cells. To achieve lens-specific differentiation, we applied a 3-step induction procedure, as reported by Yang et al EMT is the major cause of posterior capsule opacification (PCO) after cataract surgery, a phenotypic conversion characterized by the sequential loss of epithelial markers  and acquisition of mesenchymal cell markers . This study describes a highly efficient procedure for generating lens cells from patient-specific iPSCs. The ability of different hESC and iPSC lines to differentiate into specific cell types has been shown to vary by cell line. For example, foreskin iPS lines spontaneously differentiate into retinal pigment epithelium (RPE) cells at a lower rate than iPS lines from the eye Lens research aims to gain insights into the cellular and molecular basis of ophthalmological disease. Furthermore, the lens serves as a valuable experimental system with which to address fundamental biological questions. The lens is an encapsulated avascular organ that focus light onto the retina. Millions of individuals are blinded or exhibit visual impairment, due to pathologies of the lens Clearly, iPS technology provides a new method for establishing a patient-specific model of lens development and disease. In 1901, Hans Spemann introduced the concept of inductive interactions by studying lens development Our data demonstrate that the transduction of defined factors  into patient-specific HLECs leads to the formation of iPSCs with high reprogramming efficiencies. Our analysis indicates that one iPS clone, iPS2, was only partially reprogrammed to an ES cell state based on gene expression profiles and the inability to form EBs. The iPSCs we generated via the expression of defined factors in HLECs were highly similar to HESCs in terms of both morphology and physiology. Next, we use small molecules to induce the lens-specific differentiation of the patient-specific iPSC. Multiple signal transduction pathways, including FGF, TGF-β and Wnt, have been implicated in lens development In vertebrates, lens progenitor cells originate from the preplacodal region (PPR) Approximately 20–25% of patients undergoing cataract surgery experience PCO within 2 years Cataracts are a common human disease often observed in animal models as well. Over the last several decades, considerable progress has been made in identifying and characterizing many of the molecules involved in normal lens biology and its pathology. Much of this research has been made possible through the establishment and use of lens models. However, a systematic approach for studying human cataracts has been hampered by the lack of appropriate human-derived models. Moreover, because of the small size of the families available for detailed genetic investigations, it is necessary to develop appropriate human-derived models to identify the genes responsible for cataract formation and to analyze the mechanisms leading to lens opacification. There are several advantages of using patient-specific HLEC-derived iPSCs regarding efficiency, convenience and application value. First, several studies have demonstrated that cells from the target tissue are more easily differentiated back to their original source than other cells HLECs have generally been discarded in cataract operations. In our study, we found that these cells were useful materials for the production of cataract patient-specific iPSCs. These iPSCs can be efficiently induced to differentiate into lens cells using defined chemical conditions. Our research revealed that iPS cells that are induced by OCT-4, SOX-2, and KLF-4 inherently express lens-specific markers, indicating that these cells are valuable for lens regeneration research. In this study, we present a technique for reprogramming HLECs to pluripotent stem cells and the direct differentiation of these cells into lens progenitor cells, thereby artificially directing cell fate through the use of transcription factors. It is necessary to study iPS lines from multiple patients and compare these different iPS lines with different ES cell lines. We will further investigate this human-derived model, thoroughly characterize it and put it into effect in our future research. In conclusion, we present a preliminary step towards the goal of patient-specific model construction and lens regeneration based on iPS technology and a three-step induction procedure. These findings demonstrate the usefulness of this model for studying the molecular mechanisms of human lens development and the biology of lens cells differentiated from cataract patient-derived iPSCs.


To compare the population-level impact of two World Health Organization-endorsed strategies for improving the diagnosis of tuberculosis (TB): same-day microscopy and Xpert MTB/RIF .We created a compartmental transmission model of TB in a representative African community, fit to the regional incidence and mortality of TB and HIV. We compared the population-level reduction in TB burden over ten years achievable with implementation over two years of same-day microscopy, Xpert MTB/RIF testing, and the combination of both approaches.Same-day microscopy averted an estimated 11.0% of TB incidence over ten years , and prevented 11.8% of all TB deaths (95% UR: 7.7%–27.1%). Scaling up Xpert MTB/RIF to all centralized laboratories to achieve 75% population coverage had similar impact on incidence  and greater effect on mortality . Combining the two strategies  generated synergistic effects: an 18.7% reduction in incidence (95% UR: 5.6%–39.2%) and 33.1% reduction in TB mortality (95% UR: 18.1%–50.2%). By the end of year ten, combining same-day microscopy and Xpert MTB/RIF could reduce annual TB mortality by 44% relative to the current standard of care.Scaling up novel diagnostic tests for TB and optimizing existing ones are complementary strategies that, when combined, may have substantial impact on TB epidemics in Africa. Tuberculosis (TB) remains a leading infectious cause of death worldwide, contributing to over 1.4 million deaths annually; yet 35% of all cases go undetected, and an additional 7% are diagnosed too late to prevent death A key contributor to this burden of morbidity and mortality is poor diagnosis; only 60% of new TB cases in Africa are ever detected Since 2010, the WHO has issued policy guidelines to mitigate both of these weaknesses. To reduce losses to follow-up, the WHO endorsed “same-day microscopy,” recommending that systems be developed to collect sputum, perform microscopy, report results, and initiate treatment on the day of initial presentation In making this decision, one important consideration for policymakers is the projected