Acquiring a subterranean lifestyle entails a substantial shift for many aspects of terrestrial vertebrates’ biology. Although this lifestyle is associated with multiple instances of convergent evolution, the relative success of some subterranean lineages largely remains unexplained. Here, we focus on the mammalian transitions to life underground, quantifying bone microanatomy through high‐resolution X‐ray tomography. The true moles stand out in this dataset. Examination of this family's bone histology reveals that the highly fossorial moles acquired a unique phenotype involving large amounts of compacted coarse cancellous bone. This phenotype exceeds the adaptive optimum seemingly shared by several other subterranean mammals and can be traced back to some of the first known members of the family. This remarkable microanatomy was acquired early in the history of the group and evolved faster than the gross morphology innovations of true moles’ forelimb. This echoes the pattern described for other lifestyle transitions, such as the acquisition of bone mass specializations in secondarily aquatic tetrapods. Highly plastic traits—such as those pertaining to bone structure—are hence involved in the early stages of different types of lifestyle transitions. So what makes some lineages more evolutionarily successful than others? Here, we show that some groups of subterranean mammals have convergently evolved a specialized trait that involves the presence of large amounts of a rare bone tissue type, the compacted coarse cancellous bone. However, the true moles’ condition largely exceeds that of other digging mammals. This unique morphology can be detected in some of the earliest fossils of the family, suggesting that a bone microanatomy specialization might have had an important role in the evolution of true moles and predated the acquisitions reflected in their skeleton's external morphology. This echoes a similar pattern described in multiple lineages of vertebrates that acquired bone mass increase as part of their adaptation to an aquatic lifestyle. Specializations involving bone inner structure, which is highly adaptable throughout an individual's life, can hence be associated with different types of evolutionary transitions.Lifestyle transitions drastically affect the evolution of many lineages. Such transitions, when examined at a large scale, are often associated with instances of convergent evolution , the African golden moles (Chrysochloridae), and the Holarctic true moles . To these specialized lineages with extant representatives should be added species for whom such adaptations are inferred from the fossil record, which already concerns the early evolution of mammaliaformes , making it ideal for comparative analyses  data was combined to histological and developmental observations to (1) identify patterns of phenotypic evolution that concern the humeral bone microanatomy among subterranean mammals (and their close relatives) and (2) describe the bone histology and maturation in true moles , which stood out in the former analysis.Uropsilus spp.) because of their fossorial habits and the fact that they are nested within an entirely subterranean clade. The extinct Tegulariscaptor minor was also added to the dataset. For a subset of species, skeletal elements of the rest of the forelimb, the hind limb, and vertebral column were also scanned. Specimens of extant species are wild‐caught museum specimens devoid of apparent disease. All specimens included in the quantitative analyses (see below) were skeletally mature . Additional specimens at earlier ontogenetic stages were examined qualitatively. A bone histology dataset was built adding new thin sections of a humerus of T. minor .The Maximum Clade Credibility DNA‐only node‐dated mammal phylogenetic tree of Upham et al.  was modiTegulariscaptor minor . For the first topology, the divergence times were set arbitrarily at 5% and 95% of the branch length (Trees 1A and 1B). For the second topology (Tree 2), the divergence age of talpines  had to be made older to accommodate the age of the fossil: this node's age was arbitrarily set 1 Ma older than the T. minor’s age.The phylogenetic position of  Hopkins ) is not Area/Volume fraction and Thickness  of the sub‐stacks corresponding to the VOIs. Diaphyseal structure was assessed following Amson  was defined in the center of the head following Amson and Kilbourne  Fig. S1S1. The sng Amson . We examSimilar to the epiphyseal VOIs, a VOI was also set for the mid‐lumbar vertebra . The Nagelkerke pseudo R2 was computed with the piecewiseSEM package . The strength of the convergence among the 11 independent acquisitions of a subterranean lifestyle here sampled (see above) was assessed with a modified version of the package convevol . For thy Revell ), body sP < 1 × 10–7 whatever the alternative topology in use; Fig. P < 0.038). Running the same analysis excluding talpids yields a clearer instance of convergence , showing that most talpids acquired a phenotype that exceeds the optimum toward which some other subterranean clades seemingly evolved. Moderately high to high bone fraction is found in all examined talpids except for the ambulatory shrew‐like moles, the sister group of the rest of the family —the oldest and potentially most basal non‐uropsiline talpid for which humeral material is known—indicate that this distinctive phenotype is well expressed in the early history of the clade. A similar increase in bone fraction is also observed at the distal articulation  is caused by the presence in large quantities of compacted coarse cancellous bone , display a particularly compact diaphysis. This is caused by a thickening of the cortex, with bone tissues representing about 85% of the total cross‐sectional area at mid‐diaphysis , mole‐rats and kin , the mole‐like tenrecs (Oryzorictes), and the marsupial moles , mole rats (Bathyergoidea), pocket gophers (Geomyidae), Tegulariscaptor minor, from the early Oligocene  or semifossorial/ambulatory (“Urotrichus‐like”) habits cannot be ruled out. Furthermore, our results suggest that specializations pertaining to bone microanatomy evolved faster than gross morphology in talpids. Considering other lifestyle transitions preserved in the fossil record, it is noteworthy that a similar pattern occurred in the evolution of several lineages that adapted to the aquatic environment. This is the case in particular for sirenians, cetaceans, and thalassocnine sloths, which all acquired bone mass increase (BMI)—a pattern of bone structure alteration linked to buoyancy and trim adjustment —early in their evolutionary history, before most other identifiable aquatic specializations , for whom BMI has already been documented  and star‐nosed mole (Condylura cristata), the mean humeral diaphysis compactness is intermediate between those of the Russian desman and the shrew‐like moles. This is consistent with the fact that these other talpids are more incipiently adapted to water, which is also indicated by their gross morphology  and lesHoxD9, in particular, is argued to be involved in the shortening of the humerus . Custom R code is available on GitHub (https://doi.org/10.5281/zenodo.468447099).Computed tomography scan dataset was archived on MorphoSource (Legend for Movie S1Click here for additional data file.Figures S1 to S10Tables S1 to S6Click here for additional data file.Legend for Dataset S1Click here for additional data file.


The implantable cardiac defibrillator (ICD) is common for the management of nonischemic cardiomyopathy (NICM). Mortality is a crucial issue for patients with NICM. We can understand the mortality events of ICD versus medicine treatment via a systemic review and meta‐analysis of randomized clinical trials. The comparison between ICD treatment and medicine treatment was performed to find if the ICD treatment can be associated with lower relative risk and hazard ratio of mortality than the medicine treatment. In addition, the different kinds of mortality events were analyzed for the ICD treatment. After a restricted selection, 9 studies with a total of 4001 NICM patients were enrolled. The focused outcome was the events of all‐cause mortality, sudden cardiac death, and cardiovascular death. The results showed that ICD treatment might be associated with lower relative risk and hazard ratio of all‐cause mortality and sudden cardiac death. However, the relative risk and hazard ratio of cardiovascular mortality was not significantly different between ICD treatment and medicine treatment. In the current meta‐analysis, the ICD treatment might show a lower relative risk and hazard ratio of all‐cause mortality and sudden cardiac death when compared with medicine treatment. However, no significant differences were observed in cardiovascular mortality between ICD and medicine treatment. However, the evidence was limited by the conflicting results between the positive results of the Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)In the current meta‐analysis, we would enroll more updated randomized clinical trials for the ICD versus medicine treatment  in the patients of NICM, especially after 2017. According to previous meta‐analysis results,22.1The following keywords of “defibrillator,” “ICD,” “nonischemic,” “cardiomyopathy,” “trials,” “randomized,” “clinical,” “controlled,” “treatment,” “therapy,” “efficacy” or “outcome,” “comparison,” “versus,” “implantable,” and “cardiac” were used to search and collect the related prospective RCT articles in the PubMed, ScienceDirect, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). The articles were limited to those published or e‐published online before May 2022.The eligible criteria of enrolled studies were as follows: (1) The comparisons between ICD therapy and medicine  alone treatment for the NICM patients. (2) The studies investigating the baseline and posttreatment outcome profile for the mortality, including all‐cause, cardiovascular mortality and sudden cardiac death. (3) The studies with detailed data of outcome in the perspective of mortality. (4) Restriction to be published in the English language style in the journals of science citation index database. (5) Randomized clinical trials. (6) The trials of the patients without a family history of a fatal tachyarrythmias or cardiac arrest.2.2The systematic review and meta‐analysis study was conducted based on the Cochrane Handbook for Systematic Reviews and Interventions. The results were reported according to the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines.2.3Two reviewers reviewed the abstracts to screen the articles and then independently evaluate the full‐text version of the selected citations. Then the two