To evaluate the use of social media of individuals with diabetes mellitus (DM).Both web-based and in-clinic surveys were collected from individuals with DM. Descriptive and correlation analyses were employed to evaluate respondents’ diabetes-specific social networking site behaviors.Forty-five patients with DM completed the web-based survey and 167, the clinic-based survey, of whom only 40 visited diabetes-specific social networking sites. Analysis of online survey data indicated that self-reported adherence to lifestyle recommendations was significantly correlated (p < 0.01) with visiting the sites. Clinic-based survey data found that patients who reported using DM-specific web sites monitored home glucose values more often and had better compliance with insulin administration (both p < 0.05) compared with nonusers.This study provides insight into why individuals visit DM-specific social networking sites. Certain self-management behaviors may improve as a result of visiting these sites. Further work is needed to explore how to leverage social media technology to assist patients with the management of DM. Social media has gained prominence as a source for healthcare information. This study used both online surveys and surveys of clinic patients with diabetes to understand why patients with diabetes use DM-specific social networking sites. The authors found that patients go to these resources to both offer and receive encouragement for their health condition. Visiting DM-specific social networking sites influenced more positive diabetes care behaviors, such as adhering to diet and exercise, glucose monitoring and insulin use. Further research is needed to understand how to incorporate social media into the care of diabetes. Social media is becoming an important resource for healthcare information . Based oDiabetes mellitus (DM) is a chronic illness that can be effectively managed through physical activity, healthy dietary habits and the appropriate and timely use of pharmacotherapies to lower blood glucose levels . ResearcMost of the research on the influence of social media on DM care has focused on widely used platforms without a clear focus on a specific health condition . ResearcSupplementary Material.Information regarding DM was collected through surveys. As part of the survey, participants were asked to answer questions broadly classified as: demographic information; educational level; marital status; diabetes-specific information ; nature and frequency of diabetes-specific social networking site usage; dietary habits and diabetes self-care activities and reasons for using the site . The surSupplementary Material for list of sites). Participation was anonymous and required individuals to be at least 18 years old. The clinic-based survey was offered to all patients with DM returning for a follow-up appointment to an outpatient academic endocrinology practice in the southwest USA. Once individuals read a brief consent document and agreed to participate, they proceeded with the self-completed paper survey. No compensation was offered for participation. Questions on the clinic survey were identical to the web-based version, except formatting was adjusted to accommodate the flow of the outpatient setting . Additionally, the clinic-based survey incorporated chart review to obtain accurate information on medications, most recent HbA1c value and body mass index. A question on self-reported income range was added as well. The study was approved by the Institutional Review Boards of the participating institutions.Both the web-based and clinic surveys were convenience samples. The web-based survey data were collected through a self-administered Qualtrics platform, advertised through DM-specific social networking sites  and UK (n = 14) combined submitted their responses to the web-based survey . Mean  logged into the DM-specific social networking sites and analyzed the frequency of reasons for both offering and seeking information (derived from Question 15). The two most common reasons respondents indicated they would be moderately to extremely likely to visit the website was to offer support or encouragement to other individuals with DM or to share personal experiences A. For inNext, we separately examined self-reported behaviors reported by persons who completed the web-based survey data and those who completed the clinic-based survey. Looking at the data from the web-based survey first, significant positive correlations were observed between respondents who offered advice on social media versus their own self-reported eating A and exeClinic-based surveys did reveal some significant differences between DM-specific social networking siteusers and nonusers. Users had a slight but significant increased frequency in the number of days per week where they reported checking their glucose. DM-specific social networking site users reported checking their glucose on average 7 (1) days per week while nonusers checked 6 (2) days per week (p = 0.047). Self-reported insulin therapy compliance was also slightly but significantly (p = 0.014) higher among users of social media, with users taking insulin 7 (1) days per week and nonusers 6 (2) days per week. No differences in other behaviors, such as dietary and exercise compliance or compliance with oral medications were detected.When combining web and clinic based surveys (n = 85), data showed that 57/85 (69%) of respondents were moderately to extremely likely to follow the advice they received from the website about lifestyle changes for DM management and 54/85 (65%) were moderately to extremely likely to follow the advice received from the website about clinical DM care . Moreover, the information obtained from the websites helped about 52/85 (63%) of DM survey participants in communicating with their healthcare provider about their DM.Social media has now become an important source of healthcare information for patients and their caregivers. Patients use online resources to join the community of patients with similar diagnoses to engage, share information on management of their health conditions and provide and receive support for themselves. Previous studies have shown that social media websites can help patients gain knowledge about DM and information to cope better with their daily management routine. However, little is known about the reasons they may visit these sites or if visiting these sites somehow positively impacts diabetes self-management behaviors.In the current study, we assessed DM-specific social networking site utilization to gain an insight into how patients employ these resources and to determine if there was any impact on self-management behaviors. Two different approaches were applied. First, an online survey was conducted of individuals while they were actively utilizing the website. This provided information on users only. Second, an assessment of a clinic-based population of patients with DM was conducted. The second method, in addition to providing information on prevalence of DM-specific social networking site usage in a clinic-based population, yielded preliminary data on the characteristics of users and nonusers and differences in self-management behaviors between the groups.Statistical comparisons are not appropriate between data derived from the websites and the clinic, but some similarities and differences in characteristics of survey participants can be noted in data derived from the two sources of information. For instance, the mean age of participants from the online survey and that of the clinic-based survey was in the 50s. Additionally, website users in both surveys predominately used insulin, were predominately white and had education beyond high school. Those who completed the survey online were comprised mostly of women and reported having balanced mixed of Type 1 and Type 2 DM. In contrast, DM-specific social networking site users who completed the clinic survey had a similar composition of men and women and were mostly patients with Type 2 DM.The clinic-based survey indicated that the prevalence of DM-specific social networking site use, at least in this population was low – only about a quarter of respondents stated they visited these sites. The clinic survey revealed some differences in users versus nonusers. Social media users were significantly younger, and a greater proportion had Type 1 DM versus nonusers, whereas nonusers had a predominance of Type 2 DM. Additionally, more users reported as not being married and it could be speculated that a lack of family support drove more of the users to seek support on social media sites. Finally, a majority of users were employed, while nonusers were either unemployed, students or retired. It is possible that work-life balance may have driven busier employed individuals to the convenience of social media use.Beyond simply examining reasons for visiting DM-specific social networking sites, we also sought to evaluate whether utilizing these tools were associated with any specific desirable diabetes behaviors. For instance, when analyzing survey data completed online , there was a positive correlation between the self-reported frequency of following a healthy dietary plan and performance of physical activity with going to the website to offer advice about these activities. It is likely that individuals going to the sites to offer advice were already successful at self-management and wanted to pass on tips. Analysis of the clinic-based surveys also revealed some positive impacts of DM social media use on reported self-management behaviors. Compared with nonusers, users had a slight but significantly increased compliance with the frequency of weekly glucose monitoring and insulin administration.Diabetes self-management education and providing individualized strategies to achieve metabolic and lifestyle goals is integral to effective management. To this end, specific standards of care have been developed . What haThere are limitations to the current study. First, the sample size of website users, both online and clinic-based participants was small. In particular, the low participation in social media use noted in the clinic participants may have precluded detection of differences in other measures, such as HbA1c or body mass index. Furthermore, participants in both the web-based and clinic survey overall had reasonably good glycemic control, as evidenced by the HbA1c (both self-reported from the online survey and measured from the clinic). In the clinic-based survey, social media nonusers had an HbA1c comparable with the users, so the nonusers may have felt that additional advice  may not have been needed to improve glycemic control. Finally, the survey was limited to English speakers only, respondents were largely of white race and behaviors were self-reported.Despite the limitations, results of this study provided insight into why individuals visit DM-specific social networking sites. Moreover, certain self-management behaviors, such as self-monitoring of blood glucose and insulin administration may be improved. The results from the in-clinic surveys showed that only a small number of participants use social media for their diabetes management. Further work is needed to explore how to incorporate DM-specific social networking site use into the clinical environment and how to leverage the technology to assist patients with their condition.The role of social media in management of DM remains relatively unexplored. Rather than a convenience sample (such as this study), a randomized control trial, appropriately statistically powered to detect differences in reported self-management behaviors or HbA1c, would be helpful. DM patients  could be randomized to visiting social media sites, with a control group maintaining usual care. Outcomes such as HbA1c and behaviors as measured here could be tracked. Future research that examines the relationship between online posting and diabetes-related self-care behaviors in a longitudinal design would help to clarify the role of website use in diabetes management. Lastly, including a more diverse race/ethnic patient population in future studies is needed.Social media is becoming an important resource for healthcare information.There remains a paucity of data on how patients with diabetes mellitus (DM) use social media or how it may impact their behaviors.Both internet- and clinic-based surveys were conducted of patients with DM to assess the behaviors of individuals with DM who either offered or sought information on diabetes-specific social media websites.Forty-five patients completed the web-based survey and 167 the clinic-based survey, of whom only 40 visited social media sites.Respondents most often visited sites to offer support for DM or to seek such support for themselves.Analysis of online survey data indicated that self-reported adhering to lifestyle recommendations was significantly correlated (p < 0.01) with visiting the sites.Clinic-based survey data found that patients who reported using DM-specific web sites stated they monitored their home glucoses more often and reported better compliance with insulin administration (both p < 0.05) compared with nonusers.Study limitations included small sample size, lack of race/ethnic diversity of respondents and self-reported behaviors.Further work is needed to explore how to incorporate DM social media use into the clinic environment and how to leverage the technology to assist patients with their condition.Click here for additional data file.


