Recent studies have assessed diet quality of low-income U.S. children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but differences by race/ethnicity remain unknown. We assessed racial/ethnic disparities in nutrient intake from dietary sources (not supplements) among children participating in WIC, with a focus on priority nutrients and food groups for future WIC food package revisions, as described in a recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM). We used data from the 2011–2014 National Health and Nutrition Examination Surveys (NHANES) and multivariable linear regression analysis to evaluate relationships between race/ethnicity and nutrient/food group intake of children participating in WIC. All data were analyzed using SAS 9.4 survey procedures, accounting for the complex survey design of the NHANES. Compared to non-Hispanic White children, Hispanic children had diets with better nutrient distribution and lower dietary energy density, while non-Hispanic Black children had diets with poorer nutrient intake. Hispanic children had higher potassium and fiber intake, and consumed more legumes, while non-Hispanic Black children had lower calcium and vitamin D intake, higher sodium intake, and lower total dairy intake, compared to non-Hispanic White children. These findings can inform WIC nutrition education messages and future food package revisions. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a United States nutrition assistance program that has significant capacity for early intervention to establish adequate nutritional intake among children and women in low-income households. WIC provides nutrient-dense foods, nutrition education, and referrals to health/social services to children and women at nutrition risk living in low-income  households . ApproxiRacial/ethnic disparities in nutrient intake of children participating in WIC are important considerations for WIC nutrition education and future food package revisions. The National Academies of Sciences, Engineering, and Medicine (NASEM) recently reviewed the WIC food package and defined nutrient inadequacies and excesses linked to adverse health consequences relevant to WIC-participating populations, and determined potential food package changes . HoweverWhat We Eat In America, are designed to monitor the health and nutritional status of non-institutionalized civilians in the U.S. [This national cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES). The NHANES is a continuous survey conducted by the National Center for Health Statistics (NCHS) using a complex, multistage probability cluster-sampling design that is representative of the U.S. civilian, noninstitutionalized population . NHANES the U.S. . NHANES The NHANES collected dietary data via 24-hour recall assessments using the United States Department of Agriculture (USDA) Automated Multiple Pass Method . A parenThe sample included children 1–4 years of age from households income-eligible for WIC  with complete information on WIC participation status and one full day of dietary intake. Children who were breastfeeding or had unreliable, missing, or incomplete recall data were excluded from the sample. We defined WIC participation status using the household-level question due to larger sample size, and in order to account for potential spillover effects from siblings participating in WIC . We asseDistribution of socio-demographic characteristics  was assessed by Wald Chi-squared test. The primary measure for this study was population mean nutrient/food group intake, reported as least-square means with standard error. The variables selected for analysis included nutrients linked to adverse health consequences relevant to WIC children, and priority food groups for future WIC food package revisions, as described in the NASEM report . Analysep-value of <0.05 was considered statistically significant.Multivariable linear regression was used to compare nutrient/food group intake of non-Hispanic Black, Hispanic, and other/mixed race children to a reference group of non-Hispanic White children. The model was adjusted for all relevant covariates, including age, sex, household income (using NHANES-provided poverty income ratio), and total energy intake. Analyses were weighted using the NHANES day-1 dietary sample weight to adjust for day of week for diet recall and dietary interview specific non-response . All datn = 15), had unreliable dietary recall status (n = 34), or missing/incomplete dietary data (n = 89) were excluded. Children 1-4 years of age who consumed breast milk (p < 0.001) than non-Hispanic White children (1.9 ± SE 0.1). Nutrient intake of Hispanic children was greater than non-Hispanic White children for fiber , and potassium . Conversely, non-Hispanic Black children had nutrient distribution across the diet that was poorer than their non-Hispanic White counterparts. Nutrient intake of non-Hispanic Black children was lower than that of non-Hispanic White children for calcium  and vitamin D , and higher in sodium . There was one instance of better nutrient intake among non-Hispanic Black children compared to non-Hispanic White children; saturated fat intake was lower . Mean estimates for nutrient intake on a given day for children of all race/ethnicities appeared to fall short of several dietary recommendations, including fiber, potassium, vitamin D, and exceeded recommendations for sodium, but met recommendations for calcium, iron, and zinc. Further research is needed to statistically compare intake by race/ethnicity to dietary guidelines. In a nationally representative sample of U.S. children participating in the WIC program, racial/ethnic disparities in nutrient intake were observed. Compared to non-Hispanic White children, Hispanic children had diets with lower energy density and better nutrient distribution while non-Hispanic Black children had nutrient intake estimates that were poorer. p = 0.020). Hispanic children consumed more legumes than non-Hispanic White children . Total protein food consumption of non-Hispanic Black  and Hispanic  children exceeded that of non-Hispanic White children (2.19 oz-eq ± SE 0.23). Importantly, among WIC-participating children of all race/ethnicities, mean estimate of intake on a given day for several food groups appeared to fall short of weekly recommendations converted to a per-day basis, including seafood, total vegetables, whole grains, nuts and seeds, total dairy, and legumes, though further research is needed to statistically compare intake by race/ethnicity to dietary guidelines.Racial/ethnic differences in food group intake of children participating in WIC were analyzed to determine differences in dietary intake that may contribute to the observed differences in nutrient intake. As shown in The relationship between nutritional status and chronic disease is a major focus of public health nutrition research and practice. Low-income, minority populations are disproportionately impacted by obesity and chronic disease , and eviCalcium and vitamin D intake of non-Hispanic Black children 1–4 years old who were participating in WIC were significantly lower than their non-Hispanic White counterparts. For non-Hispanic Black children, average calcium intake met guidelines for children 1–3 years of age but fell short of the guidelines for 4–5 years of age. Children in all other racial/ethnic groups had average calcium intake that met or exceeded recommendations for children 1–5, though further research is needed to statistically compare intake by race/ethnicity to dietary guidelines. Understanding disparities in calcium and vitamin D intake is important because both are short-fall nutrients, identified in the Dietary Guidelines for Americans as being under-consumed by a significant portion of Americans . In addiIn our analysis of food group intake for U.S. children participating in WIC, we found non-Hispanic Black children to consume less total dairy than their non-Hispanic White counterparts, which may contribute to the lower calcium and vitamin D intakes, given that three servings of fortified milk provide 70% of calcium and vitamin