reviewers performed the extraction of clinical outcome data from text, tables, and figures of the enrolled articles independently. The enrolled articles basically had the data of all‐cause mortality, sudden cardiac death, and cardiovascular mortality in the full‐text content. The risk of bias was evaluated by the bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome, and bias in the selection of the reported result. Then all authors performed collaborative reviews to resolve any discrepancies to achieve the strong agreement (κ = .9). All authors participated to review the final results.2.4χ2 tests were used to study heterogeneity between enrolled studies. The derived I2 statistic was used to estimate statistical heterogeneity of studies included in the meta‐analysis. The cutoff value of the Higgins I2 index was as follows: 0%–40%: might not be important; 30%–60%: may represent moderate heterogeneity*; 50%–90%: may represent substantial heterogeneity*; 75%–100%: considerable heterogeneity.p values were two‐sided. Publication bias was assessed using a funnel plot and Eggers's test to find if there was a symmetric distribution of pooled studies.For all‐cause mortality, cardiovascular mortality, and sudden cardiac death, we generated pooled estimates of relative risks (RR) or hazard ratios (HR) along with the associated 95% confidence interval (CI). Due to the lack of patient‐level data, we used summary statistics for each trial by extracting the reported HRs. In studies without HRs and respective 95% confidence intervals, the Kaplan–Meier survival curves were calculated for each individual study and used the Guyton algorithm to reconstruct individual patient data for subsequently obtaining an estimate of HRs and 95% CI in survival analysis. We used the Cochrane Collaboration Review Manager Software Package (Rev Man Version 5.4) to perform the meta‐analyses. We reported Mantel–Haenszel RR using DerSimonian and Laird's random‐effect models by using the summary statistics. The data was transformed to the log‐HRs using the HR and the start of 95% CIs in the Rev Man calculation function. The risk estimates of individual studies were combined via the inverse variance weighted averages of log HRs in the random‐effects model. In addition, the random and fixed effects models were used with inverse variance function weighted log HR. The ICD therapy and medicine treatment were compared with each other to find if ICD therapy will be superior in decreasing the events of all‐cause mortality, sudden cardiac death, and cardiovascular mortality. The 33.1A total of 2817 articles from database search and 59 additional records from other sources were initially collected. Within these articles, 721 duplicate articles were removed. Then the relevance of abstracts and titles were screened for the residual 2155 articles. The 2113 articles were excluded after screening the relevance. Full‐text contents of screened 42 articles were assessed for the eligibility. After the assessment of full‐text content, 33 articles were discarded Figure . The qua3.2I2 was 79%, which revealed the high heterogeneity. The test for overall effect was Z = 2.26 (p = .02) and the meta‐analysis results showed significant difference of RR of all‐cause mortality events between ICD and medicine treatment under random effects model  and the meta‐analysis results showed significant difference of log HR of all‐cause mortality events between ICD and medicine treatment under random effects model  and the meta‐analysis results showed a significant difference of RR of sudden cardiac death events between ICD and medicine treatment under random effects model  and the meta‐analysis results showed significant difference of log HR of sudden cardiac death events between ICD and medicine treatment under random effects model  and the meta‐analysis results showed no significant difference of RR of cardiovascular mortality events between ICD and medicine treatment under the random effects model  and the meta‐analysis results showed no significant difference of log HR of cardiovascular mortality events between ICD and medicine treatment under random effects model  in heart failure. In previous studies, the angiotensin‐neprilysin inhibitors showed superior clinical efficacy to reduce sudden cardiac death by 20% and improve the overall survival and reduce death due to worsening of heart failure.A recent large registered non‐randomized trial also supported the results of DANISH trial. It also replicated the findings of older NICM patients (>68 years old) would have a higher risk of overall mortality after implantation of ICD when compared to the younger NICM patients (<68 years old).p value.In a recent study of best practice alert suggested that patients with left ventricle ejection fraction lower than 35% should be the candidate of ICD treatment and the HR of mortality is 0.85 even with a trend (not significant) The current meta‐analysis has several limitations. First, most enrolled studies were relatively far from the current time and the variety of duration of follow‐up might influence the meta‐analysis results. However, the funnel plot showed the risk of publication bias might be low. Second, the medicine treatment might be variable in the dose and kinds of pharmacological treatment, which might influence the interpretations of our results. However, the medicine therapy for NICM with heart failure might not changed so significantly in recent years. Therefore, the medicine treatment in the enrolled studies might still represent the pattern of clinical practice. Third, the risk of device‐related infections or other adverse events might not be revealed in the current meta‐analysis. However, the lower risk of all‐cause mortality with ICD therapy might represent the clinical meaning with possibly less risk of infection mortality. Fourth, the lack of patient‐level data might also influence the interpretations of our results due to the lack a full evaluation of patient‐level covariates in across comparisons. It is impossible to confirm a possible subgroup effect related to patient age and explore the impact of enrolled studies' NHYA class and baseline mortality risk on the benefit of ICD. Fifth, the influence of cardiac resynchronization therapy in some enrolled studies should not be ignored when we tried to interpret the meta‐analysis results. Sixth, the relatively low number of enrolled studies in the meta‐analysis of sudden cardiac death and cardiovascular mortality might limit the interpretations of our findings.5In the current meta‐analysis, the ICD treatment might show a lower RR and HR of all‐cause mortality and sudden cardiac death when compared with medicine treatment. However, no significant differences were observed in cardiovascular mortality between ICD and medicine treatment. Future randomized studies of clear patient‐level data, elderly patient groups, and possible biomarkers might be warranted.The authors declare no conflicts of interest.Supplementary information.Click here for additional data file.


The US Department of Agriculture (USDA) categorizes the risk of African swine fever virus (ASFV) entry into the United States through non‐animal origin feed ingredients as ‘negligible to moderate, with high uncertainty’. Both Canada and Australia have implemented policies that are suggested to reduce the risk of ASFV entry through feed ingredients, but the United States has not because of scientific limitations that have been addressed by recent publications. As regulators and industry consider a potential pathway forward, the objective of this manuscript is to describe a process to determine if a voluntary or regulatory import policy is warranted by the United States. Initially, the volume and types of non‐animal origin feed ingredients imported from countries with ASFV were quantified and assigned a level of risk , and low risk: amino acids, vitamins, and other synthetically produced products from countries that have ASFV). In 2020, moderate‐ and high‐risk ingredients from ASFV‐positive countries represented 3.1% of all ingredients imported into the United States. Policies from Canada and Australia were evaluated for practicality of implementation by US government officials. Industry representatives from both countries consistently stated their policies would not be feasible in the United States due to the differences in cost and complexity of the swine and feed industries. Overall, unprocessed, or high‐risk, ingredients from ASFV‐positive countries represent a low percentage of imported ingredients into the United States; however, cautionary procedures may still be warranted given industry demand. As the number of affected countries grows, so does the risk for virus entry into the United States. The most likely method of ASFV transmission is direct contact between pigs. In countries free from disease, prevention of entry is focused on preventing fomite‐based transmission. One potential route for fomite‐based transmission is the feed supply chain. The USDA cites that used tote bags carrying feed ingredients was the most likely source of porcine epidemic diarrhoea virus (PEDV) entry into the United States from China in 2013  with the Harmonized Tariff Schedule (HTS) found in Table 2.2To understand the complex environment of importation requirements across three countries, the guidelines from the United States, Canada and Australia were initially reviewed. Canada and Australia were selected for comparison because, similar to the United States, they are countries free from ASFV but depend on imports from ASFV‐positive countries. They also had implemented significant policies to prevent disease entry through ingredients. Independent interviews were also conducted with representatives in each country representing the federal government, feed industry and swine industry. Positions interviewed to compile this information from the United States include USDA APHIS‐PPQ National Policy Manager, USDA APHIS‐VS Director of Animal Product Imports, American Feed Industry Association Vice President of Public Policy and Education, and National Grain and Feed Association Senior Vice President of Feed Services. Positions interviewed from Canada include Canadian Food Inspection Agency Programs and Policy Branch National Manager, Canadian Food Inspection Agency Animal Health Risk Assessment and Intelligence Section Risk Analyst, Canadian Food Inspection Agency Foreign Animal Disease Section National Manager, Canadian Pork Council, Animal Nutrition Association of Canada Technical Services Director and Animal Nutrition Association of Canada Executive Director. Positions interviewed from Australia include Australian Department of