impact of each approach on TB incidence and mortality. Epidemiological models can provide valuable insight in this regard We constructed a compartmental model of a generalizable African TB epidemic using ordinary differential equations, with a structure  based onIndividuals enter the model at age 15 and exit at death. Upon infection, individuals progress either to latent infection or active TB, which is modeled as a combination of smear-positive  and smear-negative (modeled as a weighted average of smear-negative pulmonary and extrapulmonary) disease. Individuals with active TB undergo diagnostic attempts at a constant rate, and the success of each attempt depends on the diagnostic sensitivity , probability of loss to follow-up before treatment initiation, and probability of treatment success after initiation. Successful diagnostic attempts  result in immediate reduction of mortality risk and elimination of infectiousness. Unsuccessful attempts result in return to the active infectious pool. Reactivation of latent disease, reinfection, and relapse all occur at defined rates. We incorporated HIV status (positive versus negative), assuming that people living with HIV have a higher probability of developing active TB  and undergo diagnostic attempts more often, as the symptoms of their disease are more severe. However, people living with HIV are also more likely to have smear-negative TB and are more likely to die, either from TB or from other causes. Because the logistics of diagnosing and treating drug-resistant TB are complex (and not undertaken to a great extent in Africa), and data on rates of drug resistance outside of South Africa are sparse, we did not explicitly include drug resistance in this analysis. However, since the number of drug resistant cases detected by Xpert may be a key consideration in decision-making, we do provide estimates of this quantity as a function of the overall prevalence of drug resistance among incident TB cases over the subsequent ten years in any given local setting.We fit the model to a generic population representative of the WHO African Region by bringing the population to equilibrium in 2002, using an iterative routine Standard of Care: 15% of people with TB presenting for evaluation are lost to follow-up before initiating treatment , scaled-up over two years, starting in 2013;Xpert MTB/RIF: Replacement of sputum smear with Xpert (resulting in increased sensitivity for smear-negative TB from 0% to 72% Same-day Microscopy plus Xpert: Simultaneous implementation of same-day diagnosis (modeled as a reduction in pre-treatment loss to follow-up for smear-positive TB) and scale-up of Xpert MTB/RIF as a replacement for smear microscopy (modeled as an increase in sensitivity for smear-negative TB) over two years, starting in 2013.Under each scenario, we assume that a similar proportion of individuals who test negative with the primary test (sputum smear microscopy or Xpert) will nonetheless be diagnosed with TB and started on therapy, due to a combination of high clinical suspicion and results of ancillary testing . This proportion of people with TB who are treated empirically is assumed to remain constant regardless of whether Xpert or smear is used for primary diagnosis.th and 97.5th percentiles of results from 1000 simulations.Additional model parameters were estimated from the literature and derived from WHO estimates for the African Region . Our priOver the ten-year period from 2013 to 2022, adult TB incidence was projected to fall from 417 to 331 per 100,000/year in the absence of additional diagnostic interventions . This deThe adult TB mortality rate fell from 92.4 to 59.2 per 100,000/year. Because we assumed a continued linear decline in HIV incidence, HIV-associated TB accounted for a decreasing proportion of TB deaths, from 52% in 2013 to 44% in 2022. By contrast, the annual number of TB deaths in adults without HIV remained relatively stable, declining by only 5.4% from 2003 to 2022.Implementation of same-day microscopy in 2013–2014 reduced cumulative TB incidence over the ten-year period by 11.0% . This reduction in incidence corresponds to 58,000 cases averted in an area with a 2003 adult population of 10 million  and inteMortality declined by a similar proportion: an 11.8% cumulative reduction (95% UR: 7.7%–27.1%), corresponding to 12,000 lives saved. This mortality reduction was differential according to HIV status, with same-day microscopy averting 16.2% of all TB deaths among HIV-uninfected adults, but only 6.9% of HIV-associated TB deaths.Over the ten-year analysis period, scale-up of Xpert MTB/RIF as a first-line diagnostic test – achieving 75% population coverage by January 1, 2015 – averted a similar proportion of TB incidence  as immediate implementation of same-day microscopy . This imScale-up of Xpert reduced cumulative mortality by 23.8% (95% UR: 8.6%–33.4%), a substantially greater impact than seen with same-day microscopy. The mortality benefit of Xpert relative to same-day microscopy was confined to people living with HIV: Xpert averted 17.3% of TB deaths among HIV-uninfected adults versus 16.2% for same-day microscopy, but 30.9% of HIV-associated TB deaths versus 6.9% for same-day microscopy.Scale-up of Xpert in an area with a 2003 population of 10 million adults resulted in 325,000 true-positive diagnoses of TB being made by Xpert over the ten-year period from 2013–2022. Thus, if one in ten Xpert test results were positive for TB, 325,000 tests would need to be performed per year on average: assuming a mean volume of 12.5 tests per day and 260 testing days per year from a four-module Xpert machine , 100 machines would be required to achieve this level of scale-up. If 2.9% of TB cases were multidrug-resistant (MDR) A combined diagnostic strategy in which smear-positive patients were treated on the same day, while smear-negative patients had access to centralized Xpert, yielded additive effects on both incidence and mortality, averting 99,000 cases in an area with a 2003 population of 10 million  and saving 35,000 lives  . Under tThe effect on mortality was even greater, with the combined diagnostic intervention achieving a 44.2% reduction (95% UR: 26.8%–69.5%) in the annual TB mortality rate relative to the standard of care by the end of 2022.The impact of same-day microscopy on TB incidence after ten years was most sensitive to parameters that determined the relative amount of incident TB due to recent infection (versus reactivation of latent disease) and the proportion of TB that would be diagnosed empirically. Same-day microscopy had greater effects in scenarios where more