Antiepileptic drugs (AEDs) have repeatedly shown inconsistent and almost contradictory effects on the neurocognitive system, from substantial impairments in processing speed to the noticeable improvement in working memory and executive functioning. Previous studies have provided a novel insight into the cognitive improvement by bumetanide as a potential antiepileptic drug. Through the current investigation, we evaluated the longitudinal effects of bumetanide, an NKCC1 co-transporter antagonist, on the brain microstructural organization as a probable underlying component for cognitive performance. Microstructure assessment was completed using SPM for the whole brain assay and Freesurfer/TRACULA for the automatic probabilistic tractography analysis. Primary cognitive operations including selective attention and processing speed, working memory capacity and spatial memory were evaluated in 12 patients with a confirmed diagnosis of refractory epilepsy. Participants treated with bumetanide (2 mg/ day) in two divided doses as an adjuvant therapy to their regular AEDs for 6 months, which followed by the re-assessment of their cognitive functions and microstructural organizations. Seizure frequency reduced in eight patients which accompanied by white matter reconstruction; fractional anisotropy (FA) increased in the cingulum-cingulate gyrus (CCG), anterior thalamic radiation (ATR), and temporal part of the superior longitudinal fasciculus (SLFt) in correlation with the clinical response. The voxel-based analysis in responder patients revealed increased FA in the left hippocampus, right cerebellum, and right medial temporal lobe, while mean diffusivity (MD) values reduced in the right occipital lobe and cerebellum. Microstructural changes in SLFt and ATR accompanied by a reduction in the error rate in the spatial memory test. These primary results have provided preliminary evidence for the effect of bumetanide on cognitive functioning through microstructural changes in patients with drug-resistant epilepsy. Impairment in diverse cognitive domains is a frequently occurring component in epileptic syndromes either due to the natural course of the disease or the antiepileptic drug (AED) related adverse effects. Various forms of epilepsies cause neurocognitive abnormalities such as substantial memory disturbances –3. The sStructural neuroimaging studies have repeatedly reported the association between cognitive deficits and changes in white matter microstructure in epileptic syndromes , 21. StrPatients with the diagnosis of medically refractory epilepsy entered the study. The criteria were considered according to the International League Against Epilepsy (ILAE), Classification of Epileptic Seizures ; that dePatients monitored 4 months prior to bumetanide administration in order to ensure the steady therapeutic doses and effects. Subsequent to these primary steps, based on observations from our former work  bumetaniAll of the participants or their guardians assigned written informed consent. The study protocol approved by the ethical committee of Tehran University of Medical Sciences and got its' registration code from the Ministry of Health and Medical Education (IRCT201012115368N1). The basic characteristics of the participants are described in 2 with 30 directions. The repetition time (TR) and echo time (TE) were 13 and 101 ms for this image. Extra brain volumes received four no diffusion weighting (b = 0 s/mm2) with opposing phase-encode directions (Anterior-Posterior and opposite). The EPI readout uses the size of 128 × 128 and field of view (FOV) of 256 × 256 mm2 and a slice thickness of 2 mm, isotropic voxels of 2 × 2 × 2 mm3. Sixty eight slices acquired to cover the whole brain. The total acquisition time for imaging was about 10 min.MRI scans were acquired from the patients in two time-points; once before adding bumetanide to their stable regimen and the second 6 months after receiving bumetanide. The same scanning procedure run one time for healthy controls. We used a 3.0T Siemens Magneto Tim Trio whole-body scanner  with a 32-channel head coil. Anatomical images acquired with a high-resolution, T1-weighted MPRAGE . One hundred and seventy six contiguous sagittal slices provided whole-brain coverage. The Diffusion Weighted Imaging obtained using a single-shot spin echo EPI sequence. Whole brain diffusion images received b = 700 s/mmFor each subject, all DWI scans with b = 700 concatenated into a single data set and corrected for the subject head motion. Eddy current and EPI distortions also corrected with required B-matrix adjustments. The tensor model fitted to the corrected data and then mean diffusivity (MD) and fractional anisotropy (FA) calculated from the tensor's eigenvalues . Data prp < 0.05 level in cluster size ≥20 voxels which were considered as significant. Further on, the mean value of FA and MD in significant areas calculated for longitudinal analysis. Finally, GLM was set up to run paired comparison (t-test) in order to assess other brain regional changes between pre- and post-treatment phases.Voxel-based analyses (VBA) were performed using statistical parametric mapping 12 (SPM 12). To create study template, B0 images of control subjects normalized to the Montreal Neurological Institute (MNI) EPI template. Estimated parameters applied to all FA and MD images. Then these images averaged and smoothed with 6 mm full-width at half-maximum (FWHM) smoothing filter. Afterward, native FA and MD images of controls and patients in two-time points normalized to the study templates and smoothed with a 6 mm FWHM. The general linear model (GLM) was set up to evaluate group differences (pre-treatment vs. control). The statistical threshold of SPM [The Family Wise Error (FWE)] used for multiple comparisons correction of the voxel at a Longitudinal tractography was performed by TRACULA tool in Freesurfer . AutomatSince there is a difference in the signal-to-noise ratio (SNR) in diffusion images, we operated our calculations through TRACULA based on the mean of the signal intensity of whole brain images. SNR values averaged for each participant and applied for statistical variability analysis. As the differences in head motion between the study groups could induce false difference diffusion parameters . The aveij is the value of the j-th motion measure of the i-th subject. Mj, Qj, and qj are the median, upper quartile, and lower quartile of the j-th motion measure over all subjects who were included in a group comparison  consisted of three conditions: neutral, congruent and incongruent. These assessments illustrated the image processing speed and working memory capacity as parts of the executive functions. Tests were computerized using Psychopy software v.1.84.2 and were used through standard operating procedures.Percentage of changes in seizure frequency was the clinical efficacy index. Seizure frequency calculated according to the following equation:nth month)/n(Seizure frequency in 1st month+… + Seizure frequency in the Patients with at least 50% monthly seizure frequency reduction were considered as responders .t-test). It should be noted that all these analyses corrected for 18 comparisons (reflecting 18 tracts) using Bonferroni correction and the significance level considered <0.002 (P < 0.002). Longitudinal analysis was performed using a linear mixed model in which FA and MD values incorporated in each tract equation as the dependent variables. Being responder or non-responder considered as the between-subject factor while the scan order  and intended hemisphere regarded as within-subject repeated measures. Gender, age, intracranial volume, and TMI considered as the covariates in this analysis. Significant differences in responder group were considered supportive of the study hypothesis. Also, this model determined whether changes in cognitive scores varied in responders, non-responders and over time that bumetanide administered. We calculated FA and MD values of changes between before and after phases of bumetanide administration. Then Spearman correlation analysis applied between them and changes that found through cognitive assessments. P < 0.05 was considered as the significance level. SPSS v23.0  was used for all the performed analyses.Comparison between the control group and pre-treatment phase of the patient group done with mann-whitney . Also, there were no significant differences in TMI between groups in two comparison settings , the cerebellum (P = 0.02) and in the left parahippocampal gyrus (P = 0.01) independent to the seizure frequency index after treatment  of tracts. Based on the longitudinal analyzing of 18 tracts, significant reversal changes found in FA (FA increased) in the UF, ATR, and CST tracts over time that bumetanide administered. Additionally, MD decreased in the SLFt tract . The obsn = 8) and non-responders (n = 4)] presented in Moreover, our data showed that FA increased in the CCG, ATR, and SLFt which meaningfully correlated with the clinical response . Data [Mp-value:0.001) and performance in the spatial memory enhanced  after regarding age and sex as covariates; but no significant changes observed in association with the clinical response. These data suggest that bumetanide affect the memory function independent of the seizure frequency fluctuations.Cognitive measures of the control group, pre- and post-bumetanide administration phases can be seen in Spearman correlation analysis of cognitive functioning and DTI changes revealed a significant relationship between changes in FA, MD, and cognitive indices. Statistically, are markable association observed between FA in left ATR, MD in the right SLFt, and the percentage of the errors in the spatial memory test .In this study, we explored the association between brain microstructural abnormalities and different dimensions of the neurocognitive functioning after bumetanide administration in medication-resistant epilepsy. Significant changes in DTI metrics were revealed in different neuronal tracts in patients compared with control subjects and also in pre- and post-treatment phases of the patient group within a 6 month period. Moreover, this analysis successfully provided evidence for the existence of the hypothesized causal link between the indices of cognitive functions including reaction time and errors, and FA or MD values.Currently provided data showed 67% responsiveness to bumetanide as an add-on therapy. Despite the low concentrations of the bumetanide in the brain following systemic administration , 38, recAlthough the combination therapy makes the accurate pharmacological interpretations difficult, it might be noticeable that 10 patients had been receiving different dosages of valproate within their background anticonvulsant regimen which signify the possible positive interactions. Valproate is a broad spectrum anticonvulsant drug that exerts its effects through several ways that could potentially underlie the observed clinical responses and cognitive impacts . BesidesSix patients had brain lesions while remaining of the cases were MRI negative. There have been works pointing to the increased expression levels of bumetanide-sensitive co-transporter, NKCC1, in hypoxic, edematous or secondary progressive hemorrhagic states in animal models of traumatic brain injuries , 51. On Upgrading the observed correlation between increased FA in the CCG, ATR, and SLFt and better bumetanide response, to a more precise cause and effect model requires a well-controlled study that enables statistical inferences. However, it might be assumed that efficient neuronal connections shift the overall states of the brain toward more stable states and subsequent cognitive and clinical improvements.In order to provide a framework for understanding the central effects of bumetanide in temporal lobe epilepsy, we investigated microstructural changes in the cerebral white matter. The possible mechanisms underlying TLE include disturbed myelination patterns and alteration of neuronal density , 55. AftThe decline in white matter integrity has been represented by the two key changes: the reduction in FA and enhancement in MD . One recIn addition to the research-based applications of probabilistic tractography approaches , recent Previous studies indicated that FA value could be an appropriate representative of the white matter constitution . We showFinally, one of the mortality related phenomenon of epilepsy is the sudden unexpected death in epilepsy or “SUDEP” that frequently occurs in resistant states. The underlying processes of SUDEP are yet to be clarified but some cardiovascular related mechanisms such as the myocardial atrophy and leucocyte infiltration—due to the catecholamine surge of seizures- have been evidenced through microscopic analyses . Due to In accordance with our findings, there is a wide microstructural distortion in the brain of epileptic patients which might be the cause of the observed abnormalities