Agriculture, Water, and the Environment Data Analyst, Australia Department of Agriculture Program Lead for Biosecurity and Social Science, SunPork Australia Veterinarian and African Swine Fever Liaison to Australian Pork Limited, SunPork Australia Nutritionist, Australian Pork Limited Manager of Production Stewardship and Stock Feed Manufacturers’ Council of Australia Executive Officer.33.1From 2016 to 2020, the quantity of feed ingredients imported into the United States ranged from 11.6 to 12.8 million metric tons per year Figure . The PorThe moderate‐risk ingredients were imported from 10 different ASFV‐positive countries Figure . Soy oil3.23.2.1Seeds not for Planting guide that seeds from certain countries to be accompanied by phytosanitary certificates to eliminate the risk of pests, such as Khapra beetles in soybeans from Nigeria  includes foreign animal disease prevention and surveillance and partners with US Customs and Border Protection to enforce importation requirements. Two agencies within USDA‐APHIS share this responsibility. Veterinary Services (VS) ‘regulates the importation of animals and animal‐derived materials to ensure that exotic animal and poultry diseases are not introduced into the United States’  or upon arrival at a Canadian port. The required conditions include (1) heat treatment with a minimum temperature of 70°C for 30 min or 85°C for 5 min or holding of the product should occur for a minimum of 20 days at 20°C or 100 days at 10°C and (2) prevention of cross‐contamination via unidirectional traffic at the processing facility, single use containers or bulk containers with plastic liners and no additions of unprocessed ingredients added to the finished product.Health of Animals Act and Health of Animals Regulations, the Minister of Agriculture can declare Secondary Control Zones (SCZ) to prevent disease entry into Canada. By declaring certain zones or countries areas of concern regarding ASFV, the Canadian Food Inspection Agency can create restrictions when importing certain ingredients from ASFV‐positive countries. The amendments to Health of Animals Act and Health of Animals Regulations allowed for rapid implementation of the new policies; however, more than just the swine industry would be affected by the new import requirements. The swine and feed industry met with the National Farm Animal Care Council (NFACC), a unified organization representing all livestock sectors, to discuss their need for import policies from ASFV‐positive countries. There was no opposition from any other industries which also eased the way for the Minister of Agriculture to approve the new policies. Canada only has 6 marine ports compared to 50 within the United States Canada, like the United States also imports a relatively low amount of bulk grains and oilseeds . Accepted processing methods include (1) heating the product to a core temperature of 85°C for 10 min if it originates from a low‐risk country or to 100°C for 30 min if it originates from a high‐risk country; (2) pH reduction by 3.3 or (3) irradiation of 50 kGy. Australian pork industry officials interviewed described that even with these import restrictions in place, they frequently implemented their own holding time mitigation strategies due to their lack of confidence in effective processing by importing countries. The Australian government is currently conducting a cost:benefit analysis to determine the value of mitigation strategies to prevent ASFV. However, their analysis does not consider the role of feed or ingredients as a vector of ASFV entry or transmission. All Australian representatives stated that they did not believe a policy similar to Australia's would be practical to implement in the United States due to the size of the US feed and pork industries. In fact, both regulators and industry representatives alike expressed their concern that existing policies reduced the ability for pork producers to have access to low‐cost ingredients, which limited the industry's domestic growth and international competitiveness.In comparison to Canada and Australia, the US regulations may appear lacking. However, there is a growing proportion of production companies taking innovative steps to secure their ingredient supply chains. In a preliminary survey, which represented companies owning one‐third of the pigs marketed annually, over half of the participants utilized holding times for imported vitamins, minerals and supplements from ASFV‐positive countries. Moreover, half of the participants were working towards sourcing only domestic grains and oilseeds. Other companies have privately been tracing their ingredient supply chain back to the original sources as well as quarantining those ingredients in segregated warehouses. Ingredient tracing programs allow the entire supply chain, including the veterinarians and producers to have more confidence in the quality and disease status of imported ingredients (Patterson et al., 4As with any study, there are limitations which must be addressed. Due to time restraints, a limited number of individuals were able to be interviewed. As the objectives were primarily focused on regulatory structure in certain countries, the interviews primarily focused on governing regulatory bodies and national organizations. This limited representation from individual swine producers and veterinarians, which may view the challenges facing the swine industry differently than those interviewed.5There continues to be a small, but realistic threat for African swine fever virus entry into the United States through non‐animal origin feed ingredients. In 2020, moderate‐ and high‐risk ingredients from ASFV‐positive countries represented only 3.1% of all ingredients imported into the United States. While the United States has policies to prevent foreign entry of plant pests and diseases, Canada and Australia have been more aggressive in their regulatory approach to prevent animal pathogens in plant‐based ingredients. Industry led practices can be developed to disallow use of high‐ and medium‐risk ingredients from ASFV‐positive countries in swine feeds and require the use of mitigation strategies in low‐risk ingredients if there is a high demand from producers and industry leaders.The authors declare no conflicts of interest in the completion and reporting of results for this investigation.


DME) patients using current intravitreal anti‐vascular endothelial growth factor (anti‐VEGF) biologics compared with the dexamethasone implant.The aim of this study was to estimate the 1‐year costs associated with treating diabetic macular oedema , Switch group (aflibercept) and dexamethasone were 9.5, 9.1 and 3.0 respectively. From a healthcare perspective, the 1‐year costs for the Naive group were 15% lower , and for the Switch group, 23% higher  compared with dexamethasone (€4252). The ‘extended’ healthcare perspective showed the cost per patient per year for bevacizumab remained nominally lower in the Naive group, while dexamethasone remained lower for the Switch group .DME treatment may increase economic costs in settings where bevacizumab is used off‐label. Treating resistant DMEwith dexamethasone may reduce the costs and treatment burden compared with switching to aflibercept.From a primary healthcare perspective, the dexamethasone as a first‐line  The global prevalence of diabetes mellitus (DM) is increasing and is projected to affect nearly 700 million people by 2045  therapies. However, not all patients respond to anti‐VEGFs, such as bevacizumab (Avastin), aflibercept (Eylea) and ranibizumab (Lucentis)  assuming bevacizumab. Patients who failed to respond after 4–6 consecutive monthly injections of bevacizumab are switched (i.e. Switch group) to another anti‐VEGF, usually aflibercept. We assume the dexamethasone could be provided to either group of patients or used data from published literature to quantify expected resource use in the first‐year. We identified, quantified and valued the costs from a healthcare perspective  and an ‘extended’ healthcare perspective , as recommended by the National Medicines Agency , Norway, combined with published literature, national fee schedules and listed drug prices to compare the 1‐year economic costs of three alternative DME treatments. The use of registry data was approved by the institutional data protection officer in accordance with the General Data Protection Regulation. Data from all intravitreal injections for the years 2017 and 2018 were collected. Although bevacizumab is the first line of treatment for centre‐involving DME and baseline visual acuity above 20/50 and aflibercept is the first line of treatment for patients with visual acuity below 20/50, we included only first‐line treatment  a Switch group, that is patients who switched from bevacizumab to aflibercept and remained on aflibercept for at least 1 year. We included all costs that were associated with each group within a 1‐year time horizon, starting from the time of treatment decision—that is either initiating treatment or switching treatments.Based on assumptions of similar drug effectiveness  from the first injection were excluded. The drugs used intermittently, such as ranibizumab or aflibercept, were also recorded. Switch patients' group included only those treated prior to 2017 with any other drug except aflibercept and had switched to aflibercept in 2017. Only those who continued treatment for the 1‐year period were included in the analysis  equal to 1 EUR. Published drug list prices, after removing value‐added tax (VAT), were used to calculate the cost of dexamethasone, bevacizumab and aflibercept. For all current anti‐VEGF biologics, ready to use syringes are compounded from vials at the OUH hospital pharmacy  for drug reimbursements Table  NoMA 20, 2018b. We further expanded our analytical perspective as recommended by the national guidelines for healthcare intervention evaluations to include transport cost for the journey to and from the healthcare centre; therefore, the transport cost was multiplied by 2 to cover the round trip. While the patient's time at the facility and the patient's time required for the roundtrip journey to/from the eye facility was averaged at 90 min, the patient's time cost was multiplied by 1.5 for both patient groups (Naive and Switch). The product was multiplied by the number of visits in each group and added to the total cost of the respective group. We applied the same to dexamethasone visits and added the intraocular pressure visits multiplied by the time cost and transport cost.We calculated the expected 1‐year treatment cost for each patient group–treatment combination by estimating the number of visits for either of the drugs used. This