D in the diet . AfricanAmong U.S. children participating in WIC, we found Hispanic children to have greater intake of both fiber and potassium compared to non-Hispanic White children. We also observed greater legume intake among Hispanic children, which may be related to the higher fiber intake. The greater legume intake among Hispanic children in this nationally representative sample is consistent with findings from regional studies of adult women participating in WIC , suggestThe Dietary Guidelines for Americans (DGA) recommend limiting intake of sodium . We founWhile we were able to identify associations between nutrient/food intake and race/ethnicity among children participating in WIC, NHANES data are cross-sectional and preclude causal inferences due to lack of temporality. Although 24-hour recalls are frequently used in dietary assessment, there are known limitations. Retrospective, self-reported data may be limited by recall bias  or social desirability bias . The resThe findings reported here compare nutrient and food group intake among racial/ethnic groups in order to study prevalence of diet-related disparities in children participating in the WIC program. Further research statistically comparing intake estimates for each racial/ethnic group to dietary guidelines is important for influencing further recommendations for the WIC food package. In addition, we studied all foods and beverages consumed; future research should investigate the contribution of WIC-eligible foods to children’s dietary intake by race/ethnicity. Lastly, the nutrient intakes were reported for children 1–4 years of age, and food group intake analysis was performed for children 2–4 years of age, so direct comparisons cannot be made between the nutrient and food group data presented here. However, this study design enhanced comparability between our results and the age groups associated with the priority nutrients/food groups in the NASEM report , which sIn this study, we highlighted differences in nutrient status of children participating in WIC across racial/ethnic groups. We also analyzed disparities in food group intake to determine differences in dietary intake that may be contributing to the observed nutrient intake disparities. Compared to non-Hispanic White children participating in WIC, Hispanic children had diets with better nutrient distribution and lower dietary energy density, while non-Hispanic Black children had diets with poorer nutrient intake. Specifically, Hispanic children had lower dietary energy density, higher potassium and fiber intake, and consumed more legumes compared to non-Hispanic White children. Non-Hispanic Black children had lower calcium and vitamin D intake, higher sodium intake, and lower total dairy intake compared to non-Hispanic White children, though non-Hispanic Black children did have lower saturated fat intake. The nutrients presented here represent inadequacies and excesses linked to adverse health consequences relevant to children participating in WIC, as well as food groups priorities for Food Package IV , and the


Persistent elevation of aspartate aminotransferase (AST) activity in serum due to the presence of a macro-enzyme form of AST (macro-AST) may lead to diagnostic confusion in many clinical conditions, particularly in those associated with chronic liver disease. We present a case of macro-AST in a patient with non-alcoholic fatty liver disease in which polyethylene glycol precipitation confirmed the cause of disproportionately elevated AST as macro-AST. Macro-enzymes are high molecular mass complexes of plasma enzymes with immunoglobulins  or other plasma components . They arIsolated elevation of aspartate aminotransferase (AST) due to macro-enzyme-AST (macro-AST) is a benign and rare condition . BecauseA 46-year-old African-American woman was referred to our hepatology clinic for evaluation of abnormal liver enzymes detected on routine blood work. The elevated AST level of 136 U/L was first noted in 2006, and other liver enzymes were within reference ranges. Subsequent measurements showed an upward trend for persistent AST elevation, as shown in Figure The physical examination was unremarkable, and the patient had no stigmata of liver disease. A review of her laboratory data revealed disproportionately elevated AST levels. A comprehensive work-up for elevated AST including screening for hemolysis, acute and chronic viral hepatitis, autoimmune hepatitis, alpha-1 antitrypsin, ferritin levels, creatine kinase (CK), and aldolase was unrevealing.An ultrasound and computed tomography (CT) scan revealed a normal liver, spleen, and pancreas on two separate occasions, with one year between the scans. Liver biopsy findings were suggestive of steatohepatitis, as shown in Figure As the tests did not reveal the cause of the unusually high AST levels, macro-AST was suspected. To confirm this, a blood sample was tested for macro-AST by the polyethylene glycol (PEG) precipitation method. Serum AST activity before precipitation was 808 U/L, but it dropped to 24 U/L post-PEG precipitation. The results were consistent with the presence of macro-AST , confirming our diagnosis.Several enzymes  complexed with immunoglobulins have been described in the literature as macro-enzymes, with macro-amylasemia being the most frequently reported. The incidence of immunoglobulin-complexed AST has not yet been established in the general population, but it appears low because the biochemical methods for diagnosis are not readily available in the laboratory. Elevated liver enzymes, such as aspartate aminotransferase and alanine aminotransferase, most commonly reflect hepatocellular injury, and therefore, prompt extensive serological, radiological, and sometimes histological evaluations are required for assessment of liver disease. The most common conditions to be ruled out include alcoholic hepatitis, viral hepatitis, hemochromatosis, autoimmune hepatitis, Wilson's disease, alpha-1 antitrypsin deficiency, medication use and congestive hepatopathy. The patient should be tested for hepatitis B and C, serum iron studies, autoantibodies, serum ceruloplasmin and serum alpha-1 antitrypsin levels. When no liver-related etiology is found, attention should be diverted to extra-hepatic sources of injury such as rhabdomyolysis and hemolysis, and the patient should be tested for myoglobinuria and peripheral blood smear study and serum haptoglobin levels. An isolated or disproportionate elevation in AST in the absence of these processes warrants an evaluation of macro-AST .Macro-AST is typically a diagnosis of exclusion. The clinician should be aware of the possibility of this diagnosis and retain a high index of suspicion for this condition. Thorough patient history and routine laboratory tests are important to ensure that no associated or coexisting condition explains the elevated AST levels. The next step is confirmatory diagnostic testing such as assessing protein electrophoresis, precipitation with PEG, exclusion gel filtration chromatography, or activation assays with pyridoxal-5-phosphate -6.We found no discernible etiology for macro-AST in our patient. Therefore, we concluded that it was a benign elevation of macro-AST that manifested incidentally. The treatment involved reassurance with routine monitoring of liver enzymes.This case illustrates the need to consider macro-AST as a cause of persistent or disproportionate elevation of AST in a patient with non-alcoholic steatohepatitis. The use of PEG is a simple and effective method for detecting macro-enzymes; it is a highly sensitive and specific test but is not widely available. This report emphasizes the need for a high clinical index of suspicion and early testing for macro-AST to avoid unnecessary expensive and invasive investigations. The presence of macro-AST is not a transient phenomenon, and elevated laboratory values attributable to immunocomplex enzymes may persist for many years. Therefore, a thorough documentation in patient notes is vital to avoid future diagnostic dilemmas. No medication is indicated, and reassurance is the mainstay of treatment.