in associative behavior and cognitive impairments. Adjunctive bumetanide treatment may lead to the microstructural reorganization that mostly affects the epileptic regions; The outcome that could be the underlying contributor for its cognition improving effects.ZG designed the experiment, collected data, contributed to the analysis and interpretation of data, and wrote the initial draft of the manuscript. LS contributed to the analysis and writing the manuscript. MO has contributed to data analysis and interpretation. AY contributed to the analysis and interpretation of data. AT designed the experiment and collected data. ES revised the draft of the manuscript. MH was main responsible for hypothesis making, general guidance and project management. The final version of the manuscript was approved by all the authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Frontal sinus mucocele with intra-orbital extension represents a rare benign cyst-like lesion. Surgical management could be summarized in an open approach, an endoscopic marsupialization or a combined procedure. The present study reports a case of frontal mucocele with wide intra-orbital invasion treated with endoscopic marsupialization assisted by an image-guided navigation system.A 34-year-old African male was referred to the otolaryngology clinic for unilateral supraorbital swelling and post-nasal drip. A clinical ophthalmic assessment showed normal ocular movement, the absence of diplopia and normal visual acuity. CT scan showed a large soft tissue density lesion originating from the right frontal sinus with a supero-medial orbital erosion. The mass invaded the orbital cavity compressing and dislocating the eyeball forward and laterally. An image-guided ESS was performed according to Draft type IIa. Frontal mucocele’s inferior wall was open in order to drain muco-purulent content. No complications were detected and the patient was completely recovered with open frontal sinus drainage at 4 months follow-up visit.We have successfully treated a wide intra-orbital frontal mucocele with an endoscopic marsupialization thanks to image-guided navigation system support. This technology prevented an external approach with associated morbidity and longer hospitalization.Navigated assisted endoscopic approach with marsupialization can be considered a safe treatment for FM with orbital extension. In particular, the image-guided system could be useful if bony landmarks are missing, if orbital erosion is present, and to completely drain lateral and multi-cystic lesions. DespiteWe report a case of a frontal mucocele with wide intra-orbital invasion which occurred in a young African male treated with endoscopic marsupialization assisted by an image-guided navigation system. This paper has been reported in line with SCARE criteria .2A 34-year-old African male was referred to the otolaryngology clinic for unilateral (right) supraorbital swelling and post-nasal drip A. The paThe patient was then referred to a clinical ophthalmic evaluation that showed normal ocular movement and absence of diplopia for any gaze position associated with normal visual acuity.Computed tomography scan showed a large soft tissue density lesion (36 x 14 mm) in the right frontal sinus. Superior wall of the sinus was intact while the frontal sinus floor was eroded and the mass extended into the supero-medial aspect of the orbit A-B. ThenPrior to surgical procedure, the patient was treated with oral levofloxacin and corticosteroid for one week. An image-guided ESS was performed using the Medtronic® Fusion Compact™ ENT navigation system. After bilateral maxillary sinus mucoceles treatment with marsupialization and hyperplastic tissue removal, the frontal mucocele was approached. To better reach the fronto-ethmoidal recess and directly visualize the mucocele the frontal sinus floor was resected between lamina papyracea and the middle turbinate (Draft type IIa). Frontal mucocele’s inferior wall was open in order to drain muco-purulent content. At the end of the procedure the orbit appeared decompressed and the periorbita intact. No intra-operative or post-operative complications were detected and the patient was discharged the day after the procedure.At 4 month follow-up visit the patient was completely recovered with open frontal sinus drainage B. In add3The first paper describing the endoscopic marsupialization of sinus mucocele was published by Kennedy et al. in 1989 . In the In this context, an-image guided ESS could represents the treatment of choice to avoid an open approach and the resulting complications. An image-guided navigation system allow the surgeon to perform surgical endoscopic procedure in a safer context thanks to a direct comparison of the intraoperative anatomy with preoperative imaging information. The surgeon may point to a specific structure during the procedure and then view the location of the instrument tip on the CT scan. This navigation system guide the ENT surgeon in surgical dissection preserving surrounding critical structures, such as the olfactory fossa, skull base, vascular structures (anterior ethmoid artery), and orbit . Frontal4Navigated assisted endoscopic approach with marsupialization can be considered a safe treatment for FM with orbital extension. In particular, the image-guided system could be useful if bony landmarks are missing, if orbital erosion is present, and to completely drain lateral and multi-cystic lesions.No funding was received for this research.All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest , or non-financial interest  in the subject matter or materials discussed in this manuscript.Ethical approval was not required and patient identifying knowledge was not presented in this report. Ethical approval is waived.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All authors contributed significantly and in agreement with the content of the article.Manuele Casale: Operating surgeon; Conceptualization; Methodology; Writing – Review & Editing.Andrea Costantino: Conceptualization; Methodology; Writing – Original Draft; Writing – Review & Editing.Lorenzo Sabatino: Operating surgeon; Data Curation.Moffa Antonio: Writing – Original Draft.Michele Cassano: Supervision.Vittorio Rinaldi: Operating surgeon; Supervision.Not applicable.Andrea Costantino, MD.Not commissioned, externally peer-reviewed.


Hemorrhagic fever with renal syndrome (HFRS) is a rodent-associated zoonosis caused by hantavirus. The HFRS was initially detected in northeast China in 1931, and since 1955 it has been detected in many regions of the country. Global climate dynamics influences HFRS spread in a complex nonlinear way. The quantitative assessment of the spatiotemporal variation of the “HFRS infections-global climate dynamics” association at a large geographical scale and during a long time period is still lacking.This work is the first study of a recently completed dataset of monthly HFRS cases in Eastern China during the period 2005–2016. A methodological synthesis that involves a time-frequency technique, a composite space-time model, hotspot analysis, and machine learning is implemented in the study of (a) the association between HFRS incidence spread and climate dynamics and (b) the geographic factors impacting this association over Eastern China during the period 2005–2016. The results showed that by assimilating core and city-specific knowledge bases the synthesis was able to depict quantitatively the space-time variation of periodic climate-HFRS associations at a large geographic scale and to assess numerically the strength of this association in the area and period of interest. It was found that the HFRS infections in Eastern China has a strong association with global climate dynamics, in particular, the 12, 18 and 36 mos periods were detected as the three main synchronous periods of climate dynamics and HFRS distribution. For the 36 mos period (which is the period with the strongest association), the space-time correlation pattern of the association strength indicated strong temporal but rather weak spatial dependencies. The generated space-time maps of association strength and association hotspots provided a clear picture of the geographic variation of the association strength that often-exhibited cluster characteristics . Another finding of this work is the upward climate-HFRS coherency trend for the past few years (2013–2015) indicating that the climate impacts on HFRS were becoming increasingly sensitive with time. Lastly, another finding of this work is that geographic factors affect the climate-HFRS association in an interrelated manner through local climate or by means of HFRS infections. In particular, location , grassland and woodland are the geographic factors exerting the most noticeable effects on the climate-HFRS association .The proposed synthetic quantitative approach revealed important aspects of the spatiotemporal variation of the climate-HFRS association in Eastern China during a long time period, and identified the geographic factors having a major impact on this association. Both findings could improve public health policy in an HFRS-torn country like China. Furthermore, the synthetic approach developed in this work can be used to map the space-time variation of different climate-disease associations in other parts of China and the World. China has the largest number of HFRS infections in the world (9045 cases in 2016). Previous studies have found that HFRS infections are related to climate. However, the spatiotemporal distribution of the association between HFRS outbreaks at a large scale and global climate dynamics , as well as the identification of the geographic factors impacting this association have not been studied yet. This is then the dual focus of the present study. Strong synchronicities between global climate change and HFRS infections were detected across the entire study area that were linked to three main time periods . Specifically, strong and weak associations with non-point effects were detected in the south and middle-north parts of the study region, respectively. The climate impacts on HFRS were becoming increasingly sensitive with time. On the other hand, the geographic location  makes a considerable contribution to the climate-HFRS association. As regards land-use, grassland and woodland were found to play important contributing roles to climate-HFRS association. Certain space-time links between global climate dynamics and HFRS infections were confirmed at a large spatial scale and within a long time period. The above findings could improve both the understanding of the HFRS transmission pattern and the forecasting of HFRS outbreaks. Hantaan virus, HTNV, and Seoul virus, SEOV) are Apodemus agrarius and Rattus norvegicus ) In total, 127 wavelet coherency spectra were obtained (one at each city in Eastern China) by means of wavelet coherency analysis . By averh| and τ denote the spatial distance (in meters) and temporal separation (in months), respectively. The numerical 10-fold cross validation results confirmed that BME generates accurate coherency estimates . Hence, the SI section presents several of these BME-generated spatiotemporal maps that offer a detailed picture of the strength of the climate-HFRS association in Eastern China for each month of the period 2005–2016 .Given the selected character bands (30–42 mos), the mean coherency values for the entire 2005–2016 period were calculated at each city (thus providing the space-time coherency dataset needed for further processing). This dataset was then analyzed using the SEKSGUI software library . The calTo avoid the edge-effects of wavelet coherency analysis at the first and last year, the 120 maps of the period 2006–2015 were used to explore further the climate-HFRS association pattern across the study area . Based oFor the entire study region, the spatial heterogeneity of q-statistic. The result showed that the maps of q = 0.80 with significance 1.68E-09). The same process was applied in q-values ranged from 0.65 to 0.84 with the associated significance ranging from 1.18E-09 to 2.00E-09  and the response variable (association strength). The results showed that all ten variables have a significant influence on the climate-HFRS association  that excluded the spatial coordinates of the ten explanatory variables in order to avoid possible interactions of the geographic factors with spatial coordinates and to obtain additional insight about the geographic factors effects on the climate-HFRS association. Comparing the results in SI  and during a relatively long time period (2005–2016). The study is characterized by the originality of the HFRS dataset and the large amount of local and regional information available about several features of the climate-HFRS association in the time-frequency and the space-time domains.Public health scientists and officers are concerned with questions like: “Are the HFRS outbreaks in a geographical