aided in calculating average visit cost or injection cost and the post‐injection care for the dexamethasone group. We thereafter adjusted the drug cost for the vial compounding; then, the product was added to injection cost and associated follow‐up cost for the 1‐year period. Based on the register data for bevacizumab and aflibercept, calculations were undertaken using the same approach to calculate the 1‐year cost per patient for dexamethasone. The primary outcome included the 1‐year costs per patient per year, as well as descriptive outcomes such as the number of patients in the Naive and Switch group, the mean number of injections for the different drugs per year and the mean duration between each individual drug injections.We stratified costs as drug cost and resource utilization cost in order to calculate the difference between the drugs and the total cost difference per patient per year. Resource utilization included visit cost to the specialist, injection cost, OCT cost and intraocular pressure management cost in case of dexamethasone. The patient transport cost and the calculated patient time cost were added to determine the ‘extended’ healthcare perspective cost. We aggregated the total to estimate the overall cost per patient per year from two perspectives for each drug in the ‘extended’ healthcare perspective and the healthcare perspective, and we differentiated each stratum between the drugs either bevacizumab (Naive) or aflibercept (Switch) total cost from dexamethasone total cost in establishing the less expensive treatment. The analysis was performed using Microsoft Excel in Office365.i.e. 2.5–4) in both Naive and Switch groups   and 70 (59%) met the inclusion criteria for this study; 49 (41%) did not continue with the treatment (with a mean (SD) of 2.5 (±2.1) injections before treatment termination). Half of the included patients continued on bevacizumab for the 1‐year period, while 35 of the patients received other drugs intermittently , or 40 eyes, completed the 1‐year inclusion period from the 49 patients. However, during the study year, one‐quarter of the patients switched back to bevacizumab or ranibizumab and were, therefore, excluded. The patients n = 28) who remained on aflibercept for the one‐year study period were included in the analysis and had received 9.1 (±2.8) injections on average during the study period  ; however, these drug costs were more than offset due to the cost‐saving dexamethasone provided on resource utilization (Table i.e. between 2.5 and 4), we found that any fewer than or equal to 2.5 dexamethasone visits per year yielded lower total cost per patient per year among Naive patients compared with bevacizumab . However, if the number of dexamethasone injections also decreased in year 2, the dexamethasone strategy becomes cost saving compared with receiving bevacizumab . With 3 or more dexamethasone injections per year, the cost savings were moderated, yet still remained lower than the use of the eye specialist in Naive patients Fig. . Among tWhen we explored the impact of varying the drug costs in the Naive group, we found that a 20% decrease in the dexamethasone drug cost would lower the total cost difference in the event of an increase of 20% of bevacizumab. However, as the drug cost dropped by 40%, there was lower total cost per patient irrespective of the cost changes among the bevacizumab patients Fig. . AccordiWhen we decreased the visit and injection unit costs in the two groups by 50%, dexamethasone remained more costly for Naïve patients and cost saving for Switch patients Table . We founvs. €4987 bevacizumab). The high cost is attributed mainly with the dexamethasone drug cost, which is over twice the cost of resource utilization (€3061 drug cost and €1191 resource utilization cost). For non‐responding Switch patients, we found that 1‐year costs for dexamethasone provided cost saving of €974 compared with aflibercept .Our study estimated 1 year cost of treating Naive patients initiated on bevacizumab compared with dexamethasone and non‐responding Switch patients with aflibercept compared with dexamethasone. Assuming a healthcare perspective for Naive patients, we found higher overall costs per patient per year for dexamethasone (€4252) compared with patients initiating bevacizumab (€3619); however, when including costs related to patient transportation and time to undergo treatments, we found only nominal cost differences  for anti‐VEGF‐resistant patients  or even when we assumed monthly aflibercept injections. However, if patients continue on a medication over many years, which is likely for DME patients, the risk of cataract may increase beyond what we assumed. In addition, due to the interaction of DM as a risk factor for developing cataract, DME patients may still experience cataract development irrespective of the treatment drug used. . Including these additional costs would have no impact on costs estimated from the primary healthcare perspective. In addition, we considered lower visual acuity that could occur during treatment—in such a case, further indirect costs may be relevant to include. In our study, considering the groups included, an indirect cost such as for vision loss is highly unlikely.We also acknowledge that evaluation studies should include a probabilistic analysis to quantify credible intervals; however, in this cost‐minimization study, the uncertainties in the cost parameters could be broadly explored through one‐ and multi‐way deterministic analyses to provide the impact of parameters on the outcomes  compared with bevacizumab by the number of visits for both drugs in Naive patients in the ‘extended’ healthcare perspective.Click here for additional data file.Figure S2. One‐way sensitivity analysis for the two‐year cost differences per patient for dexamethasone (DEX) compared with bevacizumab by the number of dexamethasone visits for Naive patients in the ‘extended’ healthcare perspective.Click here for additional data file.Table S1. Treatment modalities and cost for diabetic macula oedema with the number of patients treated at the Oslo University Hospital in the Naive group (initiated on bevacizumab in 2016–2018).Click here for additional data file.


The peripheral blood and bone marrow aspirate smear revealed small round‐to‐ovoid yeast cells located predominantly within or surrounding the neutrophil  Figure. The blood culture showed the fungus grown in a mould form arranged in a mulberry‐like pattern and produced a soluble red pigment that diffuses into the sabouraud medium (bottom left). Lactophenol cotton blue staining confirmed numerous yeast‐like organisms by the microscopic morphology . Fungus staining also showed numerous blue yeast‐like organisms by fluorescence microscope .A 31‐year‐old Chinese man referred to the haematology clinic, was presented with recurrent fever for 19 days and two enlarged lymph nodes on the left neck. Past medical history was unremarkable. Laboratory data revealed white blood cell (WBC) count 9.81 × 10Talaromyces marneffei, a dimorphic fungus that is an important opportunistic pathogen. After treatment with anti‐fungus and anti‐HIV drug, this patient had significantly improved and discharged.The patient was subsequently diagnosed with AIDS having HIV antibody, and the blood cultures showed the growth of The authors declared that they have no conflict of interest.Yingcai Huang provided the haematology picture and wrote the manuscript. Haiyan Cui provided the microbiology picture. Yanxia Chen analysed the data. Jinlin Liu wrote the manuscript. All authors reviewed this manuscript and agreed to submit it.This study was approved by the ethical committee of Longgang District People's Hospital of Shenzhen & The Second Affiliated Hospital of the Chinese University of Hong Kong (No. 2022007).This study did not involve any personal information, but only reports the laboratory data. Therefore, the patient consent was waived, and this waive was approved by the ethical committee of Longgang District People's Hospital of Shenzhen & The Second Affiliated Hospital of the Chinese University of Hong Kong.


In this issue of EMBO Molecular Medicine, the report of Sauer et al (2022) demonstrates the feasibility of longitudinal monitoring of disease burden and response using ctDNA from dried blood spots in xenograft models.The liquid biopsy concept has been introduced for circulating tumor cells more than 10 years ago  and rapidly extended to cell‐free DNA released from tumor cells  that demonstrates the feasibility of longitudinal monitoring of disease burden and response using ctDNA from dried blood spots in xenograft models. I. Heidrich and K. Pantel discuss the study by Sauer  Sauer et al  developeBesides its use in xenograft mice models, this new approach has important implications for liquid biopsy analyses in humans. Dried blood spot samples can be taken easily by the cancer patient or individual at risk of developing cancer at home and sent to a central laboratory for ctDNA‐based analysis. Self‐sampling of blood opens therefore a new avenue for liquid biopsy diagnostics. In addition, the DBS method can now also be applied to understand the biology behind ctDNA as a biomarker. To date, we still do not fully understand why even some metastatic tumors are poor shedders, which limits the use of ctDNA. This heterogeneity occurs between and within different tumor entities and cannot be easily predicted. The tumor microenvironment might play a role; primary or metastatic lesions in the brain usually show lower ctDNA concentrations than tumors in other organs. Moreover, the biological role of ctDNA encapsulated in extracellular vesicles is still debated and the hypothesis that ctDNA  might play an important functional role in disease evolution. Finally, the concentration of ctDNA depends on the background of cell‐free non‐cancer DNA, which can also change over time due to disease conditions  or therapies inducing massive apoptosis of normal tissue .et al, et al, The main source of ctDNA is apoptotic tumor cells, but active secretion through encapsulation in extracellular vesicles has been also demonstrated . Interestingly, although the tumor specificity of DNA analysis is usually higher than that of RNA or proteins, white blood cells  can harbor tumor‐specific mutations of the KRAS or TP53 genes (and others) in particular in aging individuals  are now able to fulfill this important task.To implement the DBS approach into clinical practice, future interventional clinical studies where clinical decision‐making will be based on the result of the liquid biopsy assay are required. Moreover, assay standardization and quality assurance will be important  pending.