incident TB cases were caused by recent infection and fewer cases were diagnosed empirically . The proThis mathematical model demonstrates that optimization of an existing tool (sputum smear microscopy) and scale-up of a novel tool (Xpert MTB/RIF) have similar projected population-level impact on TB incidence in communities representative of the WHO African Region. Both same-day microscopy and Xpert, implemented alone, averted 9–11% of TB cases over ten years in our model. Such reductions are likely to vary by epidemiological setting; this simplified, generic model can serve as a starting point for decision-makers across a variety of settings to develop projections that are locally relevant. Although Xpert and same-day microscopy can independently provide important impact, transforming the trajectory of the TB epidemic in Africa will require a combined diagnostic strategy that includes both rapid initiation of treatment for smear-positive patients and improved sensitivity for smear-negative TB (19% modeled reduction in cumulative incidence), in conjunction with other measures for TB prevention, treatment, and risk-factor management.Our projections of the independent effects of same-day microscopy and of Xpert MTB/RIF are comparable to those of other published models, as well as common-sense calculations. Assuming that 80% of incident TB in Africa is due to recent infection This study is among the first to evaluate alternative diagnostic tests for TB using a comparative-effectiveness framework. In the current setting of constrained resources for TB control, studies of comparative effectiveness are increasingly important to decision-makers who must frequently choose between alternative interventions, both of which are globally recommended and likely to be highly cost-effective. We show here that Xpert and same-day microscopy are similarly effective, and complementary, strategies. Combining same-day reporting with scale-up of Xpert MTB/RIF increased population-level impact substantially over either strategy alone and was the only approach that led to substantial gains toward TB elimination during our ten-year analysis period. Similarly, Theron and colleagues compared Xpert alone against Xpert with a series of adjunctive tests, finding that a combination of Xpert and smear microscopy had higher accuracy and lower cost than either test alone Optimizing existing diagnostic tests and introducing novel ones represent synergistic strategies for enhancing TB control. Same-day microscopy is a more immediately deployable intervention that can lower TB incidence by reducing losses to follow-up prior to treatment initiation and targeting those individuals who contribute most to TB transmission. Although Xpert is likely to require more resources for scale-up, it has greater benefit for those at highest risk of death, supporting the current recommendation for use of Xpert as a first-line test in people living with HIV By assuming complete scale-up over two years and very high levels of population coverage , this analysis represents an idealized “best-case scenario” and overstates the gains achievable by these interventions in practice. In reality, both ensuring same-day treatment initiation for smear-positive cases and scale-up of Xpert are challenging tasks. In the case of Xpert, we estimated that, in a setting where one in ten individuals tested actually had TB and Xpert could be deployed at high volume, at least 100 four-module machines would be needed to cover a population of 10 million adults. This number would be even higher in a setting where screening of patients with unexplained cough was less efficient  or Xpert could not be run at high volume . In addition to the logistical hurdles of developing new diagnostic algorithms and increasing laboratory infrastructure, sufficient drug supplies must be made available to handle increased demand , and clinic workflow must be changed to prioritize collection of sputum samples early in the day. Although these obstacles are difficult to overcome in many high-burden settings in Africa, innovations in technology and integration of services may make this task more feasible in coming years. Moreover, both same-day microscopy and Xpert scale-up are likely to have other beneficial effects not captured in this analysis. Use of a rapid, accurate test such as Xpert may increase physicians' index of suspicion for TB and their confidence in the laboratory system; implementation of same-day microscopy would likely support infrastructure  that could improve the management of diseases other than TB as well. Despite the difficulty inherent in explicitly modeling these various logistical hurdles, our transparent and generalizable modeling framework provides useful information to decision-makers in the field. For example, by understanding that the idealized impact of optimized smear microscopy is similar to that of replacing smear by Xpert, decision makers can prioritize these options based on the logistical hurdles and resource requirements faced in their setting rather than on expected differences in epidemiological impact.This analysis has other important limitations. As with other TB modeling analyses In conclusion, same-day microscopy and Xpert MTB/RIF are complementary diagnostic strategies with the potential to avert substantial morbidity and mortality in communities within the WHO African Region over a 10-year period. The population-level effectiveness of same-day microscopy and Xpert – each implemented in isolation – is similar (9–11% reduction in incidence), but a combined diagnostic strategy including both interventions had additive impact, reducing annual TB mortality by an estimated 44% relative to the current standard of care. Scale-up of Xpert and other novel diagnostics does not ameliorate the need to optimize smear microscopy, nor will same-day microscopy services lessen the potential impact of novel diagnostic tests. Ultimately, a combination of diagnostic improvements – addressing both diagnostic sensitivity and the speed of initiating treatment – and other TB control strategies will be necessary to make transformative progress toward TB elimination.Information S1Model Description and Equations. Full description of mathematical model and symbolic representation of equations.(DOC)Click here for additional data file.Information S2Model Code. Model code in R format.(R)Click here for additional data file.Information S3Equilibrium Population. Comma-separated value (CSV) file containing the equilibrium population, required for running of the model code (Information S2).(CSV)Click here for additional data file.