The AMP-activated protein kinase (AMPK) is an important cellular energy sensor. Its activation under energetic stress is known to activate energy-producing pathways and to inactivate energy-consuming pathways, promoting ATP preservation and cell survival. AMPK has been shown to play protective role in many pathophysiological processes including cardiovascular diseases, diabetes, and cancer. Its action is multi-faceted and comprises short-term regulation of enzymes by direct phosphorylation as well as long-term adaptation via control of transcription factors and cellular events such as autophagy. During the last decade, several studies underline the particular importance of the interaction between AMPK and the post-translational modification called O-GlcNAcylation. O-GlcNAcylation means the O-linked attachment of a single N-acetylglucosamine moiety on serine or threonine residues. O-GlcNAcylation plays a role in multiple physiological cellular processes but is also associated with the development of various diseases. The first goal of the present review is to present the tight molecular relationship between AMPK and enzymes regulating O-GlcNAcylation. We then draw the attention of the reader on the putative importance of this interaction in different pathophysiological events. The majority of proteins playing essential biological roles undergo post-translational modification (PTM) to regulate their structure, cellular localization, activity and biological function. Accordingly, many metabolic enzymes and regulators, such as acetyl-CoA carboxylase and ULK1, are known to be phosphorylated in conditions of metabolic stress to adapt to energy imbalance . SimilarAMPK is a heterotrimeric protein composed of one catalytic subunit α  and two regulatory subunits, β (β1 and β2) and γ  . AMPK isProtein O-GlcNAcylation is a PTM that promotes the O-linked attachment of a single N-acetylglucosamine moiety on Ser/Thr residues of over 4000 proteins including nuclear, cytosolic, and mitochondrial proteins . O-GlcNAO-GlcNAc to proteins, and the protein O-GlcNAcase (OGA) that removes it  that adds moves it  . It has been shown that AMPK can interact with and phosphorylate OGT on Thr444 in vitro . Moreovein vitro , 31. Intin vitro . In addiin vitro . Moreovein vitro . Hyaluroin vitro .AMPK has also been proposed to regulate OGT expression. In Neuro-2a neuroblastoma cells, glucose deprivation induces an AMPK-dependent increase in OGT mRNA and protein expression, leading to elevated O-GlcNAc levels . HoweverEvidence of direct regulation of OGA by AMPK has not been demonstrated so far. However, mice deficient for the AMPKα2 isoform are characterized by an elevated basal level of cardiac O-GlcNAcylation that is associated with decreased OGA protein levels . The molin vitro in MEFs and that OGT knock-down reduces AMPK phosphorylation on Thr172, suggesting that OGT positively regulates AMPK activity  associated with obesity-linked hypertension. Indeed, PVAT from male offspring of rodent fed with an obesogenic high-fat diet (HFD) are characterized by reduced anti-contractile effect, elevated O-GlcNAc levels and low AMPK activity . InteresElevated protein O-GlcNAcylation has been reported in various cancer cells, including prostate, colon, breast and lung cancer as well as chronic myeloid leukemia  whereas Similar data were obtained in breast cancer cell lines by the group of Reginato –57. IncrLastly, AMPK and O-GlcNAcylation can compete for a same Ser75 regulatory site of chromatin-associated FH involved in tumorigenesis. This gives rise to opposite effects of FH on the regulation of histone methylation . The incAn increase in global cardiac protein O-GlcNAcylation is commonly observed in pathological cardiac hypertrophy and heart failure, although the exact mechanism is not fully understood –60. AMPKVarious observations raise evidences that AMPK activation reduces O-GlcNAcylation levels in several pathologies and, consequently, prevents adverse effects. At contrary, O-GlcNAcylation of AMPK observed in different diseases reduces its capacity to play its beneficial role, contributing to the progression of the disease. This highlights AMPK and O-GlcNAcylation crosstalk as novel putative therapeutic target for important diseases such as cancer, diabetes and cardiovascular diseases. However, additional studies are still required to fully unravel the complexity of the relationship between AMPK and O-GlcNAcylation with respect to these diseases.RG, JD, LaB, and LuB wrote sections of the first draft of the manuscript. JD realized the figures. RG, SH, CB, LaB, and LuB participated in the fusion of the global version. All authors contributed to manuscript revision, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To describe the patterns of second-line treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) after docetaxel treatment in a Spanish population, to identify the factors associated with those patterns, and to compare the efficacy and safety of the treatments most frequently administered.Observational, prospective study conducted in patients with histologically or cytologically confirmed prostate adenocarcinoma; documented metastatic castration-resistant disease; progression after first-line, docetaxel-based chemotherapy with or without other agents.Of the 150 patients recruited into the study, 100 patients were prescribed abiraterone acetate plus prednisone (AAP), 44 patients received cabazitaxel plus prednisone (CP), and 6 patients received other treatments. Age  and not elevated lactate dehydrogenase (LDH) levels  were independently associated with the administration of AAP. Treatment with AAP was associated with significantly longer clinical/radiographic progression-free survival  and overall survival  compared to CP, while no significant differences between the treatments were found regarding biochemical progression-free survival . However, in a post-hoc Cox regression analysis adjusted for potential confounders there were not differences between AAP and CP in any of the time-to-event outcomes, including overall survival. We observed no new safety signals related to either regimen.Second-line AAP for patients with mCRPC is the most common treatment strategy after progression with a docetaxel-based regimen. When controlling for potential confounders, patients receiving this treatment showed no differences in PFS and OS in comparison to those receiving CP, although these latter results should be confirmed in randomized controlled trials. Since the landmark study by Huggins et al.  in 1941,The objective of this prospective, observational study was to describe the patterns of second-line treatment of patients with mCRPC after docetaxel treatment in a Spanish population. Secondary objectives were to identify the factors associated with those patterns and to compare the efficacy and safety of the treatments most frequently administered.This was an observational, prospective study conducted under real-world conditions from July 2013 to June 2016 in 24 centers in Spain. The study was reviewed and approved by the Ethics Committee of the Hospital Clínico San Carlos . All patients provided written informed consent before being included in the study.Participating investigators had to include ten consecutive patients meeting the following criteria: 18 years of age or older; histologically or cytologically confirmed prostate adenocarcinoma; documented metastatic castration-resistant disease; progression after first-line, docetaxel-based chemotherapy with or without other agents; and administered a second-line treatment for mCRPC according to routine clinical practice. To be defined as castration-resistant, patients needed to have been on continuous androgen-deprivation therapy and show serum castration levels of testosterone < 50 ng/dL or < 1.7 nmol/L and three consecutive rises of prostate-specific antigen (PSA), 1 week apart, resulting in two 50% increases over the nadir, with PSA > 2 ng/mL. Patients were excluded if they exhibited cognitive deterioration that precluded understanding the patient information sheet for informed consent or if they received a second-line treatment in the setting of a clinical trial, an expanded access program or a Name Patient Program. Retreatment with docetaxel was considered a second-line treatment.The study was conducted through 3 types of visits. The initial visit occurred when a patient who met the selection criteria initiated a second-line treatment after docetaxel-based, first-line treatment. Follow-up visits were scheduled every three months according to routine clinical practice. The final visit was scheduled when the patient initiated a third-line treatment, withdrew from the study or died. At the initial visit, we recorded demographic data, risk habits, medical history, and data on the first-line docetaxel-based chemotherapy, including the dates of starting and finishing first-line treatment, the number of cycles and dose, the Eastern Cooperative Oncology Group (ECOG) performance status and visual analog scale (VAS) score for pain at the beginning and end of first-line treatment, metastases at the beginning of first-line treatment, the best response to first-line treatment, the time to and type of progression in the first-line treatment, and toxicity and concomitant/palliative medication during first-line treatment. Additionally, the