Two major studies of structural changes associated with aging in human kidneys are reviewed and new information presented. The studies are the Monash University stereologically analyzed series of 319 autopsy kidneys from the United States in which 44% were white and the Mayo Clinic CT angiogram/biopsy analysis of 1,388 US kidney donors in which 97% were white. Hypertension rates in the Monash series were 48% and included moderate and severe hypertension. In the Mayo Clinic study, 12% had mild hypertension. The studies showed no relationship between glomerular number and hypertension except for a weak relationship with older white women in the Monash series. An inverse relationship was present between glomerular number and glomerular volume, a reciprocity that tended to enhance glomerular mass and by inference filtration capacity with lower nephron numbers. This relationship seemed to be present whether low nephron numbers were intrinsic or acquired. In the Mayo Clinic studies, pretransplant iothalamate clearances demonstrated that single nephron (SN) glomerular filtration rates (GFR) were similar throughout the range of glomerular number in subjects younger than 70 years, but that increased SNGFR correlated with nephron hypertrophy and increased nephrosclerosis particularly at 70 years of age and over. Hypertension at least through middle age cannot be related to a deficiency of glomeruli, but glomeruli are lost with later aging in association with adaptive nephron hypertrophy that can maintain GFR near normal. These studies help define an age‐related nephropathy that overlaps with hypertension as a potential cause of end‐stage renal disease when glomerulosclerosis is advanced. The disector/fractionator is used primarily at autopsy, whereas the CT/biopsy method can be conducted on living persons. These studies have clinical significance because low nephron endowment may help define patients at high risk for progressive chronic kidney disease who may benefit from early clinical intervention to prevent ESRD  yielding the second “slice” sampling fraction. The location of the samples from the cortex can be determined by the subsequent histologic sections showing capsule, a rim of upper medulla, or none.The selected sample blocks are embedded in glycol methacrylate to avoid the shrinkage of processing into paraffin and then completely serially sectioned at a thickness of 20 μm to produce approximately 100–150 section pairs per kidney. Every 10th and 11th paired sections are selected producing a “section” sampling fraction. The 10th (“reference” section) is examined with the 11th “look‐up” section. Identical regions of the section pairs are projected onto unbiased counting frames (grids) from tandem microscopes  in the kidney is calculated. The glomerular tuft areas are calculated from the points that they overly on the grid. The average glomerular volume (Vglom) is derived from the volume density divided by the numerical density of glomeruli in the kidney. Multiplication of Nglom by Vglom provides an estimate of the total glomerular volume of the kidney .The number of disappearing glomeruli in the serial sections represents the number of glomeruli in the block. From the individual blocks representing a known fraction of the whole cortex, the total number of glomeruli . For this reason, counts are often referred to as “unbiased,” but this is only the case if the technique is used correctly.The percent of glomerulosclerosis, the severity of arteriosclerosis, and the percent of interstitial fibrosis and tubular atrophy were analyzed morphometrically as planar data with Image ProPlus software as described previously  was calculated. The causes of death among this autopsy cohort closely resemble that of the general Mississippi population with approximately one‐third of deaths being caused by CVD  of 29–51 years. To prevent excessive glomerular loss due to renal scarring from interfering with glomerular counting, the collection excluded diseased kidneys or kidneys with any more than moderate arteriolonephrosclerosis. This restriction resulted in the collection of only 20 subjects 65 years or older. Clinical information on the subjects included cause of death, hypertension history, and height and weight from which body mass index  with a more than 9‐fold range from 210,332 to 2,702,079. There was no significant racial difference (P = 0.29), but females had significantly fewer glomeruli than males .The median NP = 0.66) but with females having lower birth weight than males (P = 0.04). For subjects 18 years or older, there was a significant direct correlation between birth weight and Nglom  with each 1 kg increase in birth weight predicting an increase of 132,446 glomeruli   with each kilogram increase in birth weight predicting an increase of 4.8 cm in height  and between height and Nglom  with each 1.0 cm increase in height predicting an increase in 3,737 glomeruli   with no significant difference by race (glom increased with age and reached adult size at about 20 years of age. The median adult Vglom was 7.1 μm3 × 106 (IQR 5.5–8.9) with a more than 6‐fold range from 2.7 to 17.0 μm3 × 10,6 and with African Americans having significantly larger Vglom than whites (P < 0.001). There was an inverse correlation between Nglom and Vglom  with each decrease of 46,067 Nglom predicting an increase of 1.0 μm3 × 106 in Vglom   with every 1.0 cm increase in height predicting an increase of 0.89 cm3 of Vglomtotal  and was not significantly different than the median Nglom of either non‐hypertensive (P = 0.75) or hypertensive African Americans (P = 0.65).Birth weight had no association with hypertension in either race, and Table P < 0.001) and female sex  but not BMI  or Nglom . For sex alone, lower Nglom was significant for 13 hypertensive females (P = 0.02) but not for 35 hypertensive males (P = 0.15). When age was examined as a single variable, hypertensive white women were significantly older than those without hypertension . The findings suggest that the lower Nglom in hypertensive white women was likely to be an age‐related nephron loss and probably not a primary factor in the elevated blood pressure.White hypertensives had significantly fewer glomeruli than non‐hypertensives Table . In logiglom was determined by African American race , male sex , higher BMI , hypertension , and lower Nglom . African American race, hypertension, obesity, and aging are significantly related to chronic kidney disease  and the Mayo Clinic study (CT/biopsy method). These estimates are compared by age range using non‐paired These are minor age differences that do not detract from important similarities that include a direct correlation between height and glomerular number, an inverse correlation between glomerular volume and glomerular number, and an increased glomerular volume with increased BMI. The Monash series found that birth weight was related to both height and glomerular number suggesting that birth weight was essentially “right sizing” the number of glomeruli in a kidney for an individual's adult height. The Mayo Clinic study showed an absence of a relationship between glomerular number and mild hypertension, while the Monash series findings showed no significant association between glomerular number and hypertension among African Americans of either sex nor among white males.The substantial loss of glomeruli with aging that was found in the Mayo Clinic donor kidneys helps explain the large population of older persons, classified as having “ vascular disease”, but without any elevation of blood pressure or with only mild hypertension that are second only to diabetes as a cause for entry into US ESRD programs . Persons 70–75 years old had a substantial loss of glomeruli and SNGFR increased presumably as an adaptation to glomerular loss (Denic et al., glom, the reciprocity between lower glomerular number and larger volume enhances glomerular mass and supports increased glomerular filtration. Additionally, the larger glomerular volume attenuates the perfusion pressure of individual glomeruli and the potential for glomerular hypertension. This has been studied in transplant donors, where despite increased SNGFR in the remaining kidney, glomerular hypertrophy compensated for the reduction in glomerular mass, and estimates of glomerular capillary pressure remained constant (Blantz and Steiner, In kidneys with low NThe convergence of BMI and glomerular number may be a factor in the development of obesity‐related glomerulopathy. With low glomerular number, a threshold may be reached in the capacity of glomeruli to adaptively enlarge with larger BMI, and increased glomerular perfusion may eventually result in glomerular hypertension. A similar phenomenon may occur with aging, where the enlargement of remaining, non‐sclerotic glomeruli may be limited and eventually reach a point recognized as decompensated hypertensive injury (Hughson et al., 4These two studies of the US subjects showed that there was a wide range in the number of nephrons in normal kidneys and that lower glomerular number was associated with an increased mean glomerular volume. The studies also showed a decline in glomerular number with age and nephrosclerosis that is quite marked in the Mayo Clinic subjects after 70 years of age. Among Mayo Clinic subjects, an increased SNGFR was observed with acquired glomerular loss in the over 70‐year‐old group, but among younger subjects what appeared to be intrinsic differences in glomerular number and volume were not associated with alterations in SNGFR. Exceptions were seen in subjects with obesity and height ≥190 cm where SNGFR did increase in association with larger glomerular volume (Denic et al., These findings have important implications for understanding the risk of ESRD among the large population of kidney patients that are neither diabetic nor have any defined type of kidney disease. As many as 55% of persons entering the US ESRD programs fall into this category and are diagnosed as mildly hypertensive or have never been recognized as being hypertensive at all (Klag et al., Obesity‐related renal disease consists of diabetic changes, glomerulomegaly with proteinuria, and focal segmental glomerulosclerosis (Kambham et al., in utero to meet the metabolic demands of an also predetermined adult body size, albeit without the burden of obesity. Both birth weight and adult height are predictive of glomerular number, but because of the wide variance in glomerular number throughout the range of body height or birth weight, this requires robust numbers of subjects to demonstrate. The Monash series and Mayo Clinic studies provide those numbers and are showing that glomerular number is unlikely to be related to the initiation of hypertension, at least in young‐ and middle‐aged adults. It is doubtful that this will be regarded as a completely settled question, but interest is shifting toward the relationship between low glomerular number with its attendant large glomerular size on the risk for progressive nephrosclerosis.The kidney is composed of a highly redundant system of nephrons whose numbers seem to be predetermined The Mayo Clinic studies show that large numbers of glomeruli disappear from the aging kidney and that kidney donors having family members with ESRD have reduced numbers of glomeruli (Elsherbiny et al.,