Interleukin-10 (IL-10) is a negative regulator of immune responses and was previously shown to be expressed by human nasal endothelial cells, while the adhesion molecule MECA-79 plays a role in trans-endothelial migration of immune competent cells. In this study we investigate the relationship between endothelial IL-10 and MECA-79 expression to address the question whether immune competent cells could be affected at the mucosal entry site.Nasal turbinate biopsies were taken from house dust mite allergic patients, before and after nasal allergen provocation. Subsequent slides of biopsies were stained for IL10, MECA-79, CD34, and IL10-Receptor. Capillaries, arteries/veins, and sinusoids were evaluated separately.90% of sinusoids are IL-10 positive and all sinusoids are negative for MECA-79, while 4.8% of capillaries are positive for IL-10, and 2.2% are positive for MECA-79. Although about 47% of arteries/veins are positive for IL-10 and 57.1% are positive for MECA-79, only about 20% are positive for both markers. Furthermore, we showed that the myo-fibroblasts surrounding all sinusoids stain positive for IL10R.IL10 expression on vascular structures is not related to MECA expression for sinusoids and capillaries and only partly related on arteries/veins, however sinusoidal endothelial IL10 expression is always seen in combination with IL-10R expression of sinusoidal myo-fibroblasts. Allergic rhinitis is a disease with a severe impact. As many as 10-25% of the population in Western societies suffers from allergic rhinitis and its prevalence of allergic rhinitis continues to increase. AlthougThe nasal mucosa is characterized by a complex micro vascular anatomy. It consists of a dense subepithelial network of capillaries, a system of capacitance vessels or sinusoids and arteriovenous anastomoses; the arteries/veins. Vascular activities are involved both in the mucosal defence and physiological functions of the nose, thereby also contributing to inflammatory airway diseases such as allergic rhinitis. Nasal oWe investigated the three morphologically different endothelial structures vessels separately. Firstly, the sinusoids are specialized structures that may expand and contract thanks to smooth muscle actin (SMA) positive (myo)fibroblasts that line these structures. Their capacitance volume is under neural regulation and may also be influenced by humoral factors, allowing for direct action on the vasculature, or indirectly via sensory neural stimulation.Secondly, the blood vessels are the main avenue by which inflammatory cells reach the nasal mucosa. Given the role of IL-10 in regulating the activity of mast cells-16 dendrThirdly, capillaries’ main function of local oxygen supply would at best only indirectly contribute to an allergic response, albeit that, like for all types of blood vessels, vascular leakage from capillaries will contribute to mucosal swelling and rhinorrhoea.In this manuscript we will focus on potential mechanisms by which endothelial IL-10 expression may affect clinical symptoms. To this extend we looked into the expression of IL-10 and the IL-10 receptor on the different endothelial structures in the nasal mucosa. In order to look into the effect on cell-trafficking, we identified the main cellular entry sites for inflammatory cells in the nasal mucosa by using the MECA-79 antibody which is directed against ligands of L-selectin, We aimed to investigate how these entry sites relate to endothelial IL-10 expression, at baseline as well as after nasal provocation.In a previous study we colleDermatophagoides pteronyssinus ALK-Abellò, Nieuwegein, the Netherlands]. On day 7 (24 hours after the provocation), patients re-entered the clinic and a second nasal biopsy was obtained. All visits took place between February and May 2000, outside the Dutch grass pollen season. Neither vehicle provocation nor local anaesthesia led to the induction of clinical symptoms and incubated with 10% (v/v) normal goat serum (NGS)  for 10 minutes. To block endogenous avidine and biotin, antibodies were diluted in 1% (v/v) blocking reagent . The sections were then incubated for 60 minutes at room temperature with the primary antibody. Mouse anti-human monoclonal antibodies directed against functionally active L-selectins (CD62L) as detected with anti-MECA-79 (dilution 1:100) [BD Pharmigen] and against endothelial cells (anti-CD34 dilution 1:400)  were used, or appropriate IgG isotype control  at room temperature. The sections were then rinsed with PBS for 5 minutes and incubated for 30 minutes with a biotinylated goat anti-mouse (1:50) immunoglobulin antiserum  at room temperature. Subsequently, the sections were rinsed with PBS for 5 minutes and incubated for 30 minutes with alkaline-phosphatase conjugated goat anti-biotin, and New Fuchsine substrate for 20 minutes.Staining against IL-10 receptor was performed with poly power vision-mouse-AP against IL-10R (dilution 1:50)  according to manufacture’s instructions. Slides were incubated for 30 minutes. The sections were then rinsed with PBS for 5 minutes and incubated for 30 minutes with PV-mouse-AP at room temperature. The sections were then rinsed with PBS for 5 minutes and incubated with New Fuchsine for 20 minutes. Subsequently, the slides were incubated with haematoxylin for 10 min.Staining with anti IL-10 (dilution 1:150) was performed using tyramine signal amplification (TSA). After incubation with biotinylated goat anti-mouse Ig serum, endogenous peroxidise was blocked using 0.2% (w/v) hydrogen peroxide and 50% (v/v) methanol in PBS. Slides were then incubated with streptavidin conjugated peroxidise  for 30 minutes, biotinyl tyramide in Tris-HCl buffer for 10 minutes for amplification of the signal, alkaline-phosphatase conjugated goat anti-biotin, and New Fuchsine substrate for 20 minutes.All slides were evaluated by two observers who were blinded from the clinical outcomes and time point of provocation. The number of positive and negative vessels was determined per square millimetre. The capillaries, arteries / veins, and sinusoids were distinguished on the basis of histology, as well as the CD-34.We used the Mann-Whitney test to assess statistical differences between medians of different groups. P-values < 0.05 were considered statistically significant.In this analysis we consider the different types of endothelial structures in the nasal submucosa. To detect the vessels, we used the general blood vessel specific marker CD34 Figure . We diffNext we investigated which types, or parts, of vessels could act as entry site for inflammatory