region associated with global climate dynamics?” “How global climate dynamics affects the HFRS transmission pattern at a large spatial scale?” “Which geographic factors have significant impacts on the climate-HFRS association?” Answers to these and similar questions can offer valuable information for HFRS early warning, monitoring, and control purposes. The present work developed a novel synthetic quantitative analysis that can help answer these scientific questions. Methodologically, this approach is based on an integration of wavelet analysis, Bayesian maximum entropy, hotspot analysis and gradient boosting machine techniques. To the best of our knowledge, this is the first study that uses such a synthetic framework to assess climate-HFRS associations at a large geographic scale  that has been found to be suitable for large-scale analysis of ecological processes . It has Another outcome of this work is related to the fact that wavelet analysis detected a strong association coherence between global climate dynamics and HFRS infections in Eastern China at 3 yrs cycle, indicating that both climate index and HFRS infections possess character multi-cycles with a 3 yrs period . In thisWe further explored the features of the climate-HFRS association by integrating information about the temporal variation of the association at Eastern China cities using the BME theory. The space-time variability of the climate-HFRS association represented quantitatively by the coherency covariance model showed a strong temporal dependence , indicatAt this point, another potentially significant finding was the presence of an upward climate-HFRS coherency temporal trend, especially during the period 2013–2015, which indicated that the climate impacts on HFRS in Eastern China were becoming increasingly sensitive with time. This phenomenon may be due to the fact that the frequency of extreme precipitation events shows a temporally increasing trend in the monsoon region of Asia , 54, whivs. cold spot map of Public health officers may find it useful to study and evaluate, as appropriate, the geographical distribution of the climate-HFRS association in the BME-generated maps, like that of In light of the above findings and inferences, an important further objective of this work was to investigate potential geographic determinants of the variation of climate-HFRS associations in Eastern China during 2005–2016. Generally, global climate dynamics is a macroscopic natural process at the earth scale exerting certain impacts on microscopic climate in local or regional domains with specific geographic features. In other words, local geographic information may either strengthen or weaken the link between global climate dynamics and HFRS infections by revealing local climatic conditions that can affect the rodents’ living environment , 11. Acc# model is used  the partial dependencies of the geographic factors exhibit a few minor differences compared to the GBM model above. These findings deduced that interaction effects exist between the geographic factors, and that the GBM# model can provide additional information concerning the possible effects of the geographic factors.Such findings would be valuable for local health management purposes, since, as was suggested earlier, health officers in hot spot areas should pay more attention to the global climate effects on HFRS transmission . NoticeYet another objective of this work was to study the way geographic factors impact climate-HFRS associations in Eastern China. We considered that a better investigation of the phenomenon is possible if the impacts of the geographic factors on the climate-HFRS association were divided into two parts, including impacts on climate and impacts on HFRS infections (rodent population). When the geographic factors have significant effects on both local climate and HFRS infections, they were expected to also impact the climate-HFRS association. Global climate dynamics drives local climate with various consequences . For exIt is hoped that the synthetic quantitative approach (developed in this work to map the space-time variation of climate-HFRS association in Eastern China) could be also applied in the study of different climate-disease associations in other parts of China or the world. Lastly, future work should be directed toward integrating the general knowledge and the site-specific information of the present study to forecast HFRS outbreaks at a large spatial scale covering the entire China.S1 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 FigPopulation in 2015 was used to standardize the HFRS cases in each city. The unit of HFRS incidence is cases/100,000 population.(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 FigPurple line represents the cone of influence that delimits the region that is not influenced by edge effects; black line shows a = 5% significance level computed based on 500 bootstrap.(GIF)Click here for additional data file.S5 FigA–S represent Inner Mongolia, Heilongjiang, Jilin, Liaoning, Beijing, Tianjin, Hebei, Shanxi, Shandong, Shaanxi, Henan, Jiangsu, Anhui, Hubei, Zhejiang, Hunan, Jiangxi, Fujian and Guangdong, respectively.(TIF)Click here for additional data file.S6 FigA Composite space-time empirical and fitted theoretical covariance; B empirical and fitted theoretical covariance when T-lag equals to 0; C empirical and fitted theoretical covariance when S-lag equals to 0.(TIF)Click here for additional data file.S7 Fig(TIF)Click here for additional data file.S8 Fig(TIF)Click here for additional data file.S9 Fig(TIF)Click here for additional data file.S10 Fig(TIF)Click here for additional data file.S11 Fig(TIF)Click here for additional data file.S12 Fig(TIF)Click here for additional data file.S13 Fig(TIF)Click here for additional data file.S14 Fig(TIF)Click here for additional data file.S15 Fig(TIF)Click here for additional data file.S16 Fig(TIF)Click here for additional data file.S17 Fig(TIF)Click here for additional data file.S18 Fig(TIF)Click here for additional data file.S19 Fig(TIF)Click here for additional data file.S20 Fig(TIF)Click here for additional data file.S21 Fig(TIF)Click here for additional data file.S22 Fig(TIF)Click here for additional data file.S23 Fig(TIF)Click here for additional data file.S24 Fig(TIF)Click here for additional data file.S25 Fig(TIF)Click here for additional data file.S26 Fig(TIF)Click here for additional data file.S27 Fig(TIF)Click here for additional data file.S28 Fig(TIF)Click here for additional data file.S29 Fig(TIF)Click here for additional data file.S30 Fig(TIF)Click here for additional data file.S31 Fig(TIF)Click here for additional data file.S32 Fig(TIF)Click here for additional data file.S33 Fig(TIF)Click here for additional data file.S34 Fig(TIF)Click here for additional data file.S35 Fig(TIF)Click here for additional data file.


The goal of this study was to compare the performance of several database algorithms designed to identify red blood cell (RBC) Transfusion Related hospital Admissions (TRAs) in Veterans with end stage renal disease (ESRD).Hospitalizations in Veterans with ESRD and evidence of dialysis between 01/01/2008 and 12/31/2013 were screened for TRAs using a clinical algorithm (CA) and four variations of claims-based algorithms (CBA 1–4). Criteria were implemented to exclude patients with non-ESRD-related anemia . Diagnostic performance of each algorithm was delineated based on two clinical representations of a TRA: RBC transfusion required to treat ESRD-related anemia on admission regardless of the reason for admission (labeled as TRA) and hospitalization for the primary purpose of treating ESRD-related anemia (labeled TRA-Primary). The performance of all algorithms was determined by comparing each to a reference standard established by medical records review. Population-level estimates of classification agreement statistics were calculated for each algorithm using inverse probability weights and bootstrapping procedures. Due to the low prevalence of TRAs, the geometric mean was considered the primary measure of algorithm performance.After application of exclusion criteria, the study consisted of 12,388 Veterans with 26,672 admissions. The CA had a geometric mean of 90.8%  and 94.7%  for TRA and TRA-Primary, respectively. The geometric mean for the CBAs ranged from 60.3%  to 91.8%  for TRA, and from 80.7%  to 96.7%  for TRA-Primary. The adjusted proportions of admissions classified as TRAs was 3.2%  and TRA-Primary was 1.3% .The CA and select CBAs were able to identify TRAs and TRA-primary with high levels of accuracy and can be used to examine anemia management practices in ESRD patients. In 2011, the Centers for Medicare and Medicaid Services (CMS) changed their reimbursement policy for dialysis centers. Before 2011, certain items, including erythropoiesis-stimulating agents (ESAs) and iron for anemia, were billed separately as fee-for-service. Starting in 2011, CMS bundled ESAs into the case-mix-adjusted bundled payment system 45. Furth4clinical or claims-based algorithms exist to help identify hospital admissions where RBC transfusions were used to treat patients admitted with ESRD-related anemia.These studies, however, did not adequately isolate the indication for RBC transfusions, making it difficult to estimate the true prevalence of hospital transfusions as an end stage renal disease (ESRD)-related anemia management strategy 67. For e6clinical algorithms (CAs), leverage the rich clinical data available within the Veterans Health Administration (VHA) system. The claims-based algorithms (CBAs), explore measurement rules typical in administrative databases, such as Medicare and commercial health insurers.To close this gap, we evaluated two classes of database algorithms to identify Transfusion-Related Admissions (TRAs) in Veterans with dialysis-dependent ESRD. The clinical and claims-based algorithms designed to identify TRAs in Veterans with ESRD and receiving dialysis.The objective of this study was to determine the performance of the clinical and claims-based algorithms against chart-review. We produced the algorithms from historical data generated through routine care. We produced the reference standard, used to determine the performance of the algorithms, through structured chart-review by trained clinical reviewers.We used an agreement design  to evaluThis study used Veterans Affairs (VA) and Medicare data from 01/01/2008 to 12/31/2013 to evaluate the performance of the clinical and administrative TRA algorithms. The VA Corporate Data Warehouse (CDW) contains data for care provided by the VA (VA care) and outsourced care (VA fee-basis). The CDW contains nearly all clinical and administrative data found in the electronic health record for VA care but is limited to administrative data for VA fee-basis care . Since tWe used the Compensation and Pension Records Interchange (CAPRI) system, which provides National “read only” access to Veteran electronic health records, for chart-review validation . The resAll VA hospital admissions occurring in Veterans with an ESRD diagnosis and evidence of dialysis in the six months prior to admission met the initial inclusion criteria. Admissions in Veterans with alternative etiologies of anemia  were excluded. Healthcare Cost and Utilization Project (HCUP) Single-level Clinical Classification Software (CCS)  was usedclinical algorithm defined a TRA as a hospital admission with evidence of anemia (hemoglobin <9.0 g/dL) 24 hours prior to admission or 24 hours after admission AND a RBC transfusion occurring after the hemoglobin measurement AND within 24 hours after admission. Measurement details are provided in Section 2 of Appendix A for all algorithms.The claims-based algorithms identified TRAs in typical administrative claims data. The four claims-based algorithms map to the two definitions of TRA described in Section 3.4 below. The first, more inclusive definition represented anemia management with RBC transfusion regardless of the reason for hospitalization (labeled TRA). The second represented anemia management with RBC transfusion for Veterans hospitalized primarily for ESRD-related anemia (labeled TRA-primary).We evaluated how well four Claims-Based Algorithm 1 – Primary ESRD: Admission with a principal discharge diagnosis of chronic kidney disease (CKD) or ESRD AND a secondary diagnosis of anemia AND a procedure code for a RBC transfusion during the first two days of admission. This algorithm reflects standard coding practices for anemia in ESRD/CKD.Claims-Based Algorithm 2 – Any ESRD:Any discharge diagnosis for CKD or ESRD AND any discharge diagnosis for anemia AND a procedure code for a RBC transfusion during the first two days of admission.Claims-Based Algorithm 3 – Primary Anemia: Admission with a principal discharge diagnosis of anemia AND a procedure code for a RBC transfusion during the first two days of admission. This algorithm captures deviation from standard coding