following information related to the second-line treatment was recorded: starting date and reason for initiating second-line treatment, therapeutic regimen, laboratory tests, ECOG performance status and VAS score for pain at the beginning of second-line treatment, and metastases at the beginning of second-line treatment. During follow-up, we recorded information on current treatment, laboratory tests, ECOG performance status, VAS score for pain, prostate cancer-related symptoms and signs, response and progression to the second-line  based on the criteria established by each site in their routine clinical practice, concomitant/palliative medication, and toxicities. In the final visit, we recorded the vital status and the reason for finalizing treatment.Adverse events were monitored throughout the study using open-ended questions, and the severity of these events was categorized by the investigators as mild, moderate or severe based on interference with daily life activities. Adverse events were coded with the Medical Dictionary for Regulatory Activities .Sample size estimation was based on the descriptive objectives of the study. Thus, for estimating a characteristic with a relative frequency of 10% and a precision of ±4%, and assuming that 5% of patients will be excluded from the analyses due to missing data or other reasons, a total of 240 patients were required.Efficacy outcomes included overall survival (OS), defined as the time from study inclusion  to death from any cause, clinical or radiographic progression-free survival (PFS) and PSA progression , defined according to each investigator/center criteria, and PSA response, defined as a reduction in the PSA level from baseline greater than or equal to 50%.Quantitative variables were described using the mean and standard deviation or the median and interquartile range if required. Qualitative variables were described with absolute and relative frequencies. Binary outcomes are presented with the relative frequency and the corresponding 95% confidence interval (CI). The Kaplan-Meir method was used to describe the distribution of time-to-event outcomes, and we used the log-rank test to compare distributions among subgroups. Furthermore, time-to-event outcomes were compared using univariate Cox proportional-hazards regression analysis.p < 0.2 among the following: age, ECOG performance status, diabetes, cardiovascular disorders, hypertension, symptoms, anemia (defined as Hb < 11), increased lactate dehydrogenase (LDH) (≥250 IU/L), increased alkaline phosphatase (AP) (≥160 IU/L), PSA (as a continuous variable), and early progression to first-line treatment (defined as progression during treatment). Finally, a post-hoc Cox proportional-hazards regression analyses were performed for evaluating overall survival and clinical/radiographic and biochemical progression-free survival, adjusting for those variables that were significant at a level of p < 0.2 in the bivariate analysis.To evaluate factors associated with the prescription of abiraterone acetate plus prednisone, we used multiple logistic regression analysis with the prescription of abiraterone acetate plus prednisone as the dependent variable. Independent variables were selected from those in the bivariate analysis that were significantly different at a level of p < 0.05 was considered significant unless otherwise indicated.Statistical analyses were performed using SPSS v.22.0 . All tests were two-sided, and We recruited 150 patients with a median age of 72.6 years at the time of initiating second-line treatment after docetaxel. All patients received docetaxel monotherapy (the median number of cycles was 6) and androgen-deprivation therapy . Sixty-three (42.0%) patients progressed during the first-line treatment, 31 (20.7%) within the first three months after finalizing first-line treatment and 56 (37.3%) after three months of the finalization of first-line treatment.As second-line treatment, 100 patients were prescribed abiraterone acetate plus prednisone, and 44 patients received cabazitaxel plus prednisone. Six patients received other treatments  and are not discussed further in this report.The demographic and clinical characteristics of the patients are presented in Table . A largep < 0.2) with the prescription of abiraterone acetate plus prednisone compared with receiving treatments other than abiraterone acetate included age, the presence of anemia, increased LDH, increased alkaline phosphatase (AP), and PSA level. In the multivariate analysis, age and not elevated LDH levels were associated with the administration of abiraterone acetate plus prednisone as a second-line treatment for mCRPC . Similarly, the median overall survival was increased for patients treated with abiraterone acetate plus prednisone (not reached) compared with cabazitaxel plus prednisone (20.3 months) . However, there was no statistically significant difference in the median biochemical PFS between both treatment groups . However, in the post-hoc Cox regression analysis adjusted for age, Gleason score, and presence of LDH increased, anemia and alkaline phosphatase increased, variables that were significant in the bivariate analyses, there were not differences between abiraterone acetate plus prednisone compared with cabazitaxel plus prednisone regarding the likelihood of clinical/radiographic progression , overall survival  or biochemical PFS . A PSA response was observed in 43 out of the 91 evaluable patients treated with abiraterone acetate plus prednisone  and in 10 of the 31 evaluable patients treated with cabazitaxel plus prednisone , a difference that was not statistically significant .Treatment with abiraterone acetate plus prednisone was associated with a 43% reduction in the likelihood of clinical/radiographic progression compared with cabazitaxel plus prednisone . The most frequent adverse events in both treatment groups included asthenia, pain, and anemia. Additionally, an increased incidence of edema was noted among abiraterone acetate-treated patients, and an increased incidence of anorexia was noted in patients who received cabazitaxel plus prednisone Table . The majThis observational and prospective study evaluated the pattern of treatment after progression with first-line docetaxel-based chemotherapy in patients with mCRPC. Our results show that the most common therapeutic strategies after progression with first-line docetaxel-based chemotherapy in patients with mCRPC include treatment with abiraterone acetate plus prednisone in two-thirds of cases and cabazitaxel plus prednisone in one-third of cases. Similar patterns of treatment were found in a study comparing new hormonal therapies and cabazitaxel in mCRPC patients after progression on docetaxel . HoweverThe efficacy results of abiraterone acetate plus prednisone in our study were better than those reported in the pivotal COU-AA-301 trial for this setting. In this trial , the medPrescription patterns differ between the two treatment strategies, and thus, when comparing these strategies a selection bias exists. Thus, in contrast to the crude analysis, our post-hoc Cox proportional-hazards regression analyses found no difference between abiraterone acetate plus prednisone and cabazitaxel plus prednisone in any of the time-to-event outcomes, including overall survival. These latter results are consistent with a recent meta-analysis that indirectly compared three therapies for mCRPC after docetaxel chemotherapy , concluding that there was no significant differences in terms of OS favoring any of the treatments .No new safety signals related to either abiraterone acetate plus prednisone or cabazitaxel plus prednisone were observed in this study, and tolerability profiles were consistent with those reported in previous trials. Moreover, both agents exhibited a low frequency of severe adverse events. However, the frequency of adverse events was increased in cabazitaxel plus prednisone patients. In addition, a higher proportion of adverse events was related to the study drug among cabazitaxel plus prednisone-treated patients than among patients who received abiraterone acetate plus prednisone. These results suggest that abiraterone acetate plus prednisone could be better tolerated than cabazitaxel plus prednisone in this setting.In addition to the lack of balance between abiraterone acetate plus prednisone and cabazitaxel plus prednisone groups at the initial visit, our study has some limitations that should be noted. In addition to the currently available enzalutamide in Europe, abiraterone acetate plus prednisone has been demonstrated to be effective as a first-line treatment in chemotherapy-naïve patients with mCRPC , 21, andOverall, our results indicate that second-line abiraterone acetate plus prednisone for patients with mCRPC is the most common treatment strategy after progression with a docetaxel-based regimen. In this real-world setting, abiraterone acetate plus prednisone is a useful, valid treatment for mCRPC after docetaxel, and does not differ from cabazitaxel plus prednisone in terms of PFS and OS. These latter results should be confirmed in randomized controlled trials, preferably with a pragmatic design, which will also help to elucidate whether efficacy results with abiraterone acetate plus prednisone or cabazitaxel plus prednisone are superior to those reported in the pivotal explanatory trials.