cells by determining the expression of activated L- selectin ligand (MECA-79), which is required for transendothelial migration. Under steady state conditions, hardly any MECA expression could be detected on sinusoids  in lymphoid tissues. However, in diseases characterized by chronic inflammation such as asthma, Crohn’s disease and rheumatoid arthritis induction of L-selectin ligands is seen in postcapillary endothelial cells in tissues other than lymphatic tissue,26. It aTo our knowledge, this is the first detailed report on MECA- and IL-10 distribution among the different vascular structures in the nasal mucosa. We found that the sinusoids are mostly negative for MECA. This expression pattern suggests that, at the site of the sinusoids, IL-10 cannot play a role by influencing the activity of cells entering the tissue influx. The presence of IL-10R positive (myo)-fibroblast around the sinusoids suggests that we must consider a direct affect on the sinusoids. This staining pattern suggests the existence of a ‘functional unit’ of IL-10 expressing sinusoidal endothelial cells and IL-10 receptor expressing myofibroblasts around these sinusoids. Such functional unit could theoretically influence vasoconstriction and relaxation of these sinusoids. Interestingly, it was shown that IL-10, in addition to its anti-inflammatory activity, influences the contractibility of (myo)fibroblasts. BecauseIn the current study, we saw a significant rise in sinusoidal IL-10 expression after provocation. This could be in line with the observation that IL-10 has a direct inhibitory effect on smooth muscle cells which woCapillaries do not seem to play a role in the inverse relationship between endothelial IL-10 expression and clinical symptoms, as these structures are hardly ever IL-10 (4.8%) or MECA (2.2%) positive. The most complicated relationship we observed between IL-10 and MECA is for the remaining blood vessels comprised of arteries and veins. Both markers are expressed at about 50% of the vessels. However these are not the same vessels. Detailed analysis of arteries/veins suggests that IL-10 and MECA have an independent expression pattern, were the number of double positive vessels in a given patient can accurately be predicted on the basis of the individual expression pattern of IL-10 and MECA in that same patient. Even if we would consider this observation to be representative of a potentially dynamic inflammatory process, this would still imply that in a substantial number of blood vessels the endothelial IL-10 expression would be able to influence the biological activity of inflammatory cells that migrate into the tissue. Although potentially interesting we have not explored whether the 50% of vessels that stain positive for either IL-10 or MECA could represent just arteries or veins.While elaborating on the function of IL-10 localised on the different vessels we can think of two possible ways in which IL-10 could work. Given the inhibitory effect of IL-10 on leukocytes, the firIn the present study, on the basis of immunohistochemical findings, elaborations were made on two possible ways in which endothelial IL-10 expression could play a role in symptoms of allergic rhinitis. We hypothesize that both a direct effect of sinusoidal IL-10 expression on the surrounding (myo)fibroblasts and an indirect effect of IL-10 on the biological activity of migrating inflammatory cells is likely. Our approach also revealed that although blood vessels form a continuum that each of the type of vessels  has an a unique expression pattern in regards to IL-10 and MECA, and that even within the latter group of arteries and veins local differences occur. This work contributes to our understanding of local regulation of inflammatory processes.WF and CvD have received private and public funding for basic research and clinical studies from GSK, Allergopharma, Stallergen, ALK, NWO, FWO, and the European union. The other authors have no conflict of interest.BM analysed/interpreted the data and drafted the manuscript, DvE and EdG preformed the immunohistochemistry and contributed the manuscript, while WF and CvD designed the study, interpreted the data, and contributed to the manuscript. All authors have approved the final version of the manuscript.


India carries one quarter of the global burden of multi-drug resistant TB (MDR-TB) and has an estimated 2.5 million people living with HIV. Despite this reality, provision of treatment for MDR-TB is extremely limited, particularly for HIV-infected individuals. Médecins Sans Frontières (MSF) has been treating HIV-infected MDR-TB patients in Mumbai since May 2007. This is the first report of treatment outcomes among HIV-infected MDR-TB patients in India.HIV-infected patients with suspected MDR-TB were referred to the MSF-clinic by public Antiretroviral Therapy (ART) Centers or by a network of community non-governmental organizations. Patients were initiated on either empiric or individualized second-line TB-treatment as per WHO recommendations. MDR-TB treatment was given on an ambulatory basis and under directly observed therapy using a decentralized network of providers. Patients not already receiving ART were started on treatment within two months of initiating MDR-TB treatment.Between May 2007 and May 2011, 71 HIV-infected patients were suspected to have MDR-TB, and 58 were initiated on treatment. MDR-TB was confirmed in 45 (78%), of which 18 (40%) were resistant to ofloxacin. Final treatment outcomes were available for 23 patients; 11 (48%) were successfully treated, 4 (17%) died, 6 (26%) defaulted, and 2 (9%) failed treatment. Overall, among 58 patients on treatment, 13 (22%) were successfully treated, 13 (22%) died, 7 (12%) defaulted, two (3%) failed treatment, and 23 (40%) were alive and still on treatment at the end of the observation period. Twenty-six patients (45%) experienced moderate to severe adverse events, requiring modification of the regimen in 12 (20%). Overall, 20 (28%) of the 71 patients with MDR-TB died, including 7 not initiated on treatment.Despite high fluoroquinolone resistance and extensive prior second-line treatment, encouraging results are being achieved in an ambulatory MDR-T- program in a slum setting in India. Rapid scale-up of both ART and second-line treatment for MDR-TB is needed to ensure survival of co-infected patients and mitigate this growing epidemic. In India, multidrug-resistant tuberculosis (MDR-TB) is estimated to account for 2.3% : 1.8–2.8) of new cases and 17.2% (95% CI: 14.9–19.5) of previously treated TB cases Infection