practices for patients admitted for anemia management.Claims-Based Algorithm 4 – Any Anemia: Admission with any discharge diagnosis for anemia AND a procedure code for a RBC transfusion during the first two days of admission.reference standard was established by human chart-review and used to evaluate the performance of the clinical and claims-based algorithms.The rd year resident in General Surgery). The form was pre-populated from VA clinical data with patient identifiers, date of admission, and the lowest hemoglobin value during the 24 hours before and after the admission.The electronic chart-review form guided the reviewers though the chart abstraction steps and captured standardized responses. The form was revised and tested during a series of meetings with clinical experts  and the two chart reviewers , and were allowed to search other notes as necessary. Chart-abstraction details and images of the user interface are provided in Appendix C.clinical algorithm , hypertension [99.2% ], dyslipidemia [75.5% ], heart failure [62.4% ] and coronary artery disease [72.4% ]  was 7.3 g/dL  for admissions not reviewed and 7.2 g/dL  for the admissions randomized to chart-review. Sampling Rule 2 (evidence of anemia but not RBC transfusion) had a slightly higher average hemoglobin 8.3 g/dL  and 8.1 g/dL  in both the non-reviewed and the chart-review groups, respectively. The average hemoglobin levels for Sampling Rules 3–4, which did not meet criteria for anemia, were above 10 g/dL for both chart-reviewed and the other hospital admissions  and the four claims-based algorithms (CBAs) based on the more inclusive TRA definition. Recall that, for this definition of TRA, the chart-reviewers were instructed to assume the anemia was related to ESRD unless alternative evidence was documented in the notes  and the RBC transfusion was the assumed management strategy for ESRD related anemia unless other evidence was observed in the notes .Table The geometric mean was the primary measure of performance for the database algorithms designed to identify ESRD-related TRAs. The geometric mean for TRAs ranged from 60.3%  for CBA 3 to 91.8%  for CBA 4. The CA had a geometric mean of 90.8%  and accuracy of 98.4% . The CBAs requiring principal discharge diagnoses of CKD/ESRD (CBA 1) and anemia (CBA 3) had the lowest geometric means 61.7%  and 60.3% , respectively. They also had the greatest discrepancy between geometric means and accuracy. Table Table deficiency and other anemia (73), hypertension with complications and secondary hypertension (2), CKD (3), and syncope (1). The more inclusive definition of TRAs grouped into 32 CCS categories, with deficiency and other anemia (82), hypertension with complications and secondary hypertension (13), and congestive heart failure (10) representing the top three reasons for the hospital admission. Admissions classified as not being TRAs grouped into 94 different CCS categories. Table The discharge summary principal diagnoses differed substantially by TRA designation. Admissions identified as TRA-Primary grouped into four principal discharge diagnoses based on HCUP CCS categories: transfusion related admissions (TRAs) within the Veteran population, using two categorization criteria aimed at identifying ESRD-specific events from other reasons to transfuse. Recently, a series of related studies have provided notable real-world evidence of how top-down CMS policy and reimbursement changes impact ESRD-related anemia management practices. Interpreting the effect of these changes on the use of RBC transfusions for anemia management, however, is difficult due to lack of validated criteria for attributing RBC transfusions to ESRD-related anemia. The previous studies often lacked exclusion criteria for alternative explanations of anemia  bleeding and surgery) and did not use laboratory data or medical codes to indicate anemia was present on admission. Furthermore, they made no attempt to establish rules linking transfusion procedures to hospital admission dates to differentiate community onset vs. nosocomial anemia – an important distinction since CMS reimbursement changes may incentivize cost shifting from dialysis facilities to hospital-based environments [clinical algorithm (CA) performed well for both TRA concepts, with a geometric means above 90% for TRA and TRA-Primary. The CBAs that did not require principal diagnoses of CKD/ESRD (CBA 2) or anemia (CBA 4) on the discharge diagnoses performed better than the CBAs that required principal discharge diagnoses of CKD/ESRD (CBA 1) and anemia (CBA 3).This study compared the classification performance of multiple database algorithms designed to identify ronments 23. Our sSurprisingly, the CBA 2 and CBA 4 performed as well or slightly better than the CA, indicating that clinical laboratory data may not be needed for identification. Conversely, the CA used laboratory data to identify anemia on admission, and multiple sources of information, such as orders, laboratory data, and procedure codes, were used to identify the administration of RBC transfusions. Error analysis of the validation data indicated that many false positives were due to our lack of ability to adequately exclude patients with alternative explanations of anemia. This was, in part, due to the lack of medical codes supportive of the medical notes, which may have included references to conditions like a GI bleed. Problems with sensitivity, using the CBAs was more often a result of TRAs not including CKD/ESRD or anemia codes rather than missed transfusions.The CA and all CBAs had excellent specificity for both TRA and TRA-Primary and overall performance was better across all algorithms for TRA-primary compared to the TRA definition. This finding can be intuitively explained because TRA-Primary was more likely to have discharge diagnoses codes consistent with ESRD-related anemia and therefore had a lower proportion of false positives due to alternative reasons for anemia.The two concepts of TRA defined in our study provide an instrument to investigate whether dialysis facilities are referring patients to hospitals for RBC transfusions to manage anemia; or if patients maintained at lower hemoglobin levels meet clinical requirements for transfusion when presenting to the hospital for acute exacerbations of conditions other than ESRD. Increases in the prevalence of the TRA-Primary may indicate the former, while increases in the prevalence of the more inclusive concept of TRA may indicate the latter.The hemoglobin distribution among the randomized chart-reviewed admissions and the non-reviewed population in each of the four sampling rules were remarkably similar. The similarities support our sample findings’ utility for estimating population performance and adjusted prevalence using the sampling weights technique employed in this study. Clinical guidelines do not suggest transfusing patients at a hemoglobin threshold and recommend avoiding when possible . In contAny increase in the use of RBC transfusions to treat ESRD-related anemia is alarming since the chronic dialysis population is associated with increased risk of transfusion-related complications, such as hemolytic and non-hemolytic transfusion reactions, infections, and reduction in transplant potential . The preTRAs and TRA-primary. This will allow us to more effectively analyze changes in anemia management practices in VA and will inform measurement and validation strategies for application to CMS and other data environments. More broadly, the separation of ESRD specific (TRA-primary) and ESRD non-specific (TRA) events may complement recently available CMS anemia management measures, such as the Standardized Transfusion Ratio (STrR) [As a result of the sampling strategy employed in this study, we were able to investigate key metrics of algorithm performance making it possible to estimate adjusted population prevalence of o (STrR) 27. The SVA is not directly linked to CMS reimbursement criteria, and so may exhibit different coding practices performed by outside facilities. Nevertheless, VA policy requires that all administrative data are accurate and consistent. Administrative coding in VA, however, is primarily used for resource and personnel management along with managing quality and safety of health care delivery. For this reason, the CBAs that heavily rely on discharge diagnoses may not perform as well in CMS data. However, if facilities and providers are following CMS coding guidelines, then we would expect to see similar algorithm performance for TRA-Primary since the algorithms were derived from CMS coding guidelines for ESRD-related anemia management. Performance of the algorithms to measure the more inclusive TRA concept may not be as robust when anemia management is not the primary reason for admission.clinical algorithm, in CMS and United States Renal Data Systems (USRDS) data [clinical algorithm may be warranted to account for evidence of anemia reported by dialysis facilities when admissions were not within 24 hours of a dialysis events.Medicare now requires reporting of hemoglobin/hematocrit levels along with dates of service for all ESRD dialysis patient to support the new Quality Incentive Program, rather than only reporting hemoglobin/hematocrit levels for patients administered ESAs, will make it possible to monitor the more inclusive TRAs concept by applying the DS) data . HoweverOur initial error analysis found that the majority of false positives were due to missed exclusion criteria, specifically regarding GI bleeding. We often found evidence in the medical note of GI hemorrhage, but patients admitted for another condition may not have had the condition coded in the discharge summary. For this reason, we expanded the exclusion criteria to include clinical data that may not be routinely available in CMS claims data. For example, we included evidence of intravenous (IV) administration of proton pump inhibitors and positive guaiac tests. The algorithm performance estimates are dependent on the population studied and this must be taken into consideration if attempts are made to implement these algorithms in claims-based data marts.Since VistA Blood Establishment Computer Software (VBECS) data available in CAPRI had a date and not a time stamp, the reference standard was established by allowing the RBC transfusion to occur on the day of admission or the following day. The CBAs also lacked a time stamp since we tried to mimic data we have available from CMS. The CA, on the other hand, used a date-time stamp and required RBC transfusions to occur within 24-hours of admission. This difference may account for the slightly better performance of the two of the CBAs. Additional work is needed to define the optimal time limit for attributing RBC transfusion as treatment for “community-onset” ESRD-related anemia.As seen in Table Finally, inclusion/exclusion criteria and CBAs were based on ICD-9 codes. The current coding standard has migrated to ICD-10 codes, which may affect performance of both the CA and CBAs if coding practices do not represent diagnostic intentions. Nevertheless, we anticipated this issue and used HCUP CCS ICD grouping software, which provides a well-documented and maintained crosswalk between ICD-9 and ICD-10. Meaning, the algorithms do not require modification to implement using ICD-10 codes, but additional validation would be prudent to ensure stability of performance.Both our CA and select CBAs perform well and can be used to study CMS policy and reimbursement changes. This work also represents a crucial step in generating more knowledge surrounding transfusions related ESRD-anemia in the absence of alternative indications. The measurement of SE and SP supports computation of adjusted prevalence estimates to more accurately reflect the true proportion of admissions meeting TRA and TRA-Primary criteria. We expect our CBAs are portable to other claims-based data sources, nevertheless, validation in new populations is suggested to accurately account for measurement performance to produce adjusted prevalence estimates specific to population being studied.We would like to highlight key take-home messages of our work.New policies established by the FDA and CMS may have affected anemia management strategies causing a shift in RBC transfusions, ESAs, and intravenous iron after 2011.Related studies do not separate the cause of RBC transfusions is an important step in understanding the true prevalence and implications of these events in ESRD patients with anemia.Related studies do not separate the cause of RBC transfusions in ESRD patients; and so, validated methods are needed to estimate the true prevalence of ESRD-related anemia.The additional files for this article can be found as follows:10.5334/egems.257.s1Appendix A.Database measures.10.5334/egems.257.s2Appendix B.Error analysis performed on algorithms prior to study implementation.10.5334/egems.257.s3Appendix C.Chart review procedures.