The objective was to compare COVID‐19 outcomes in the Omicron‐driven fourth wave with prior waves in the Western Cape, assess the contribution of undiagnosed prior infection to differences in outcomes in a context of high seroprevalence due to prior infection and determine whether protection against severe disease conferred by prior infection and/or vaccination was maintained.In this cohort study, we included public sector patients aged ≥20 years with a laboratory‐confirmed COVID‐19 diagnosis between 14 November and 11 December 2021 (wave four) and equivalent prior wave periods. We compared the risk between waves of the following outcomes using Cox regression: death, severe hospitalisation or death and any hospitalisation or death  adjusted for age, sex, comorbidities, geography, vaccination and prior infection.We included 5144 patients from wave four and 11,609 from prior waves. The risk of all outcomes was lower in wave four compared to the Delta‐driven wave three (adjusted hazard ratio (aHR) [95% confidence interval (CI)] for death 0.27 . Risk reduction was lower when adjusting for vaccination and prior diagnosed infection  and reduced further when accounting for unascertained prior infections (aHR: 0.72). Vaccine protection was maintained in wave four .In the Omicron‐driven wave, severe COVID‐19 outcomes were reduced mostly due to protection conferred by prior infection and/or vaccination, but intrinsically reduced virulence may account for a modest reduction in risk of severe hospitalisation or death compared to the Delta‐driven wave. Following the identification and early spread of the Omicron B.1.529) SARS‐CoV‐2 variant of concern (VOC) in November 2021, South Africa observed the steepest surge in COVID‐19 cases to date .529 SARS, 7, 8.South Africa had previously experienced three COVID‐19 waves related to different SARS‐CoV‐2 variants , each more clinically severe than the previous one with substantial mortality . These wWhilst there is emerging biological evidence of possible lower virulence of Omicron compared to previous variants due to modified cell entry mechanisms and preferential replication in bronchi rather than the lung parenchyma , 14, 15,We compared outcomes of laboratory‐confirmed SARS‐CoV‐2 infections across four successive waves in those aged ≥20 years using public sector services in the Western Cape Province, South Africa, accounting for prior infection and vaccination. We also assessed whether protection against severe disease conferred by prior diagnosed infections and/or vaccination was maintained in those infected during the Omicron‐driven fourth wave and examined the extent to which undiagnosed prior infection may account for observed reductions in clinical severity during the Omicron wave.We conducted a cohort study using de‐identified data from the Western Cape Provincial Health Data Centre (WCPHDC) of public sector patients aged ≥20 years with a laboratory‐confirmed COVID‐19 diagnosis (positive SARS‐CoV‐2 PCR or antigen test). For this analysis, each wave was deemed to commence on the date when COVID‐19 hospital admissions in public sector patients showed a sustained >10% week‐on‐week increase. We included cases diagnosed from 7 days before the wave start  and for the following 4 weeks, to allow for at least 2 weeks of follow‐up in the most recently diagnosed patients in wave four. We, thus, included data for the fourth wave on cases from 14 November to 11 December 2021, with follow‐up through to 26 December 2021, which corresponds to the period when Omicron rapidly became the dominant variant in the province accounting for nearly 100% of sequenced cases. [The study was approved by the University of Cape Town and Stellenbosch University Health Research Ethics Committees and Western Cape Government: Health. Individual informed consent requirement was waived for this secondary analysis of de‐identified data.The Western Cape has nearly 7 million inhabitants, of whom approximately 75% use public sector health services . The WCPγ is the relative risk of the outcome in those with versus those without prior infection, ρ is the proportion of reinfections detected and θ is the observed proportion of reinfections with Delta and Omicron, respectively [We assessed three outcomes: (i) death, (ii) severe hospitalisation or death and (iii) any hospitalisation or death. We only included outcomes within 14 days of COVID‐19 diagnosis to allow for comparable ascertainment across all wave periods. Hospitalisation included admission within 14 days before or after a COVID‐19 diagnosis except for admissions to long‐term psychiatric or rehabilitation facilities where the COVID‐19 diagnosis was likely to be incidental. Severe hospitalisation was defined as admission to intensive care or mechanical ventilation or oral/intravenous steroid prescription. Deaths within 14 days of COVID‐19 diagnosis were included unless a clear non‐COVID‐19 cause of death was recorded.n et al.  to assesn et al. , 30. We ectively . The proectively  was violIn addition, to assess whether protection conferred by prior infection and vaccination was similar in the Omicron and Delta periods, we compared the association between these variables and the three severe COVID‐19 outcomes separately for just the wave three and wave four periods. The wave three period was cases diagnosed between 1 September and 15 October 2021 as too few people had been vaccinated during early wave three (26 May to 23 June 2021) since vaccination only commenced for those 60 years and older on 17 May 2021. All analyses were conducted using Stata 17.1.We included 5144 patients diagnosed in wave four and 4403, 3902 and 3304 patients from waves three, two and one, respectively  of cases were hospitalised or died within 14 days of diagnosis in wave four compared to 16.5%  across the previous three waves . Results were sensitive to the extent of protection assumed to be provided from prior infection and the proportion of prior infections assumed to be ascertained Table . For exaAmongst COVID‐19 cases, protection by vaccination against all outcomes was similar in wave four compared to the prior wave Figure . For exaIn this study of Western Cape public sector laboratory‐confirmed COVID‐19 cases, we found a substantial reduction in all severe COVID‐19 outcomes in wave four compared to previous waves with 28%  reduced risk of any hospitalisation or death and 59%  reduced risk of death only after adjusting for sociodemographic characteristics, comorbidities and vaccination. Whilst some of this reduction is likely due to retained protection conferred by prior SARS‐CoV‐2 infection against severe disease in Omicron‐infected patients, even when accounting for protection conferred by prior unascertained infections in patients with Omicron, we found a modest reduction in severe hospitalisation or death in wave four versus wave three.Our findings concur with current literature reporting less severe disease associated with Omicron versus other variants of concern and previous waves , 19, 20.The finding of increased prevalence of HIV‐1 in wave four compared to the previous two waves illustrates the importance of adjusting for prior unascertained infections. Poorer urban communities tend to have higher HIV‐1 prevalence and so the pattern of decreasing HIV‐1 prevalence in the second and third waves, with increased prevalence among fourth wave cases, is unlikely to be due to HIV‐1 itself, but because HIV‐1 infection is a proxy for living in a community like Khayelitsha subdistrict, with high SARS‐CoV‐2 seroprevalence by the end of the first wave, which protected against infection in the two subsequent waves, but less so in wave four.For the less severe outcome of any hospitalisation or death, whilst risk in wave four was less than in wave three, after adjusting for vaccination and prior diagnosed infections, it was similar to that of wave one. This is notable as wave three was driven by the Delta variant, which has been shown to cause more severe disease than ancestral strains , 25, 26.Strengths of our study include complete ascertainment of hospitalisations and deaths in all laboratory‐confirmed COVID‐19 cases across a public sector health service and ability to robustly adjust for comorbidities as well as SARS‐CoV‐2 vaccination. Our analysis also has several limitations. First, we compared outcomes across waves as a proxy for the variant that dominated in each wave and not in patients with genomically confirmed variants. Nonetheless, each wave in South Africa was dominated by a different variant which accounted for >90% of sequenced specimens at the wave peak and using wave as a proxy allowed for a much larger number of cases to be included in the analysis than would have been feasible if limited to genomically confirmed cases. Second, whilst health service pressures which impact disease outcomes are likely to be more similar at ‘equivalent wave periods’, identifying such ‘equivalent periods’ across waves can be challenging. Since we only compared the early part of each wave, our results could be biased if disease severity outcomes differ between the early and later parts of each wave and this difference varies across waves. However, we adjusted for sociodemographic and clinical predictors of disease severity and the results were similar when using slightly different wave periods. Third, most cases in our study would have been tested because of having clinical symptoms, and our findings may have differed if those with asymptomatic infection could have been included. Additionally, as the peak of each wave approached, the Western Cape restricted public sector SARS‐CoV‐2 diagnostic testing to those at greatest risk of severe disease  which could have impacted on comparison of disease outcomes across waves. However, since we only included the early part of each wave in this analysis, there were only 4 days included  when testing was restricted, and the results did not differ when we excluded these 4 days from the analysis. Fourth, adjustment for comorbidities was limited to those algorithmically identified in the WCPHDC and does not include undiagnosed comorbidities and other important risk factors for poor COVID‐19 outcomes such as obesity. Fifth, prior diagnosed infections substantially under ascertain all prior infections, and whilst we addressed this by determining the likely impact of undiagnosed infections in wave four, this is based on assumptions. Furthermore, due to the high prevalence of prior infections in our population, our estimates of vaccine protection against severe disease among COVID‐19 cases may underestimate the full protection that vaccines would provide in an infection‐naive population. Sixth, we could not distinguish between admissions and deaths where the diagnosis of COVID‐19 may have been incidental or contributory rather than causal. However, our main analysis focused on mortality and we found stronger protection of both wave four and vaccination against the more severe outcomes , suggesting that results are robust despite misclassification of admissions with incidental COVID‐19. Nonetheless, a different clinical profile of hospitalised and deceased patients with COVID‐19 has been reported, with less COVID‐19 pneumonia and a greater proportion of patients with severe comorbidities where COVID‐19 may be contributory, but not causing typical respiratory presentation . We may,In conclusion, we found substantially reduced disease severity amongst diagnosed COVID‐19 cases in the Omicron‐driven fourth wave compared to previous waves. Whilst this appears to be largely due to retained protection against severe outcomes conferred by prior infection and vaccination, our data suggest that there may be a modest reduction in severe outcomes due to intrinsically reduced virulence of Omicron.All authors declare that they have no conflicts of interest.The funders had no role in the study design, data collection, data analysis, data interpretation or writing of this report. The opinions, findings and conclusions expressed in this manuscript reflect those of the authors alone. For the purposes of open access, the author has applied a CC‐BY public copyright to any author accepted version arising from this submission.Table S1 Associations between different waves and severe COVID‐19 outcomes adjusted for patient characteristics, subdistrict, vaccination and prior diagnosed infection using logistic regressionTable S2 Range of possible values for the true hazard ratio for the association between wave four (vs. wave three) and each COVID‐19 outcome for different assumptions of the protection that prior infection provides against the outcome and the proportion of reinfections detected among cases diagnosed during the fourth waveClick here for additional data file.