with Human Immunodeficiency Virus (HIV) further complicates the management of MDR-TB. India has the third highest HIV burden in the world with an estimated 2.5 million people living with HIV/AIDS in 2006 Systematic reviews have shown that few studies describe MDR-TB treatment outcomes from high HIV prevalence settings and that HIV status is often inconsistently reported Overall, there is a serious deficiency in reports describing treatment of MDR-TB in HIV-infected patients, especially in programmatic settings in resource-constrained countries. A recent study from Lesotho showed that starting early empirical treatment for suspected MDR-TB patients using a community-based treatment approach in mainly HIV-infected adults resulted in high culture conversion, although significant mortality remained While Mumbai has a widely accessible DOTS program in place under the Revised National Tuberculosis Control Program (RNTCP) for treatment of drug-susceptible tuberculosis, treatment for drug-resistant TB was, until recently, only available through the private sector. As a result, MDR-TB treatment has often been administered in a chaotic, unregulated manner using non-pre-qualified anti-TB drugs and at prohibitive prices for the large majority of patients. Given the large MDR-TB disease burden, there is an urgent need to scale up appropriate treatment for MDR-TB in India and in order to achieve this, a decentralized approach may be most appropriate. Special focus should be on early diagnosis and treatment initiation, particularly among HIV-infected populations.In February 2006, Médecins Sans Frontières (MSF) started an HIV project in Mumbai, offering care and treatment to people living with HIV unable to access the public system or who could not obtain appropriate ART regimen, including second-line antiretroviral drugs. MSF has been treating MDR-TB among HIV-infected individuals in this project since May 2007. MDR-TB treatment subsequently became available in the public sector in Mumbai in late 2010.This report aims to describe patient and treatment outcomes in a cohort of HIV/MDR-TB co-infected patients treated on an outpatient basis, in an urban, overpopulated slum setting in Mumbai, India. To our knowledge, this is the first analysis of MDR-TB patient outcomes in HIV-infected patients in India.This was a prospective, observational cohort study using data routinely collected at each consultation and entered into an electronic database.MSF has been operating a clinic in Khar, a suburb in Mumbai, India since 2006. It is specialized in HIV care and provides treatment free of charge to patients referred by accredited public and public-private Antiretroviral Treatment Centers (ART Centers) from the greater Mumbai area and by a network of community non-governmental organizations (NGOs). The great majority of patients are slum-dwellers.An MDR-TB component was added to the HIV treatment program in May 2007. MDR-TB care and treatment is offered on an outpatient-clinic basis. In general, patients have been referred to the clinic for evaluation of confirmed or suspected MDR-TB, by clinicians working in the Ministry of Health and Family Welfare network of ART centers, and by private physicians or community NGOs.All HIV-infected patients with bacteriologically confirmed MDR-TB or those suspected to have MDR-TB, based on clinical findings and TB treatment history but without bacteriological confirmation who were followed up in the clinic between May 2007 and May 2011 were included in this study.HIV-infected patients with symptoms suggestive of TB or any patient referred to the clinic with MDR-TB suspicion were screened with two sputum samples for acid-fast bacilli (AFB) by sputum smear microscopy and two for AFB culture. Culture and DST was performed using BACTEC MGIT 960 system . Drug susceptibility testing (DST) was performed on all culture positive isolates against four first-line TB drugs: isoniazid, rifampicin, ethambutol and streptomycin and four second-line drugs  and ofloxacin) using World Health Organization (WHO) approved guidelines for drug concentrations. Samples were processed in the Laboratory Medicine Department of the P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, which is accredited by the Revised National Tuberculosis Control Program (RNTCP) and the College of American Pathologists (CAP) to perform first line DST to Streptomycin, isoniazid, rifampicin and ethambutol. For the phenotypic second line DST, the laboratory was performing internal quality control weekly and twice a year inter –laboratory external quality control with CAP accredited laboratories. Some patients (approximately ten) brought DST results from various private TB laboratories in Mumbai showing resistance to isoniazid and rifampicin. Patients were started on treatment with second-line TB drugs, after baseline investigations and counselling were completed, and were asked to produce sputum for culture and DST before starting treatment.The clinic treatment protocols follow WHO international guidelines The standardized regimen included six drugs: pyrazinamide, capreomycin, moxifloxacin, ethionamide, cycloserine and PAS. The standardized regimen was modified once the DST results became available. The same standardized regimen was continued for patients with unconfirmed MDR-TB, diagnosed on clinical grounds and treatment history. All TB drugs were dosed according to bodyweight. Dosing and drugs were also changed in response to severe adverse effects. The severity of adverse events was defined by laboratory criteria (whenever quantifiable) or based on effect on patient tolerance and adherence. Adverse events were aggressively managed and regimen modification was done as last resort.st line ART, while patients in need of 2nd line ART  received a protease inhibitor-based regimen Patients, unless already on ART, were started on antiretroviral drugs as soon as they were tolerating second-line TB drugs, irrespective of CD4 cell count. Two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor were used for patients being prescribed 1Patients in stable clinical condition were started on MDR-TB treatment on an ambulatory basis. Patients were evaluated by a multidisciplinary team of trained physicians, nurses, social workers and psychologists. The same team provided care and treatment for HIV in a “one stop” service. The attending physician examined patients clinically at least once a week in the first month of treatment and once or twice a month thereafter, depending on the patient's clinical condition. Special attention was