CSF flow disorders are frequently encountered in children. The advent of MR technology with the emergence of new pulse sequences allowed better understanding of CSF flow dynamics. In this pictorial review, we aim to conduct a comprehensive review of the MR protocol used to study CSF flow disorders and to discuss the utility of each pulse sequence in the adopted protocol. We will focus on the key anatomical structures that should be examined to differentiate hydrocephalus form ventricular dilatation ex-vacuo. The MR features of obstructive and communicating hydrocephalus will be discussed, in addition to the manifestations of CSF disorders associated with posterior fossa malformations . Moreover, the value of MRI in the assessment of patients following interventional procedures  will be addressed.The online version of this article (10.1186/s13244-019-0686-x) contains supplementary material, which is available to authorized users. MRI is the ideal modality to investigate CSF flow disorders in children.Our practical illustrated protocol based on 3D high-resolution T2-WI and phase contrast along with conventional sequences helps to recognize different entities of CSF flow disorders in children.Most cases of hydrocephalus are related to obstruction with the aqueduct of Sylvius being the commonest site.The advent in MRI technology has led to better understanding of CSF flow disorders which are frequently encountered in children , 2. FlowThe MRI protocol should include brain imaging with T2-weighting in axial and coronal planes, axial fluid attenuation inversion recovery (FLAIR), and sagittal T1-weighted image (T1-WI) Figs. . Post-coCine phase-contrast sequence can demonstrate CSF pulsatile flow throughout the cardiac cycle. It can be acquired in sagittal section to monitor the CSF flow through the aqueduct and basal subarachnoid spaces . Also, it can be acquired in axial section for quantification of CSF flow (quantitative assessment)  demonstrates CSF flow as a bright signal throughout the cardiac cycle. (MP4 418 kb)Additional file 2: Video S2. Cine phase-contrast sequence (phase images) demonstrates CSF flow changes from positive to negative and back to positive throughout the diastolic and systolic phases of the cardiac cycle. (MP4 392 kb)In the phase-contrast technique, two data sets with opposite sensitization are acquired. When the two data sets are subtracted, the signal of the stationary protons is eliminated and flowing nuclei accumulate a net phase proportional to their velocity. The anticipated maximum velocity must be entered into the pulse sequence protocol before phase-contrast data are acquired . After sOne of the ongoing challenges in neuroradiology is to differentiate hydrocephalus from ventricular enlargement associated with brain atrophy  especially in children, as the sizes of the ventricles and subarachnoid spaces have variable size over the first 2 years of life. Imaging findings should be interpreted in the context of clinical data in order to reach a firm diagnosis of active hydrocephalus. Knowledge of the infant’s head size is essential; a large head or too rapidly enlarging head suggests hydrocephalus, whereas a small or diminishing head circumference is more compatible with atrophy .Coronal T2-WI and high-resolution T2-WI (3D-DRIVE) can help differentiate hydrocephalus and ventriculomegaly ex-vacuo. In cases of hydrocephalus, coronal T2-WI demonstrates commensurate dilatation of the temporal horns with the lateral ventricles associated with rounding of the lateral angles and medial displacement of the hippocampus. Effacement of pericerebral CSF spaces above the level of obstruction is also demonstrated. However, in cases with ventriculomegaly ex-vacuo, the temporal horns  are small compared to the bodies of the lateral ventricles; they retain their normal shape and the hippocampi are not displaced medially Fig. . In addiA consensus classification of hydrocephalus has been proposed to relate most cases of hydrocephalus to obstruction of the CSF pathway, reflecting the surgical approach to hydrocephalus that aims to divert the CSF between the site of production and absorption , 18.Obstructive hydrocephalus can be related to purulent or tuberculous meningitis. In the acute stage, MR assessment targets the evidence of infection or its complication via demonstration of leptomeningeal enhancement after contrast administration Fig. . At the Midline and midline-compressing brain tumors can obstruct the CSF pathway as well. A contrast-enhanced study is indicated in these instances Fig. . Among bIntraventricular hemorrhage in premature infants is the leading cause of pediatric hydrocephalus. T2* demonstrates blood and blood residue. Blood in the acute phase and hemosiderin and scarring in the chronic phase obstruct the ventricles, basilar cisterns, and arachnoid granulation, impairing CSF flow and absorption , 21.Obstruction can be encountered in the aqueduct of Sylvius, fourth ventricular exit foramina, and foramen of Monro Fig.  or seconThe criteria suggesting aqueduct stenosis include a small fourth ventricle with dilated third and lateral ventricles out of proportion to cortical atrophy. However, these have been described as non-reproducible parameters . 3D-DRIVCommunicating hydrocephalus implies cases with no obstruction in the ventricles or the cisterns. Aqueductal CSF flow void is increased in communicating hydrocephalus plausibly because of decreased intracranial compliance Fig.  20]. Aq. Aq20]. In children, the apparently non-obstructive hydrocephalus has been attributed to an imbalance of CSF secretion and absorption. Two patterns have been identified: the benign idiopathic external hydrocephalus (which is more common) and the choroid plexus papilloma-associated hydrocephalus (which is much rarer) .Benign idiopathic external hydrocephalus is also known as benign enlargement of subarachnoid spaces in infancy. It is characterized by macrocephaly with dilatation of the anterior subarachnoid spaces and ventricular system to a lesser extent. The extra-axial CSF spaces should have CSF signal in all pulse sequences and be traversed by the bridging veins Fig. . These fChoroid plexus papilloma-related hydrocephalus is assumed to be related to high secretion of CSF that overwhelms the capacity of absorption. The tumor predominantly affects infants and young children. The tumor usually appears as an avidly enhancing mass floating within the ventricular atrium .Dandy-Walker complex represents a continuum spectrum of posterior fossa malformations that are characterized by a posterior fossa cyst associated with variable degrees of abnormal development of the cerebellar vermis. The classic Dandy-Walker malformation, Blake’s pouch cyst, posterior fossa arachnoid cyst, mega cisterna, and vermian hypoplasia represent steps on this continuum. Phase-contrast sequence has value in studying CSF flow between CSF spaces in the posterior fossa and the posterior cervical subarachnoid space .The typical Dandy-Walker malformation constitutes a large posterior fossa cyst communicating with the fourth ventricle in association with partial or complete agenesis of the cerebellar vermis. A phase-contrast study demonstrates no flow between the posterior fossa cystic space and the posterior cervical subarachnoid space Fig. . HydroceBlake’s pouch cyst appears as an infracerebellar or retrocerebellar arachnoid cyst associated with tetraventricular hydrocephalus. A phase-contrast study reveals lack of communication between the cyst and the posterior cervical subarachnoid space Fig.  3, 5, 2, 25, 24.A posterior fossa arachnoid cyst appears as a well-defined extra-axial cyst or fluid collection that is associated with a normal vermis. It may produce mass effect on the cerebellum or vermis with remodeling of the overlying skull bone. A phase-contrast study can demonstrate whether the cyst is communicating to the CSF spaces which is important in preoperative planning , 24.Mega cisterna magna represents focal enlargement of the subarachnoid space in the posterior and inferior portions of the subarachnoid space with a normal vermis, cerebellum, and fourth ventricle. Phase contrast reveals free communication with the fourth ventricle and posterior cervical subarachnoid space , 24.They represent hindbrain anomalies with caudal displacement of the cerebellar tonsil through the foramen magnum causing plugging of the CSF pathway  and can be associated with myelomeningocele . A phase-contrast study provides information about the extent of CSF flow blockage at the craniocervical junction Fig.  3, 4, 2, 24, 20.3 indicates effective operation with patient improvement. A decrease of stroke volume during follow-up could indicate ventriculostomy malfunction and clinical deterioration [Phase-contrast and 3D-DRIVE sequences have high confidence in the assessment of the flow through the floor of the third ventricle with proper identification of ventriculostomy malfunction The diagnosis of shunt malfunction depends mainly on CT of the cranium along with clinical symptoms  . HoweverMRI with the advent of high-resolution T2-WI (3D-DRIVE) and phase-contrast sequences is a crucial imaging modality for the assessment of CSF motion alterations in various disorders which is important for proper patient management.