Providers’ qualification ; type of care facility ownership (for-profit [FP] or not-for-profit [NFP]) may all influence individuals’ healthcare-seeking behavior and therefore merits empirical assessment to provide valuable evidence-informed policy orientation in the present context of private health system development. Previous studies have not examined these factors in combination, especially within the urban context of sub-Sahara Africa, where the private sector is rapidly growing. This study aims to explore factors associated with urban residents’ preferences between private MD-led and private nurse-led outpatient care and how these factors vary by type of private health facility ownership (FP and NFP) and levels of disease severity (severe and non-severe cases).A cross-sectional household survey was conducted in July-November 2011 on a random final sample of 2064 adults (646 households). We used a face-to-face interview to capture participants’ choice of provider and their associated factors. A multivariable logistic regression was applied.For severe conditions, participants, almost equally sought FP and NFP facilities, only 36.4% preferred nurses compared to MDs, while for non-severe cases 53.2% preferred FP facilities and only 29.2% patronized nurses. For non-severe conditions, university educated were more likely to use MDs-led FP compared to nurse-led FP facilities  and MD-led FP over MD-led NFP facilities , for severe health conditions. Having insurance predicted MD-led FP preference over nurse-led FP. Furthermore, insurance predicted the preference for MD-led FP over MD-led NFP facilities. Employment did not distinguish participants’ choice of provider.The findings suggest that, at different levels, MDs and nurses from FP and NFP facilities importantly contribute to health services delivery regardless of the severity of health conditions. The results offer some valuable evidence for policy orientation in the current rising tide of the private system, including workforce development, and practitioners' role definition. We suggested that health insurance mechanism would reinforce the private health services utilization and could enhance progress towards the attainment of Sustainable Development Goals. Recent publications have increasingly paid attention to the mounting issue of private besides government-owned health sector—traditionally entirely state-run . In the Healthcare systems in many sub-Sahara African (SSA) countries have been structured since the colonial period and they resemble much of the colonizers’ system. Before and after the World War I, the colonial masters recruited and trained African nurses to struggle on the forefront against grand endemics. Their role has remained prominent over the successive reforms and their contribution is considered pivotal in providing primary care in many SSA countries.In Burkina Faso for instance, reliance on nurses started since the 1960s and remains a means of alleviating the hindrance of protracted physician shortage . Nurses Contrary to Burkina Faso which is a low-income country, in high-income countries (HICs) such as Australia, Canada, US, and the UK, physicians shortage and cost constrain later on have been the leading raison d’être of physician assistant (PA) and nurse practitioner (NP) emergence ,10. In tOnce physician assistants ,13, nursThe growing enthusiasm in SSA for private sector intervention in addressing some of the conundrums in the healthcare industry, fueled by the free market ideology  and otheThe traditional literature has mainly paid attention to MDs’ practice. Their services are considered the benchmark for measuring appropriateness and quality of clinical care; however, are inapposite in measuring interpersonal quality or art of care, which is the essence of nursing . With thTo our knowledge, this study is one of the first to explore such a topical issue in the shared-care market between nurses and physicians in the context of the private healthcare sector in a resource-limited setting. Further, it is among the first to directly compare preferences for MD and nurse services while putting into account the type of health facility ownership and varied health conditions (severe and non-severe). Based on the scarce existing literature and the study background private health operating system, we hypothesized that patient choice of healthcare provider would not significantly differ between nurses and MDs regardless of the type of ownership.Following the waves of economic liberalization and nascent democratization in SSA in the early 1990s, the private sector has gained impetus. Burkina Faso has experienced a rapid growth resulting today with the highest concentration of private healthcare providers, 65% in the capital city, Ouagadougou. The private sector consists of FP and NFP health facilities. The FP facilities, established since the early post-colonial era , have beStructurally, private sector system in Burkina Faso is unique, unfitting the traditional three-tier hierarchical healthcare delivery policy. Unlike some of the LMICs , the priIn planning the implementation of this population-based study, it was important that: 1) the study targeted an area that is broadly a typical urban setting and 2) served by a representative network of different provider sponsorships: non-conventional , public and private (NFP and FP). Based on the available statistics, we decided to select the capital city, Ouagadougou. It has the most heterogeneous population and the highest concentration of facility networks in the country, including primary care centers (about 60), district health centers (n = 5) and University hospitals (n = 3) . The latThe sample was derived from a large project on "Healthcare-seeking behavior in an urban area", that covered 1,600 households in Ouagadougou. This initial project applied a two-stage random sampling technique, details of which has been described elsewhere [For health condition related information, two types were defined, severe and non-severe cases, and data were collected on all the adults of selected households. This study considers visits to a private healthcare provider as the first outcome measure and the practitioner qualification, the second. Thus, only participants who choose private providers were retained in the analytic sample. Private providers are defined here as "organizations working outside the direct control of the State” , and areExplanatory variables included gender, age, insurance, education , occupation , marital status , and health condition (severe and non-severe). More specifically, we defined a severe condition as a medical condition with a perception of fatality in the absence of an urgent intervention. The following common symptoms were used as illustrative examples: loss of consciousness, coma , tachypnea, a fracture, or a bad injury caused by an accident. Non-severe conditions were defined by the interviewer as a condition that may compromise one daily life activities and/or workability in the absence of a medical care. Mild headaches, stomachaches, fevers, shivers, and coughs were some symptoms used for illustration.p < 0.05 and all analyses were performed using SPSS version 21 .Descriptive statistics of the sample characteristics included frequencies and proportions of all variables for the two conditions of interest (severe and non-severe). Owing to dichotomous measures, multivariable logistic regression models for the likelihood of the primary care visit being attended by a nurse compared to a doctor was used for each of the conditions to figure out respondents’ choice of a care provider. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Based on the study hypothesis, the models applied have been compared separately by both assessed conditions, with the following scenario: 1) different qualifications (MD against nurse) from same ownership and 2) providers of the same qualification but from different ownerships (FPMD versus NFPMD and FP nurse versus NFP nurse). 3) Finally, providers were pooled and assessed by ownership (FPMD and FP nurse versus NFPMD and NFP nurse). Statistical significance was defined as a 2-tailed We interviewed only household heads and their spouses who answered the questions for themselves and for all other household members. The informed consent statement was presented on the front page of the questionnaire. This was read and explained to each individual respondent and ended by their response labeled by a “yes” for agreeing or “no” for declining to participate. Instead of a written consent, the oral consent sought complies with the standard protocol of the Burkina Faso national demographic and household surveys. The study was approved by the Burkina Faso National Ethics Committee for Research . An administrative permission was further obtained from the Ouagadougou Town Council.Fig 1). The mean age of the study participants was 33.2 (SD 14.7) years; of whom, 51.7% were women, 51.0% married or in union, 35.3% attended junior education or higher. About 4.1% were insured and 42.8% were gainfully employed . Of the surveyed participants, a total of 1,232  and 706  would go to MD and nurse-led facilities for severe conditions respectively. For non-severe conditions, 1,461  would visit MD-led facilities whereas 603  would go to nurse-led facilities.In total, 646 households were surveyed, that finally included 2064 individuals. For severe health conditions, participants almost equally sought FP (n = 976) and NFP (n = 962) facilities and notably, only 36.4% (n = 706) preferred nurses over MDs. For non-severe conditions, 53.1% (n = 1295) preferred FP facilities and in terms of qualification, 29.2% (n = 603) favored nurses . No significant difference was found for sex across presenting conditions, however, participants' education exhibits a significant difference for both qualifications and ownership, with a dose-response relationship. Thus, for severe conditions, university educated participants have almost two folds likelihood of choosing MD-led FP facilities over nurse-led FP facilities  versus  for participants with junior education level. A similar pattern was found between MD-led NFP versus nurse-led NFP. For non-severe medical conditions, the odds of seeking MD-led FP versus nurse-led FP facilities is 2.7 times higher for those who attended university level compared to junior level. In the same comparative scheme, the OR is 3.7 times higher when comparing MD-led NFP to nurse-led NFP facilities. Finally, there is no significant difference shown for occupation, but insured participants exhibit a greater likelihood of seeking MD-led FP facilities for severe  and non-severe conditions .In Table 3 presents the likelihood of choosing a provider with same qualification but from different facility ownership. There appeared to be a positive correlation in the likelihood of visiting MD-led FP facilities over the MD-led NFP ones. For severe and non-severe conditions alike, age appeared to have a positive association with choices for both MD- and nurse-led FP facilities. For both assessed conditions, females tend to recourse to MD-led FP facilities, while, the single would likely go to FP facilities disregarding provider qualification. Furthermore, it appeared that the higher people are educated, the more they are likely to choose MD-led FP facilities regardless of the severity of their health condition. The odds is 2.84 (95%CI = 1.71–4.70) and 2.26 (95%CI = 1.45–3.50) for severe and non-severe conditions, respectively, for participants who attended a university level. Although public, para-public and formal private jobholders are likely to use MD-led FP facilities; there is no statistical association for severe cases. It however, appeared that for non-severe conditions, these groups would prefer MD-led FP facilities. Finally, people with an insurance plan were significantly more likely to seek an MD-led FP facility—only—in case of a severe health condition  or non-severe medical condition .In Table 4, nurses- and MD-led facilities were pooled into their ownership types (FP and NFP). Thus, the multivariable logistic regression exhibits the likelihood of choosing FP facilities over NFP ones. In both medical conditions, increase in age, females and insurance holders were more likely to go to FP nurses- and MDs-led than NFP ones. As for education, although highly educated markedly preferred FP, there was no dose-response pattern. Similarly, for occupation, higher paid jobholders  chose FP facilities for severe  and non-severe , but least paid categories also recourse to FP.This study is among the first of its kind to compare health care utilization putting into account individual choices between nurse- and MD-led outpatient cares in private clinical settings. Specifically, we examined factors driving these individual choices in the context of urban Burkina Faso. Essentially, provider qualification (nurse or MD) and health facility ownership types (FP and NFP) were assessed. This study becomes necessary owing to the rapid development of private healthcare sector in SSA since the endorsement of free market policy. Hence its findings could be valuable for policymakers. The present study laid out four salient findings.First, for both assessed medical conditions (severe and non-severe), the results laid out that, on one hand, highly educated people and insurance holders were more likely to choose an MD over the nurse. On the other hand, MD led FP or nurse-led FP facilities were more preferred in case of severe health conditions only. Indeed, important literature did compare doctors to nurse practitioners (NPs) and/or physician assistants (PAs) in clinical practice, however; few have made the comparison in light of the severity of health conditions or the type of health facility ownership. The United States is home to the majority of the published studies. Overall, a wealth of existing literature concurred on similar findings. For Everett et al. , predispThe second salient finding indicated that apart from comparing pooled providers (FP vs NFP), participants' occupation did not significantly differentiate their choices between the MD and nurse-led care. This appeared to contradict the findings of Das & Das , for whoThirdly, insurance played an important role in choosing either MD-led FP over MD-led NFP for both severe and non-severe clinical conditions. Most holders possess a private or corporate-based scheme and are reimbursed at up to 80–100%. Such an association motivates the choice for the well-known MDs even for minor health conditions; besides, insurance companies may be more prompt to refund MDs' prescriptions more than other providers. People with insurance voluntarily take advantage to be seen in an FP facility by a famed MD general practitioner or a specialist (moonlighting or not), even for minor conditions. MD-led FP are more likely to be solicited because they are more easily bookable and their number overweight MD-led NFP. Service fees at MD-led NFP are comparatively very low , consequFourth, adjusted results showed that educational attainment was a predictor of opting for MD-led FP facilities. This appears to contradict Druss  who did The study embeds several limitations. The use of a cross-sectional design prevented us from examining the effect of continuity of care on the patient-provider relationship. Provider choice continuity is potentially an important covariate that needs further exploration in future studies. Another limitation concerns the symptom-based classification of the condition severity (severe versus non-severe). Misclassification could occur because participants may perceive some symptoms more than others or have a special focus on one or some during a disease episode. Thirdly, there are three largest MD-led NFP facilities in the city of Ouagadougou, and the gatekeeping mechanism suggests that patients—almost all—are being first attended by nurses and then, serious cases are referred to MDs. Because it was not possible to disentangle that, all their users were considered as MD-led NFP visits. This certainly may have minored or underestimated nurses' role and must be taken with caution. A number of studies including RCTs contended that up to 95% of commonly presented cases could be handled by nurses, unaided ,50. FourThis research indicates that the rising tide of private health systems in SSA urban areas contributes and competes in the healthcare market with the traditional public health sector. The study promotes the understanding of individuals’ healthcare-seeking behavior in nascent private healthcare. More light was shed on consumers' healthcare-seeking behavior and nurses as well as MDs' contribution to the private healthcare landscape, being FP or NFP. Findings show significant differences in insurance holding as well as higher education as main vectors of resorting to MD-led or nurse-led facilities regardless of the ownership or the severity of health condition. Besides higher education and insurance, holding a good job makes people favor FP- over NFP-led facilities. These unique, but progressive findings from a low-income country offer practical implications on how to strengthen each actor’s contribution in an evidence-informed policy era focuses on cost reduction, while increasing access and quality of care is highly critical. Additionally, this study provides knowledge, translatable to strategic health workforce policy development as well as potential role redistribution or clarification towards improving access to health care. These findings have the potential to light up related policies in other SSA countries, especially those within the Western Africa sub-region with similar healthcare systems that are working towards the attainment of SDGs.S1 Dataset(SAV)Click here for additional data file.