given to identify gastro-intestinal adverse events, hearing loss or tinnitus (including monitoring audiograms), depressive or psychotic symptoms, and signs of hypothyroidism. Sputum smear and culture were repeated monthly until the end of the intensive treatment phase and every other month during the continuation phase. Chest X-ray was not routinely used for treatment monitoring.In the very early stages of the program, a self-administered treatment strategy was tried, but the strategy soon shifted to twice-daily directly observed treatment (DOT). DOT was planned to be available no more than 10 minutes walking distance from patients' homes. This was possible thanks to a community network of public/private health structures and non-governmental organizations (NGOs) that acted as DOT providers. These included public health posts, private practitioners and local NGOs, the great majority of which were based in slums.DOT providers were trained to provide DOT, administer injections and monitor for adverse effects. MSF supplied the providers with second line TB drugs, materials to give injections, masks and N95 respirators, and training on infection control. Each DOT provider was supervised weekly by phone and monthly by an MSF staff visit. Patients went to the DOT provider daily to receive TB treatment and monthly to the MSF clinic for medical and psychosocial follow-up.Patients who were unable to ambulate or were otherwise unstable clinically were admitted to a charity hospital under the supervision of the MSF clinical team. Patients were also admitted if they experienced severe adverse effects or other clinical complications precluding outpatient management. Treatment was continued for a minimum of 18 months total duration, including a minimum of 6 months intensive treatment with the injectable agent. All treatment was provided free of charge.Demographic and clinical information were systematically recorded on standardized clinical files designed specifically for the program. Information on all patients was prospectively collected and entered into an electronic database. Information on HIV and antiretroviral treatment was collected in the same patient file but entered in a separate database. Each patient had a unique identification code that was used in both databases. Trained personnel extracted clinical, treatment, and laboratory data from individual patient records regularly and entered them into both databases. A full time data manager routinely checked data entry for accuracy and completeness.The study protocol was approved by the Independent Ethics Review Board of Médecins Sans Frontières, Geneva, Switzerland. As this was a study of routinely collected monitoring data, informed consent from the patients was not obtained. The named ethics committee specifically waived the need for consent.Data from all patients diagnosed with MDR-TB between May 2007 and May 2011 were used in the analyses. Patient characteristics at admission in the MDR-TB program and their status at the end of the study period were summarized using descriptive statistics. Kaplan-Meier analysis was performed to assess survival probability. Patient follow-up ended when an outcome was recorded, or censored on May 15, 2011. Possible outcomes, defined according to WHO guidelines, included: cure, treatment completed, death, default, transfer out, treatment failure, and ‘alive and on treatment’ M. tuberculosis strains after three months of second-line treatment. This patient was switched to first-line treatment and excluded from the outcome analysis  bacteriologically confirmed and 14 (20%) unconfirmed) and registered in the MSF clinic . Twelve analysis . BaselinTwenty-five (43%) of the 58 patients were sputum AFB-positive and 47(81%) were culture positive before starting treatment. Ten patients were smear- and culture-negative, four of whom had extra-pulmonary TB. Overall, 50 patients (86%) had pulmonary TB, seven of whom were diagnosed with both pulmonary and extra-pulmonary TB . Eight patients (14%) were diagnosed as having only extra-pulmonary TB, three of whom had signs of TB at more than one site. Among the patients with pulmonary TB, 39 were confirmed and 11 remained unconfirmed, while 5 extra pulmonary TB patients were bacteriologically confirmed and three were started on treatment based on clinical condition and TB treatment history .All but five patients (91%) had received previous TB treatment, half of them in the public sector and half of them in the private or both sectors. Strikingly, half of these patients had a history of previous exposure to second-line TB drugs, most commonly fluoroquinolones. This is reflected in the 40% ofloxacin resistance among bacteriologically confirmed cases in this patient cohort . No MDR-The median CD4-count at the time of MDR-TB treatment initiation was 135 cells/µl (IQR: 85–193). Most patients, especially during the later years, were registered in the clinic at the time of diagnosis of MDR-TB. Thirty-seven patients (64%) were on ART before a diagnosis of MDR-TB was made. Eight patients were on second line ART. Three patients never started ART: two migrant workers from Nepal who defaulted early in MDR-TB treatment and one patient who was about to start at the time of the analysis.Among the 23 patients initiated on treatment prior to May 2009 (24 months of follow-up), seven patients (31%) were cured, four (17%) have completed treatment, four patients (17%) died, six defaulted (26%) and two patients (9%) failed treatment.Among these 23 patients, eight TB strains were resistant to ofloxacin ; two of them completed treatment, one died and five defaulted. Patients without fluoquinolone resistance (15) were more likely to be cured and less likely to default than patients with resistance to fluoquinolones (p<0.05). The two patients who failed treatment had no baseline resistance to ofloxacin or to injectable drugs.Overall among the total 58 patients, eight patients (14%) were cured, five (9%) completed treatment, 13 patients (22%) died, seven defaulted (12%), two patients (3%) failed treatment and 23 patients (40%) were alive and in treatment at the end of the observation period.Out of 25 patients with a positive sputum smear at baseline, thirteen (52%) achieved sputum smear conversion in the first two to four months of treatment (median 2 months). Similar rates of culture conversion were observed. Out of the 44 patients with a baseline positive culture, 23 (52%) achieved culture conversion in the first four months of treatment.Survival curves for the 58 patients who started on