Trauma‐focused interventions have been shown to be effective treatments for post‐traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals’ perceptions of what impedes or facilitates the use of trauma‐focused interventions among people with psychosis and PTSD.A qualitative study using constructivist grounded theory methodology.We conducted semi‐structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.Three inter‐related barriers to the use of trauma‐focused interventions were conceptualized: coherent understanding; structural support; and safe space.Delivery of trauma‐focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills. Health care professionals describe multiple barriers to the delivery of trauma‐focused interventions for people with psychosis and PTSD: as a result, providing these interventions continues to be considered the exception rather than the rule.Findings highlight perceived barriers in the form of coherent integration of the discussion of trauma into the clinical discourse of psychosis services; the structural support for the delivery of trauma‐focused interventions; and a safe space for intervention to occur.A range of potential opportunities to improve the delivery of trauma‐focused interventions are identified including the use of psychosocial team formulation sessions, organizational interventions, and training focused on the development of staff confidence and skills.The association between trauma and psychosis is well‐established. Individuals with psychosis are consistently shown to have experienced high levels of trauma , Trauma‐focused psychological interventions including cognitive behavioural therapy (tf‐CBT) or eye‐movement desensitisation and reprocessing (EMDR) are recommended first‐line interventions for PTSD  for people with a psychotic disorder is typically delivered by multi‐disciplinary community mental health teams within the publicly funded National Health Service (NHS). Clinical decision‐making is informed by clinical guidance published by the NICE and implemented into local services by clinical commissioning groups NICE, . SpecialTreatment decisions are complex, influenced by clients, clinicians, organizational, and treatment variables. The perspectives of health care professionals offer valuable insights into understanding the delivery of trauma‐focused interventions in this population and may offer valuable insights to implementation efforts. In the current study, we sought to explore and better understand health care professionals’ perceptions of the barriers and facilitators to using trauma‐focused interventions for people with psychosis and PTSD.We conducted individual, semi‐structured qualitative interviews with health care professionals working in the commissioning and delivery of clinical services for people experiencing psychosis. Treatment decisions within clinical contexts are social processes involving multiple stakeholders with differing experiences and perspectives. We therefore adopted a constructivist grounded theory approach to the research design.Grounded theory is an inductive methodology with systematic guidelines for collecting and analysing qualitative data . Two transcripts were independently reviewed by JB who contributed potential codes which were then compared with those developed by EC and incorporated into the provisional coding framework. The development of more focused codes and the conceptual representation of the data was then led by EC and reviewed through regular discussion in supervision to ensure credibility and face validity of the emerging framework. JB provided consultation and supervision throughout all stages of the research process.The study was approved by the University College London Research Ethics Committee, reference 15035/001.We interviewed 18 health care professionals. Interviews ranged from 25 to 57 min. Participants’ ages ranged from 33 to 58 years with between 3 and 34 years of experience working in mental health services. The professions of staff were: 11 clinical psychologists, three psychiatrists, two social workers, one nurse, and one occupational therapist. Participants were working in a range of clinical teams: four in inpatient settings; three in early intervention for psychosis services; two in recovery and rehabilitation; one each in community mental health and a specialist psychological therapies service. Six participants were in senior positions across clinical teams and one in a Clinical Commissioning Group.Across participants, strong shared narratives were identified regarding the barriers and facilitators to delivering trauma‐focused interventions for people with psychosis. The conceptual model comprises three dominant but overlapping themes: (i) coherent understanding; (ii) structural support; and (iii) safe space Figure .All participants recognized the prevalence of traumatic experiences in people with psychosis and their potential consequences, including PTSD. Despite this, they acknowledged that traumatic experiences and PTSD symptoms were frequently neglected in assessment and treatment planning. In the context of complex clinical presentations and symptoms, identification of traumatic experiences was positioned as a key facilitator to the recognition of symptoms as trauma‐related and subsequent access to trauma‐focused interventions.Participants described difficulty integrating discussion of trauma into a clinical discourse within services for psychosis. This prevented knowledge about the prevalence of trauma and trauma‐related symptoms in psychosis being translated into clinical practice including routine identification of traumatic experiences and individuals who would benefit from trauma‐focused interventions. The coherent understanding was influenced by a dominant bio‐medical model; awareness and perceptions of psychological interventions; and clinician characteristics. Illustrative quotations are included in Table the overwhelming presence of the medical model, the overwhelming presence and the overwhelming faith to chemistry Participants described the clinical discourse within services as being dominated by a bio‐medical model of psychosis as a biological illness: this was positioned as inconsistent with discussions of symptoms in relation to traumatic experiences. While the participants spoke about biopsychosocial approaches, the bio‐medical model was described as dominating the clinical discourse within services.Participants emphasized the importance of routine questions about traumatic experiences during assessments to formulate symptoms as trauma‐related and identify individuals who may benefit from trauma‐focused interventions. However, within the medically dominated understanding, participants perceived that such questions were viewed by clinicians as a tick‐box exercise or not asked at all. This could increase the risk that PTSD symptoms were not identified nor appropriate intervention offered.… talking about psychosis‐related symptoms rather than talking about their trauma ‘cause they assume that’s not what they’re here for, that’s not what’s available, that’s not what can be treated Participants also reflected on how this clinical discourse influenced service users’ own narratives about their mental health. The absence of questions about trauma, or failure to follow up disclosures, fostered an understanding that these experiences were not relevant: this could discourage service users from discussing them and further reduce the likelihood of symptoms being recognized and an appropriate intervention offered.Significant differences between participants’ awareness of and perceptions about psychological interventions indicated ambiguity about the nature and use of interventions. Participants described diverse definitions of trauma‐focused interventions. For some, they were conceptualized specifically as interventions involving the re‐living or re‐processing of traumatic memories. However, others described a broader approach whereby traumatic experiences were included within the clinical formulation but were not the focus of treatment. Terms such as ‘trauma‐focused interventions’ and ‘trauma‐informed approaches’ were used interchangeably. Systemic therapies, psychodynamic psychotherapy, peer support, and medication were also described as trauma‐focused interventions. This conflation of terminology highlighted ambiguity in the discussion of trauma and trauma‐focused interventions.Participants expressed beliefs that the provision of psychological therapies, and of trauma‐focused interventions specifically, was extremely limited and difficult to access. One psychiatrist described frustration at identifying PTSD but being unable to offer treatment within the service. Provision was perceived to be limited by the number of therapists, range of available interventions, and pressures to deliver brief interventions. Overall, psychological therapy provision was characterized as inadequate to meet the complex needs of this population.it's something that is counter‐intuitive isn’t it, that…that we are asking people to believe that you get better by diving into the depths of the worst thing that ever happened to you Participants also spoke about widespread narratives that talking about traumatic experiences would exacerbate distress. As such, participants acknowledged that clinicians and service users may view the re‐living of traumatic experiences as counter‐intuitive. Psychologists perceived the avoidance of talking about trauma due to the fear of exacerbating distress as a barrier to both the recognition of PTSD symptoms and engagement  with trauma‐focused interventions.Psychologists described the importance of psycho‐education in promoting understanding and engagement in trauma‐focused treatments. Staff reflected that their own understanding of and confidence in the treatment had improved through training and clinical experience of interventions.many professionals have traumatic experiences, and actually are as vulnerable as clients are to re‐activating traumatic experiences Participants perceived clinicians’ characteristics to influence how valuable clinicians considered trauma‐focused interventions to be, as well as how sensitively and effectively they were able to talk about traumatic experiences and PTSD symptoms. Individuals reflected on how their own experiences, including traumatic experiences, influenced them to pay more attention to trauma and PTSD symptoms in their clinical practice. Personal experiences of trauma were also considered to contribute to clinician aptitude for talking sensitively about the traumatic experiences of service users. In contrast, one participant highlighted how clinicians’ personal experiences of trauma could make discussing traumatic experiences with service users feel more difficult or potentially re‐traumatizing:Personal qualities of the clinician were considered by psychologists to be as important as clinical skills and techniques to deliver trauma‐focused interventions. Participants specifically noted the importance of courage and compassion to enable clinicians to work with emotionally evocative content of trauma‐focused interventions.Psychotherapeutic modality or theory was also presented as an important influence on the use of trauma‐focused interventions. Psychologists working within a systemic framework reported focussing on indirect and system‐level working over individual clinical work. Trauma‐focused interventions were described as incongruent with psychodynamic training and practice.Significant structural factors, including service configuration, communication between stakeholders, and training, influenced the use of trauma‐focused interventions. Recognition of symptoms as trauma‐related and access to trauma‐focused interventions was further considered to be influenced by the culture and operational mechanisms that facilitated disclosure of traumatic experiences by service users: this was created and influenced at multiple levels including socio‐cultural context, organizational structures, and individual clinicians. Illustrative quotations are included in Table I mean I do think this is a barrier, so, we…we’re a psychosis service, so in terms of what we should be offering as a service, it’s much, you know, much more it’s CBT for psychosis, as such Participants identified service configuration as a barrier to trauma‐focused interventions. Participants described distinct services for the treatment of PTSD and psychosis and uncertainty about which service was best placed to deliver trauma‐focused interventions for people with psychosis. This created ambiguity regarding where trauma‐focused interventions were situated within