The tumor-associated microenvironment plays important roles in tumor progression and drug resistance. However, systematic investigations of macrophage–tumor cell interactions to identify novel macrophage-related gene signatures in gliomas for predicting patient prognoses and responses to targeted therapies are lacking.We developed a multicellular gene network approach to investigating the prognostic role of macrophage–tumor cell interactions in tumor progression and drug resistance in gliomas. Multicellular gene networks connecting macrophages and tumor cells were constructed from re-grouped drug-sensitive and drug-resistant samples of RNA-seq data in mice gliomas treated with BLZ945 (a CSF1R inhibitor). Subsequently, a differential network-based COX regression model was built to identify the risk signature using a cohort of 310 glioma samples from the Chinese Glioma Genome Atlas database. A large independent validation set of 690 glioma samples from The Cancer Genome Atlas database was used to test the prognostic significance and accuracy of the gene signature in predicting prognosis and targeted therapeutic response of glioma patients.A macrophage-related gene signature was developed consisting of twelve genes , which was tested in the independent validation set to examine its prognostic significance and accuracy. The generation of 1000 random gene signatures by a bootstrapping scheme justified the non-random nature of the macrophage-related gene signature. Moreover, the discovered gene signature was verified to be predictive of the sensitivity or resistance of glioma patients to molecularly targeted therapeutics and outperformed other existing gene signatures. Additionally, the macrophage-related gene signature was an independent and the strongest prognostic factor when adjusted for clinicopathologic risk factors and other existing gene signatures.The multicellular gene network approach developed herein indicates profound roles of the macrophage-mediated tumor microenvironment in the progression and drug resistance of gliomas. The identified macrophage-related gene signature has good prognostic value for predicting resistance to targeted therapeutics and survival of glioma patients, implying that combining current targeted therapies with new macrophage-targeted therapy may be beneficial for the long-term treatment outcomes of glioma patients.The online version of this article (10.1186/s12967-019-1908-1) contains supplementary material, which is available to authorized users. Gliomas are among the most malignant cancers, commonly inducing profound and progressive disability and causing death in most cases . AlthougSeveral forms of cancer cell-intrinsic mechanisms of drug resistance have been revealed, including genetic/epigenetic mechanisms , posttraSystems biology approaches are powerful for quantitatively studying various forms of drug resistance at multiple scales, which can provide insights into underlying mechanisms and experimentally testable predictions . ComputaIn this study, we developed a multicellular gene network-based approach to investigating intercellular gene associations between tumor cells (TCs) and tumor-associated macrophages (TAMs) and to identify biomarkers of prognosis and drug resistance in gliomas. We used RNA-seq data from mice bearing gliomas treated with BLZ945 to construct drug-sensitive and drug-resistant multicellular gene networks. Based on the differential network, a macrophage-related gene signature was discovered using a dataset of glioma patients from the Chinese Glioma Genome Atlas (CGGA) database. An independent dataset from The Cancer Genome Atlas (TCGA) database was used for validation. Time-dependent receiver operator characteristics (ROC) analysis was used to assess the prognostic significance and accuracy of the gene signature for predicting survival of glioma patients. Moreover, the macrophage-related gene signature was found to be predictive of the targeted therapy outcome in glioma patients and outperformed existing gene signatures including conventional EGFR signature , 16 and https://www.ncbi.nlm.nih.gov/geo/) under accession number GSE69104. The preclinical experiment [RNA-seq data (FPKM) of TCs and TAMs in mice gliomas were downloaded from the Gene Expression Omnibus (GEO) website  for each pair of these DEGs. An edge is added to the TC-TAM gene network if the corresponding |PCC| > 0.95 and p value < 0.05). We then added each single drug-resistant sample  to the reference samples in the Ep group to construct 4 sets of sample-specific perturbed samples, respectively , a gene annotation and enrichment analysis database that integrates ontology sources, including the KEGG Pathway, GO Biological Processes, Reactome Gene Sets, Canonical Pathways and CORUM databases. The whole genome was used as the enrichment background. Terms of pathways or processes with a p value < 0.01 (accumulative hypergeometric test), a minimum of 3 genes, and an enrichment factor > 1.5 were collected and grouped into clusters based on their membership similarities.The functional enrichment of genes in the differential network was analyzed using the newest version of Metascape (http://www.cgga.org.cn/) and TCGA database (https://cancergenome.nih.gov/). The names of genes in the differential network were mapped to those of genes in homo sapiens, resulting in a list of 29 candidate genes. By matching both patient sample IDs and gene names from the clinical information and the gene expression data, a learning set of 310 samples from CGGA dataset and an independent validation set of 690 samples from TCGA dataset were created for prognostic signature identification, validation and further analysis. The details of the sample information were listed in Additional file The differential network might capture robust topological differences between the CSF1R inhibitor-sensitive network and inhibitor-resistant networks and reflect potential changes in the gene interactions across TCs and TAMs during the acquisition and development of drug resistance. It is therefore reasonable to speculate that the genes in the differential network play critical roles in promoting tumor growth, even under drug pressure. We hypothesized that the expression levels of genes in the differential network are associated with the survival outcomes of glioma patients. As such, we developed a differential network-based signature identification method to select prognostic biomarkers for glioma patients. We collected the clinical information and RNA-seq gene expression data from glioma patients in the CGGA database  model  and LASSThe regression coefficients at the optimal tuning parameter were computed as risk coefficients, which were used to formularize a risk signature. The same risk signature was used to compute the risk scores (RSs) for patients in the independent validation set. The patients in each dataset were classified into a high-risk group and a low-risk group according to the optimal cutoff value using the ROC method. The Kaplan–Meier (K–M) curves for patients in the high- and low-risk groups were analyzed, and the statistical significance of the difference was assessed using the two-sided log-rank test. Time-dependent ROC analysis  was furtThe survival and gene expression data from glioma patients who received targeted therapies in the independent set were extracted to evaluate the predictive effectiveness of the macrophage-related gene signature for classifying patients into drug-sensitive and drug-resistant groups. We used the observed 3- or 5-year survival status to substitute for the latent drug-resistance status in these patients. Specifically, the 3- or 5-year survival status  was defined as the outcome (sensitive or resistant) of targeted drug treatment. The above risk signature was used to classify each patient into a sensitive group  or a resistant group  according to the optimal cutoff value of the RS using the ROC method. To further compare the powers of different gene signatures to predict responses to targeted therapy, we calculated the area under the curves (AUCs) of the time-dependent ROCs to assess their accuracies.We compared the macrophage-related gene signature produced from the above multicellular gene network perturbation method with other commonly used methods, including LASSO Cox regression model  and corrMoreover, to assess whether the macrophage-related gene signature was independently correlated with the prognosis of glioma patients, we conducted univariate and multivariate COX regression analyses of clinicopathological factors and available gene signatures. Clinicopathological information, including age, gender and grade, was available for glioma patients in both the learning and validation sets. We also included the following gene signatures in the multivariate COX regression analyses: signature 1—the macrophage-related gene signature newly proposed in this study; signature 2—an EGFR gene signature studied by many groups , 16; andThe above risk factors were further extracted for construction of a combined signature using the LASSO COX model , 20. As p values were computed to assess the significance of the difference between the probability distributions of AUC values of competing signature.We tested the robustness of the macrophage-related gene signature obtained using the multicellular network perturbation analysis in comparison with LASSO Cox signature and correlation network-based signature using a bootstrapping approach. We generated 100 random datasets by randomly sampling 50% of the samples from the TCGA datasets . The AUC values of ROC with respect to overall survival, 3-year survival and 5-year survival were computed. Wilcoxon rank sum test (one-tailed) The heatmaps of DEGs in TAMs . The high-risk group of glioma patients tended to have a shorter survival time than the low-risk group. Figure We then investigated the prognostic significance and accuracy of the macrophage-related gene signature in both the learning and independent validation sets. Figure p value less than 0.0001). Figure Moreover, we tested the prognostic significance of the macrophage-related gene signature using the independent validation set Fig. c. The K–p value (0.001) from the permutation test justified the statistical significance of the prognostic accuracy of the macrophage-related gene signature.Furthermore, we tested the significance of prognostic accuracy of the macrophage-related gene signature evaluated using a bootstrapping approach. We randomly selected 12-gene sets from the whole transcriptome for 1000 times and compared their prognostic accuracy with that of the macrophage-related gene signature. CGGA dataset was used for training and TCGA dataset for validation. Figure For comparison, we also generated gene signatures using LASSO Cox regression model and correlation network-based method (see Method section). Additional file p values less than 0.0001).Considering the important roles of macrophages in glioma progression and drug resistance –12, 26, p values computed using a bootstrap method [To further assess the accuracy of different gene signatures for predicting the sensitivity or resistance to the targeted therapies, we compared 3 risk signatures that were designed for glioma patients: signature 1—the macrophage-related gene signature newly proposed in this study; signature 2—a conventional EGFR gene signature studied by many groups , 16; sigp method  further The univariate and multivariate COX regression analyses for both the learning and validation datasets revealed that the macrophage-related gene signature retained prognostic significance for glioma patients when adjusted for both clinicopathologic risk factors  and other existing gene signatures   and risk-increasing genes  for predicting the prognosis of glioma patients (Fig. A, SEMA6BAdditional file The advantages of our study originate from the use of a multicellular network-based gene screening approach, large population databases for learning and validation and robust risk signature identification methods. In future studies, we will investigate the functions and mechanisms of the 12 genes alone and in combination to verify their clinical applicability. The capability of the signature identified herein for predicting drug resistance should be further validated by prospective studies in the future. We will also leverage single cell RNA-seq data to construct multilayer networks that connect tumor microenvironmental cells to tumor cells , which wIn summary, we developed a multicellular gene network approach to investigate the role of TC–TAM interactions in the progression and therapeutic responses of gliomas. The identified macrophage-related gene signature showed good accuracy for predicting the prognosis and targeted therapeutic responses of glioma patients. The multicellular gene network-based signature provided mechanistic insights into microenvironment-mediated drug resistance and implied that combining current targeted therapies with macrophage-targeted therapy might improve the long-term treatment outcomes of glioma patients.Additional file 1: Text S1. Detailed description of the methods. Table S1. Scheme of sample grouping. Table S3. List of genes in the differential network. Table S4. Univariate Cox regression analysis for the association of each signature gene with the overall survival of glioma patients. Table S5. Experimental evidences for functional roles of the eight macrophage-related genes in cancer progression and/or drug resistance. Figure S1. Differential gene expression profiles of TAMs and TCs between the Endpoint and Rebound groups. Figure S2. TC-TAM sensitive network and its topological attributes. Figure S3. EpUReb1 sample-specific TC-TAM network and its topological attributes. Figure S4. EpUReb2 sample-specific TC-TAM network and its topological attributes. Figure S5. EpUReb3 sample-specific TC-TAM network and its topological attributes. Figure S6. EpUReb4 sample-specific TC-TAM network and its topological attributes. Figure S7. Network topological analysis of the sensitive network and 4 sample-specific resistant networks. Figure S8. Prognostic accuracies of LASSO Cox signature and correlation network-based signature. Supplementary references.Additional file 2: Table S2. Supplementary tables for the details of patient sample information from CGGA and TCGA.