Zika virus (ZIKV) infection usually presents as a mild and self-limited illness, but it may be associated with severe outcomes. We describe a case of a 30-year-old man with systemic erythematous lupus and common variable immunodeficiency who became infected with both Zika (ZIKV) and Chikungunya (CHIKV) virus during the 2016 outbreak in Rio de Janeiro, Brazil. The patient presented with intense wrist and right ankle arthritis, and ZIKV RNA and virus particles were detected in synovial tissue, blood and urine, and CHIKV RNA in serum sample, at the time of the diagnosis. During the follow up, ZIKV RNA persisted for 275 days post symptoms onset. The patient evolved with severe arthralgia/arthritis and progressive deterioration of renal function. Fatal outcome occurred after 310 days post ZIKV and CHIKV co-infection onset. The results show the development of severe disease and fatal outcome of ZIKV infection in an immunosuppressed adult. The data suggests a correlation between immunodeficiency and prolonged ZIKV RNA shedding in both blood and urine with progressive disease. The results also indicate a possible role for arbovirus co-infections as risk factors for severe and fatal outcomes from ZIKV infection. Arboviruses are among the more important emergent and re-emerging viruses in the world. The infections caused by Dengue (DENV), Zika (ZIKV) and Chikungunya (CHIKV) virus have similar clinical manifestations. Mostly, ZIKV infection lasts 2–7 days and manifests as an asymptomatic to a mild disease. However, ZIKV mono-infection can evolve into a severe and fatal disease in children and adults with increased rates of hospitalizations ,2. NeuroIn areas with arbovirus co-circulation, there is a great concern in the determination of the precise etiological diagnosis since these conditions have similar clinical manifestations . HoweverCo-infections between two or three of these viruses have been reported in areas with arbovirus co-circulation ,13,14,15On 13 May 2016, a 30-year-old male presented with fever (39–40 °C) and headache followed by severe arthralgia and arthritis of both wrists, metacarpal, and phalangeal joints bilaterally, and the right ankle. Around five weeks later, the patient remained with persistent fever. And, amoxicillin-clavulanate was started to treat a lower respiratory tract infection with remission of symptoms although arthralgia/arthritis remained. Early July, the patient evolved again with recurrent fever and severe arthralgia/arthritis associated with loss of joint function without response to non-steroidal anti-inflammatory drugs (NSAIDs), being admitted to the hospital five days post new symptom onset . InformeThe patient was diagnosed with systemic lupus erythematosus (SLE) at the age of 9; he was diagnosed with Nephritis class III/IV in 2007 and with a common variable immunodeficiency, in 2014. Despite previous irregular treatment with immunosuppressive and immunomodulatory therapy such as Rituximab (2008–2010), the patient was using Prednisone, Hydroxychloroquine and Cyclosporine in addition to Colchicine and Prophylactic Azithromycin at hospital admission .Physical examination showed a temperature of 36.5 °C, redness, warmth, and swelling of left and right wrists and right ankle. Although there were no clinical manifestations of nephropathy, laboratory results showed a slight renal impairment. In addition, he presented anemia, leukocytosis with neutrophilia, lymphopenia and elevated inflammatory markers, such as C-reactive protein (CRP) .Mycobacterium tuberculosis infections were detectable by direct examination or culture. However, viral etiology could not be excluded yet.Because septic arthritis by gonococcal infection was initially suspected, ceftriaxone and azithromycin were used in addition to prednisone dose reduction and cyclosporine withdrawal . All hemMacaca mulatta kidney (LLC-MK2) and African green monkey kidney epithelial cells (VERO and MA-104). Commercial kits Anti-CHIKV IgM and IgG ELISA  were used for detection of anti-CHIKV IgM, IgG, and the Dengue IgM Capture DxSelect, Dengue IgG DxSelect and Dengue NS1 antigen DxSelect  were used for the detection of IgM and IgG anti-DENV and NS1 antigens. CHIKV RNA amplification in the patient serum was detected on day 62 and low level of IgG anti-DENV was also demonstrated  and Zika virus (ZIKV) infection, respectively. Arthritogenic arboviruses was then investigated. Molecular diagnosis and ZIKV and CHIKV isolation in cells culture were performed in serum, urine and/or tissue samples. Viral RNA of serum, urine, and tissue were extracted from 250 μL of clinical samples using TRIzol LS Reagent  according to the manufacturer’s recommendations. cDNA synthesis and real-time RT-PCR for detection of CHIKV and ZIKV RNA were performed by GoTaq 1-Step Probe RT-qPCR System  according to the manufacturer’s recommendations. The real-time RT-PCR protocol included specific primers and probe sets previously describe ,10. Biolnstrated .The renal function declined progressively, methylprednisolone pulse therapy and intravenous immunoglobulin (IVIG) were introduced along with mycophenolate. Renal function improved to pre-admission level in addition to a modest clinical and ultrasonographic improvement of the arthropathy .After hospital discharge, the patient had another admission and needed drug adjustment after drug-induced untoward effects. In addition, recurrent arthralgia and joint immobilization correlated with active inflammatory response confirmed by bone scintigraphy, USG and MRI .Both SLE and/or viral-induced disease were investigated. After 275 days post symptoms onset, the patient still presented ZIKV RNA in both blood and urinary compartments . The patCases of arbovirus co-infections like ZIKV/DENV, ZIKV/CHIK, DENV/CHIKV, and even triple infections, have become notorious in different arbovirus co-transmission areas ,12,13,14In the present case, drug-induced decreased host immune response and/or uncontrolled SEL might be involved in disease severity, in combination with an exacerbated viral-induced disease. In this case, CHIKV RNA was also detected in a single serum sample, which could be related to the first onset of arthritic symptoms weeks before hospital admission. CHIKV RNA might persist for longer periods. In our experience, prolonged clinical manifestations are more often associated with ZIKV/CHIKV co-infection that with mono-infection. Although the persistence of ZIKV RNA shedding in different compartments has been described before, no clear correlation with disease progression was established, nor a risk factor determined . In the ZIKA and CHIKV infections might be associated with the onset or exacerbation of arthralgia/arthritis in individuals with a history of co-morbidities and rheumatological disorders or co-infection and progression to fatal outcomes . RNA seq


Application of single-cell genomics technologies has revolutionized our approach to study the immune system. Unravelling the functional diversity of immune cells and their coordinated response is key to understanding immunity. Single-cell transcriptomics technologies provide high-dimensional assessment of the transcriptional states of immune cells and have been successfully applied to discover new immune cell types, reveal haematopoietic lineages, identify gene modules dictating immune responses and investigate lymphocyte antigen receptor diversity. In this review, we discuss the impact and applications of single-cell RNA sequencing technologies in immunology. Our understanding of the immune system has been advanced over many centuries through the use of single-cell technologies, primarily microscopy and flow cytometry. However, the number of parameters that can be measured simultaneously with these methodologies is limited and reliant on a priori knowledge of which antigens to measure. The advent of next-generation sequencing to measure transcriptome at single-cell level has revolutionized our ability to interrogate the immune system . This haSeveral genomics technologies such as quantitative reverse transcription PCR (RT-qPCR) and microarray have been adapted to study gene expression in individual cells , 6 . It is [K-means  or GiniC[K-means . Finally[K-means  and path[K-means ), or to [K-means , SCENIC [K-means ). Additi[K-means  or Wishb[K-means , diffusi[K-means  or Monoc[K-means , or usin[K-means . Future [K-means . Several[K-means , Seurat [K-means  or Since[K-means ; howeverThe key applications of scRNA-seq in immunology have been to unravel cellular heterogeneity, cell development and differentiation, haematopoiesis and gene regulatory networks to predict immune functions.-MHCII+ cells consisting of known blood dendritic cells (DCs) and monocytes identified several new populations of DCs, monocytes and a DC progenitor. In this study, transcriptionally distinct cell clusters were found within what was previously thought to be a homogenous population. The identity of new cell clusters was validated by isolating cells based on surface markers predicted by mRNA expression, followed by scRNA-seq of isolated cells to validate their transcriptional identity. This enabled a cost-effective and scalable means of isolating newly identified cell types for functional characterization and demonstrating their presence as a stable cell type in a wider study population. Furthermore, by adaptively sampling peripheral blood mononuclear cells (PBMCs) using legacy knowledge of surface markers known to identify DCs and monocytes, the authors could use FACS to enrich for rare populations [A seminal early study analysing >4000 cells from mouse spleen to dissect immune cell heterogeneity demonstrated an scRNA-seq-based classification of CD11c expressing cells . scRNA-sulations . In contulations .In addition to exploring the overall cell census and discovering new cell types, scRNA-seq analysis can be focused on small and well-defined subsets. For example, a study of mouse Th17 cells identified heterogeneity within this population and uncovered molecular mechanisms regulating their pathogenicity .