services.Referral pathways between services were experienced as challenging. Participants described variable referral outcomes and examples of referrals being declined due to differing clinical opinions; rigid, changing, and ambiguous service thresholds; and how referrals were written. Clinicians described therefore lacking confidence that referrals would be accepted and being discouraged from making future referrals.not the right kind of distress’ . Clinicians expressed concern that the referral process could damage service user engagement with treatment and services generally.Transitions between services could also be distressing for service users. Participants reflected that service users sometimes perceived the referral process as a rejection: their difficulties were regarded as ‘Participants talked about the importance of communication between members of the multi‐disciplinary team in promoting appropriate referrals for psychological interventions. Limited communication and the use of psychological terminology appeared to create friction in communication between psychological therapists and colleagues from other disciplines. Clinicians described efforts to improve communication between colleagues from different professional disciplines through training, supervision, and a forum for team formulation.We’ve referred patients there instead, but I must say the difficulty then is, the people who are accepted for treatment, I must say I don’t get much feedback Communication between services and with commissioners was also emphasized. Participants talked about how outcomes and feedback from referrals to other services informed future decision‐making. The frequent absence of feedback left clinicians uncertain about the appropriateness or outcomes of referrals.Feedback from clinical services to commissioners was also described as an important influence on service planning and development.you would run a training and if it was an opt‐in option for staff, then it would very much depend on how busy staff felt they were, and if staff were over run with other things, it was, managers weren’t insisting they go, they just wouldn’t come […] it would feel like a luxury to go to training on something like that. Staff training on the assessment of traumatic experiences, PTSD symptoms, and delivery of trauma‐focused interventions was also discussed by participants. Participants highlighted the importance of management and organizational endorsement of training through the provision of funding and protected time for staff to attend training.Ongoing supervision following training was considered important to support clinician confidence and competence in the assessment of PTSD and delivery of trauma‐focused interventions.Participants spoke about the significant barriers to service users disclosing traumatic experiences and seeking help for PTSD symptoms: these included the stigma and shame often associated with such experiences. They spoke about the need for a culture that facilitated disclosure and how this was created and influenced at multiple levels from social‐political context to individual clinicians. Efforts to facilitate access to trauma‐focused interventions, therefore, required similar attention at multiple levels.At a socio‐political level, participants spoke directly about feminism and the ‘Me Too’ movement as increasing public awareness and normalizing the discussion of trauma. Others highlighted how poverty and austerity increased the risk of people experiencing trauma and reduced funding of health, social, and community services.Staff within managerial roles spoke about the influence of national policy and implementation guidance on service practices. They described difficulty prioritizing service development work around the identification and treatment of PTSD in the context of extensive national‐level key performance indicators.At an organizational level, participants highlighted the role of senior leadership in allocating resources and training to the assessment of PTSD and delivery of trauma‐focused interventions within psychosis services. Mechanisms such as patient record systems and the availability of screening tools also impacted clinical practice. Senior leaders were therefore perceived as influential in creating the organizational culture and processes that facilitated disclosure of trauma and delivery of trauma‐focused interventions.Individual therapists described feeling supported or inhibited in delivering trauma‐focused interventions by the culture and attitudes held by colleagues and the wider team. Sustaining practices designed to improve the routine identification of traumatic experiences and delivery of trauma‐focused interventions required endorsement and structural support at multiple levels of the organizational hierarchy and broader cultural context.Safety was prominent in clinicians’ minds when discussing the disclosure of traumatic experiences and delivery of trauma‐focused interventions. Participants acknowledged anxiety about the risk that assessment of traumatic experiences, PTSD symptoms, and trauma‐focused interventions could cause harm to both service users and clinicians. Finally, clinicians talked about the skills required to safely enquire about trauma and deliver trauma‐focused interventions. Illustrative quotations are included in Table ‘creating the safe space’  to ask about trauma or start trauma‐focused interventions. When speaking about the requirement of sufficient safety, participants spoke about a range of conditions including the timing of treatment, affective regulation, and coping strategies, as well as the acuteness or chronicity of their symptoms or clinical presentation. They also emphasized the importance of a supportive environment including social networks; community and clinical resources and the relational safety of the therapeutic relationship. The delivery of trauma‐focused interventions was therefore predicated on the clinical assessment of sufficient safety.Clinicians described Participants described strategies to address tractable barriers including establishing greater safety and stability before embarking on re‐processing work. Psychologists described a stabilization phase of treatment involving the development of skills such as emotional regulation, grounding, self‐soothing, and mindfulness. Other clinicians emphasized engagement and developing a therapeutic relationship to establish relational safety. Finally, therapists described focusing on other clinical targets, such as social anxiety or hearing voices, before commencing trauma‐focused interventions.people might struggle more to accept a service from a service which has already traumatised them at their point of entry Participants acknowledged that they did not always feel able to achieve sufficient safety. Perceived limitations to community and clinical service provision contributed to concerns that services were not able to provide a context of sufficient safety for trauma‐focused interventions. Participants also acknowledged that relational safety could be challenging where services themselves had been experienced as traumatic and harmful.Anxieties that trauma‐focused interventions could cause harm were raised by participants. While participants acknowledged service user anxieties, the anxiety experienced by clinicians and clinical teams was more prominent within discussions.Participants described both their own and colleagues’ anxieties that trauma‐focused interventions could be destabilizing and increase service user distress. At its most severe, clinicians expressed concern about the exacerbation of symptoms of psychosis and risk of potential adverse events including suicide. These fears appeared to be intensified by incongruence between trauma‐focused interventions and clinicians’ conceptualization of mental health treatment (Theme 1).real consequences for that person’s career […] perhaps they'll be viewed as negligent and perhaps it’ll impact whether they can continue to practice Anxieties about the risk of causing harm were confounded by the potential harm to clinicians themselves. Participants talked about the emotional impact on therapists of delivering trauma‐focused interventions, and about the possibility of vicarious traumatization. Psychologists described potentially catastrophic professional and reputational consequences for therapists if service users’ mental health deteriorated or they attempted suicide during treatment:While psychologists acknowledged experiencing anxieties about trauma‐focused interventions, few reported that these worries prevented them from delivering trauma‐focused interventions. Participants described research evidence and personal clinical experience on the effectiveness of trauma‐focused interventions as outweighing anxieties about treatment. Support from other psychologists and colleagues from other disciplines, supervisors, and managers, was identified as enabling the delivery of trauma‐focused interventions despite this anxiety.Clinicians’ skills were an important facilitator to the identification of traumatic experiences and assessment of PTSD symptoms. Participants described not believing they had the skills to respond to disclosures of traumatic experiences in a safe, helpful and therapeutic manner. Such clinician self‐evaluations of their clinical skills could inhibit them from inquiring about traumatic experiences and PTSD.he sits within a psychosis service, so there is always a slight kind of concern that maybe my competencies aren't there Psychologists described questioning their own competence to deliver trauma‐focused interventions, as well as the competence of clinicians specializing in trauma‐focused interventions to work with individuals with psychosis. While some described developing greater confidence over time, others remained uncertain of their competencies. Clinicians’ lack of confidence either in their own competence to deliver trauma‐focused interventions or the competence of others working with people experiencing psychosis may prevent service users from being offered intervention in either clinical context.This study captured the perspectives of 18 health care professionals and offers novel insights into the barriers to the delivery of trauma‐focused interventions for people with psychosis and PTSD. Identified barriers were similar to those reported by clinicians in treating PTSD more generally ; Formal analysis ; Investigation ; Methodology ; Project administration ; Validation ; Visualization ; Writing – original draft ; Writing – review & editing . Jo Billings: Conceptualization ; Investigation ; Methodology ; Supervision ; Validation ; Visualization ; Writing – review & editing . Click here for additional data file.


Pleomorphic liposarcoma (PLPS) is the rarest liposarcoma subtype, with high‐local recurrence and metastasis rates. Fine‐needle aspiration cytology (FNAC) is successfully used in the diagnosis of primary or metastatic soft tissue tumors, but liver metastases of PLPS diagnosed by FNAC have never been reported. The cytological diagnosis depends on the identification of lipoblasts with sharply defined cytoplasmic vacuoles indenting and distorting the nucleus in the context of a pleomorphic tumor and in a proper clinical and imaging context. Despite its aggressive behavior, hematogenous liver metastases are rare, with just one case reported in literature. A case of PLPS liver metastasis and concomitant primary tumor diagnosed by FNAC and core needle biopsy is herein described. Serum and hematological parameters were normal; the patient did not suffer from any hepatopathy but he had undergone lung lobectomy  and six cycles of cisplatin and gemcitabine chemotherapy. Because of his past medical history, a metastasis from the primary lung carcinoma was suspected. The patient underwent abdominal CT and ultrasonography (US), which revealed a 52 × 48 mm, hypoechoic, well‐defined mass located in the right liver lobe Figure . A diagn3FNAC smears and CB histological sections were similar in both the liver and soft tissue lesions. Smears were hypercellular, showing tightly aggregated and loose groups of highly pleomorphic cells with epithelioid features Figures  and 2B, 4The liver is a rare site for PLPS metastases: to the best of our knowledge, only one such case has been described to date.The authors declare that they have no conflict of interest.Written informed consent was obtained from the patient for publication of this article. All potentially identifying information has been anonymized as much as possible. The authors have conducted their study in accordance with the World Medical Association Declaration of Helsinki.