Nothing in biology makes sense except in the light of evolution” was argued by Theodosius Dobzhansky in 1973. After more than 100 years since Charles Darwin's Origin of Species, it was increasingly realized that the theory of evolution can help us disentangle biological mechanisms. Here we asked contributors to see their antiviral research interests “through the looking glass” of evolution and to consider how evolutionary theory may help us understand human antiviral immunity. Thus, our special topic explored the scope of the evolution of human antiviral immunity, whether this included short-term effects or long-term impact. We specifically asked contributors to provide thought-provoking manuscripts that could fall within the scope of co-evolution of viruses and the human immune response. They submitted articles discussing the ongoing dynamics of co-existing with ancient endogenous retroviruses, as well as the pressures exerted by extant exogenous viruses such as influenza and human immunodeficiency virus (HIV-1). Our understanding of antiviral immunity was broadened by papers exploring mechanisms such as T cell function and RNA structural components.“Marchi et al. explore the effects of persistent infection on T cell responses by analyzing gene expression profiles and gene networks in publicly-available data sets. Importantly, they identified T-box 21 (Tbx21)-mediated gene expression as a hallmark of inflation but not exhaustion of memory CD8+ T cells. This finding has potential to shape our understanding of the genes that define memory T-cell populations. Further, this shows how different viral infections can influence either exhaustion or inflation. This highlights the adaptability of the immune response to viral infection but also how infection could alter gene expression to shift T cell phenotypes.In a Hypothesis and Theory article, Smyth et al. discuss the contribution of RNA structure to antiviral immunity. RNA is much more than an intermediary between DNA and protein; it can adopt complex three-dimensional structures that may be altered by single nucleotide mutations, with consequent effects on its functions. Thus, since RNA structures are critical to the replication of many viruses, they are also substrates upon which evolution can act. This can include non-coding RNAs produced during replication, as well as genomic RNA and transcripts. Viral RNA is sensed by different pattern recognition receptors (PRRs) of the innate immune response, such as Toll-like receptor 3 (TLR3) and retinoic acid inducible gene I (RIG-I). There is thus pressure on viral RNA to evade immune detection such as by nucleotide and codon usage bias (adenosine by HIV-1), the presence of specific secondary structures that restrict transcription to low levels, or the maintenance of single-stranded RNA regions to avoid PRR detection. In turn, viral RNA structures have influenced the human immune system, such as the evolution of the human leukocyte antigen (HLA) locus.In one of two mini-reviews in the topic, Voskarides et al.). The authors argue that this is an example of antagonistic evolution, with influenza virus a predator and the human host as prey. This conflict manifests in the genetic variability of Influenza viruses, a result of the absence of proof-reading by the RNA polymerase, that continually challenges the host immune system. In response, the human host has genetic major histocompatibility complex (MHC) diversity which facilitates T cell-mediated immunity to diverse pathogens.The co-evolution of influenza virus and host immunity is discussed in the second mini-review . The authors use a bioinformatics approach to simulate A3G mutations and show that HIV-1 mutants are biased toward cytotoxic T cell (CTL) escape mutants. These results point toward an evolutionary adaptation of the HIV-1 genome that essentially “hijacks” human antiretroviral activity to counteract T-cell immunity.APOBEC3G  is a cellular cytidine deaminase that mutates retroviral genomes, thereby being a key host cell mechanism to debilitate viruses that embed in the genome. In an original article herein, the authors suggest that the action of A3G extends to adaptive immunity, suggesting that HIV-1 cytotoxic T cell (CTL) escape mutants are generated through A3G activity (Grandi and Tramontano). Further, four original research articles explore diverse aspects of ERVs and immunity. Firstly, ERV sequences within the genome are a potential source of genetic diversity that are known to be co-opted by the host. This has been shown most recently to include HERV-H sequences contributing to stem cell identity. Gemmell et al. explore the nature of HERV-H loci and their transcription further, showing positive correlations between particular long-terminal repeats (LTRs) and cell types (type II LTRs and embryonic cells).A cluster of papers within the topic discuss the role of endogenous retroviruses (ERV) in the immune response. This includes an up-to-date review on the shaping of the immune response by human ERVs (HERVs)  being more abundant among all HERV-K integrations, but also more active, compared to the less common motifs, in diseases such as amyotrophic lateral sclerosis and breast cancer. These results are important not only for understanding the interactions among HERV-K integrations evolutionarily, but also to appreciate the diversity of enzymatic targets when designing anti-HERV based treatments.Secondly, White et al.). Vorinostat is one latency reversing agent being examined in HIV-1 shock and kill strategies. The study found over 2000 HERV elements were modulated by vorinostat, notably the downregulation of ERVL and upregulation of HERV-9 elements, the latter of which was confirmed by digital droplet PCR. This study identified three HERV-9 members (LTR12 elements) that were upregulated by vorinostat in a dose-dependent manner. The relevance of this finding lies in the transcriptional regulation of certain genes by LTR12 elements, including the pro-apoptotic genes TP3 and TNFRSF10B . In agreement with our previous work using RT-qPCR, members of the HERV-K (HML-2), HERV-W and HERV-FRD families were not found to be upregulated by vorinostat  inhibitor vorinostat on HERV expression in CD4+ T cells was analyzed using RNA-Seq  was found to be upregulated in macaque plasma and tissues  and spleen) in response to simian immunodeficiency virus (SIV) infection. Further, upregulation of the interferon (IFN)-stimulated gene (ISG), STAT1, an important marker of the early antiviral response, correlated with the increased PcEV RNA levels . The authors posit a role for ERVs in the activation of the innate immune response.Finally, ERVs can be upregulated in response to acute exogenous viral infections and this may contribute to the antiviral response. In the paper by Williams et al. where they present the perplexing phenomenon of a “pocket” of uninfected individuals in a connected network of recently HIV-1-infected individuals. This raises the question of how a cluster of connected HIV-1 exposed individuals could remain uninfected within an HIV-1 outbreak. The authors discuss potential explanations including the possibility that long-term infections act as a “firewall” in spreading the infections to the full-population. The latter could be explained by the existence of an epidemic equilibrium of co-existence where human-HIV co-evolution would be acting in the absence of treatment.The effect of immunity-virus interface at the population level was examined by Kramvis et al. HBVeAg, as the authors explain, is a tolerogen, an antigen that increases the tolerance of HBV infection by the human host. There is significant variability in HBeAg seroconversion and transmission efficiency among genotypes, which the authors suggest can be explained as a result of short-sighted evolution. The virus-host interplay of HBV is further explored by Lumley et al. on the effects of CD8+ T cell responses. The authors review the evidence that CD8+ T cells play an important role in the chronicity of HBV infection as well as the disease outcomes such as cirrhosis and hepatocellular carcinoma . The role of interferon-α receptor-1 (IFNAR1) promoter polymorphisms on HBV infection are explored by Karamitros et al. with respect to the development of hepatocellular carcinoma. The authors show that the variable tandem repeat [VNTR: −77(GT)n] has a significant impact in the transcription profile of IFNAR1 and this may be relevant in cancer pathophysiology.The evolutionary gameplay underlying the pathogenesis of hepatitis B virus's e antigen (HBVeAg) is reviewed and explored by Beaver et al., have reviewed evidence of how Zika virus (ZIKV) evolution can explain the observed patterns of pathogenesis. The authors review evidence showing that the immune responses against African isolates differ from those observed against Asian ZIKV lineages, and discuss how this could explain observed pathogenic differences among ZIKV strains.Finally, From ancient germline infections to modern epidemics, outbreaks or emerging infections, our contributors explored the evolutionary interplay of human immunity and viruses at the molecular, individual, or population level. They offered thought-provoking hypotheses for further exploration, reviewed publications, and provided novel results in the field of human antiviral immunity field. This shows the power of integrating evolutionary theory with research of antiviral immunity and we hope that our special topic will further promote evolutionary thinking across fields of human pathogen research.TH and GM wrote the draft and edited the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.