treatment are shown in Death occurred after a median of 27 days in treatment (range 1–229 days). Causes of death for the 13 patients who died included four deaths not related to TB or treatment .Among the seven patients who did not complete treatment, one was a Nepalese migrant worker who decided to repatriate, one a sex worker who had problems to access the clinic and one a 16 year old adolescent who refused to continue after 15 months of treatment despite the absence of adverse events and receiving intensive counseling and psychosocial support. Two patients diagnosed with XDR-TB were also lost to follow-up despite efforts from the psychosocial team to trace them. Two more patients had no apparent reason to default.Adverse events associated with second line DR-TB treatment are summarized in The most common adverse drug reactions were related to abnormal thyroid function  due to PAS and/or ethionamide, and hypokalaemia, due to the aminoglycosides and capreomycin. Drug dosages had to be adjusted in two patients with renal impairment. For patients with psychosis/depression, seizures, hearing loss and tendonitis, the drugs assumed to be responsible were discontinued. All other events were managed symptomatically and without physician-directed discontinuation of therapy.Out of 58 patients who started TB treatment, 37 were already on ART, 18 started ART during TB treatment and three never started as previously described. This is, to our knowledge, the first report on MDR-TB treatment outcomes from a cohort of HIV-infected patients in India In Mumbai, MDR-TB treatment was until recently (July 2010) only available through an unregulated, private health sector The Mumbai MSF clinic has been trying to address these MDR-TB challenges since the program started in 2007. The outcomes recorded so far in the program demonstrate the feasibility of treating HIV/MDR-TB co-infected patients in such a setting. Given the high rate of resistance to fluoroquinolones in India A large investment has been made in the clinic in TB infection control measures that prevent transmission of TB. A comprehensive infection control plan was designed and implemented, including environmental and administrative measures and personal protective equipment for the clinic staff. The clinic defined specific MDR-TB days, carefully organized the spacing between MDR-TB consultations, improved ventilation in consultations rooms, corridors and waiting areas and trained the staff in prevention of TB transmission. An infection control committee was established and it is now planned to expand infection control measures to the community and household level through innovative, small-scale interventions.However, several challenges remain in this program. The high pre-treatment and early mortality rates highlight the need for intensive case finding strategies, rapid diagnosis and initiation of DR-TB treatment to reduce mortality and improve outcomes. Late referral to the clinic and advanced disease may partly explain these high rates. Studies from HIV programs have shown than even if excellent outcomes can be achieved and maintained among patients receiving antiretroviral therapy, program outcomes such as high pre-treatment mortality and pre-treatment loss-to-follow-up rates remain largely unreported In this Mumbai cohort, several patients were started empirically on second-line drugs before DST results were available, based on WHO recommendations In Mumbai, a community-based model of MDR-TB treatment was found to be feasible, as has been shown in other countries There are some limitations to our analysis. Overall, the size of the cohort is relatively small and therefore does not allow definitive conclusions to be drawn regarding factors that may contribute to patient outcomes, particularly the high pre-treatment mortality and default from treatment. Further research aims to investigate these areas in more detail.However, to date, there is a dearth of documented program experiences from resource-constrained settings treating co-infected patients; the global cohort of HIV/MDR-TB co-infected patients being treated is still discouragingly small.Despite these limitations, and despite high fluoroquinolone resistance and extensive prior second-line treatment, this report provides encouraging evidence of the feasibility of offering ambulatory MDR-TB treatment in HIV-infected populations, even in a challenging, urban, resource-constrained setting. This community-based treatment model may have been successful in reducing mortality of HIV/MDR-TB co-infected patients. Rapid scale-up of both antiretroviral therapy and second line treatment for MDR-TB is needed to ensure survival of co-infected patients, and control the emerging epidemic of drug resistant TB in Mumbai.


Stress is inherent in our society and results in great suffering, increased healthcare cost, and impaired work performance. An online program can offer a cost effective and practical solution that can help cope better with stress. In this study, we evaluated the effectiveness of an 8-week online mindfulness stress reduction (OSR) program in reducing work related stress and burnout and in improving well-being in a corporate call center. We also evaluated whether 1-hour weekly group practice and experience sharing at the workplace would improve program retention and engagement.161 participants were randomized either to wait-list control , OSR (N=54) or OSR and weekly group meetings . The Perceived Stress Scale, Maslach Burnout Inventory , Mindful Attention Awareness Scale and SF36  were administered at baseline, post intervention and at 8-week follow-up.We observed overall a greater post intervention decrease in stress and exhaustion and increase in mindfulness, emotional well-being and role functioning in the OSR+grp  compared to OSR  and wait-list control (d<0.4). This overall improvement was also maintained at follow-up for most measures. The improvement was significantly greater for the OSR compared to CTL for stress and emotional well-being, and for OSR+grp compared to CTL for all outcomes except for professional efficacy. OSR+grp improved significantly more than OSR for stress, emotional well-being and emotional role functioning. Weekly group practice significantly increased program engagement and reduced dropout rate (13% for OSR+grp compared to 55% for OSR).An online mindfulness stress management program when combined with weekly group practice can offer a practical and cost-effective approach to decrease stress and burnout and improve mindfulness and well-being at the workplace.