+ cells into T follicular helper (Tfh) and Th1 cells [scRNA-seq has been applied to study the developmental programme undergone by haematopoietic stem cells and downstream progenitors into differentiated immune cells , 54 J transcript data, has been used to study lymphocyte antigen receptors e.g. T cell receptor (TCR) and B-cell receptor (BCR) sequences. A computational method, TraCeR, was developed to reconstruct TCR sequences and reveal clonal relationships between cells. TCR reconstruction combined with T-cell transcriptional analysis was used to map T cell activation dynamics in a mouse on model . Two moron model  and an aon model . Carmonascovered . Similarscovered . Other sscovered , 73–75.Cebpb gene in monocyte and DC development [et al. [Salmonella was shown to be determined by transcriptional heterogeneity within the infecting bacteria [Salmonella growth rate was also discovered to be dependent on macrophage state [Mycobacterium tuberculosis was interrogated, and three macrophage sub-phenotypes were identified in the culture system [The application of clustered regularly interspaced short palindromic repeat (CRISPR) technology-based perturbations of genes combined with scRNA-seq (Perturb-seq) has provided a new way to study transcriptional programs and gene expression networks, and was used to identify gene targets and cell states affected by individual perturbations of transcription factors in bone marrow-derived DCs in response to lipopolysaccharide . Anotherelopment . Complex [et al. , 79 founbacteria , 81. In ge state . Bacterie system . A new me system .Treg heterogeneity uncovered their composition and identified a rare subset of CD43+CCR5+CXCR3−Tregs that express Il10 and Gzmb, which are responsible for dampening cutaneous immune responses [+ T cells in mice [Several other studies investigated specific aspects of immune cell function. Characterization of mouse esponses . Ageing  in mice , and a r in mice .+ T cells found that myeloid cell expansion is critical for the control of malaria parasite (Plasmodium chabaudi) replication and host recovery. It established that CD4+ T cells produce macrophage colony-stimulating factor and that myeloid cell expansion is dependent on these cells [In addition to infectious disease, scRNA-seq has provided new insights in cancer immunology through comprehensive tumour and immune cell profiling. Studies that combined single-cell profiling with tumour spatial heterogeneity analysis have identified multiple mechanisms of cancer-associated immunosuppression, including tumour-infiltrating T cell dysfunction  and immuse cells .in situ hybridization), such as RNA-scope, will aid dissection of functional niches and immune organisation within tissues . The feiewed in . Combineiewed in  and canciewed in , 92. In iewed in . Severaliewed in , or labeiewed in , RNA expiewed in  and celliewed in ). Microfiewed in .High-dimensional single-cell technologies present a radical departure from classical top-down hypothesis-based research. They enable a bottom-up unbiased approach with big data generation followed by hypothesis generation and testing. While high-dimensional single-cell methods have provided unprecedented resolution to observe and model biological phenomena, it is critical to extend the observations made with functional validation and experimentation to unravel mechanistic biological insights. This requires a multidisciplinary research team effort to overcome the convention of using genomics just as a tool, computation as an analytical means and immunology as a model system, as the combined expertise will have a greater impact than the sum of the individual components. This integrated approach will facilitate biological validation and meaningful experimentation and analysis of big scRNA-seq data sets. With time, costs associated with cell preparation and sequencing will decline and will be accompanied by progress in protocol automation and improvements in technical shortcomings of scRNA-seq, such as the small number of sequencing reads or the sparsity of data, which currently pose analytical challenges . These aMulti-omics approaches will provide comprehensive profiles of epigenome, transcriptome and proteome, and promise to solve some questions, such as our understanding of cell types, and the links between the genome and epigenome (reviewed in ). FinallSingle-cell sequencing technologies have revolutionized our approach to study the immune system.Enables high-dimensional dissection of cellular heterogeneity and establishes developmental relationships and functional predictions.Future integration with other types of omics data will expand our understanding of the immune system.


Biochemical remission after transsphenoidal surgery is still unsatisfied in acromegaly patients with macroadenomas, especially with invasive macroadenomas. Concerning the impact of preoperative somatostatin analogues (SSAs) on surgical outcomes, previous studies with limited cases reported conflicting results. To assess current evidence of preoperative medical treatment, we performed a systematic review and meta-analysis of comparative studies. A literature search was conducted in Pubmed, Embase, and the Cochrane Library. Five randomized controlled trials (RCT) and seven non-RCT comparative studies were included. These studies mainly focused on pituitary macroadenomas though a small number of microadenoma cases were included. For safety, preoperative SSAs were not associated with elevated risks of postoperative complications. With respect to efficacy, the short-term cure rate was improved by preoperative SSAs, but the long-term cure rate showed no significant improvement. For invasive macroadenomas, the short-term cure rate was also improved, but the long-term results were not evaluable in clinical practice because adjuvant therapy was generally required. In conclusion, preoperative SSAs are safe in patients with acromegaly, and the favorable impact on surgical results is restricted to the short-term cure rate in macroadenomas and invasive macroadenomas. Further well-designed RCTs to examine long-term results are awaited to update the finding of this meta-analysis. Because of cardiovascular, respiratory, and metabolic comorbidities, patients with active acromegaly are associated with higher mortality4, though pituitary adenomas are commonly benign. Transsphenoidal surgery is the first-line treatment of choice for patients with acromegaly. Somatostatin analogues (SSAs) and radiotherapy are considered as adjuvant treatment. The goals of treatment consist of relieving clinical symptoms, controlling tumor growth, and achieving biochemical remission.Acromegaly is a rare disease characterized by the overproduction of growth hormone (GH), which is commonly secreted by a pituitary adenoma. The clinical presentations of acromegaly are systemic such as acral overgrowth, featured facial changes, sleep apnea, diabetes, hypertension, thyroid nodules, and colorectal polyps attributing to long-term exposure to high levels of GH and insulin-like factor-1 (IGF-1)5.It is believed that the gross total resection of GH-secreting pituitary adenoma is associated with preoperative GH levels, tumor classification regarding invasiveness and size, and tumor consistency. In most patients, preoperative SSAs are proven to reduce GH and IGF-1 levels, stimulate tumor shrinkage, and soften tumor consistency. Theoretically, preoperative SSAs can promote gross total resection and biochemical remission. However, previous studies with relatively small sample sizes have shown conflicting results regarding the benefit of preoperative SSAs. Consequently, SSAs were not recommended for routine use in acromegaly before pituitary surgeryAccording to previous studies and meta-analyses, preoperative medical treatment was in favor of improving the short-term cure rate, which was thought to be exaggerated by a carryover effect. However, the impact of preoperative medical treatment on the long-term results has not been well demonstrated. Moreover, it remains uncertain whether preoperative medical treatment can benefit the invasive GH-secreting pituitary adenomas in terms of short- and long-term biochemical remission. Therefore, we performed a systematic review and meta-analysis of comparative studies to evaluate the impact of preoperative SSAs on the surgical results and postoperative complications based on the updated evidence.6, we prepared a prospective protocol of literature search, inclusion and exclusion criteria, outcomes of interest, and methods of statistical analysis.According to the Preferred Reporting Items for Systematic Reviews and Meta-analysisWe performed a literature search using databases of PubMed, Embase, and the Cochrane Library from inception to November 1, 2018. The following search terms in various combinations were searched: acromegaly, somatostatin analogue, octreotide, lanreotide, pasireotide, medical treatment, transsphenoidal, transcranial, and surgery. Only the articles written in the English language were included. Two researchers (C.Y. & S.J.) performed literature searches independently. If any discrepancy about the eligibility of an article occurred, a consensus was reached with the guidance of the senior authors (X.B. & R.W.).The literature search aimed to find articles that met the following inclusion criteria: (1) described a comparative study including patients treated with preoperative SSAs or direct surgery; (2) demonstrated the regimen of preoperative medical treatment in terms of dosage, frequency, and duration; (3) reported the number of patients and had at least five patients for each group; (4) reported at least one quantitative outcome of interest mentioned in the next section. Therefore, editorials, letters to editors, meeting abstracts, reviews, non-comparative studies, and case reports were excluded.7. Short-term biochemical remission is defined as follows: (1) conducted a biochemical assessment within six months after pituitary surgery; (2) satisfied cure criteria; (3) received no adjuvant therapy before the last biochemical assessment within six months. Long-term biochemical remission is similar as described previously except that the biochemical assessment is conducted after six months postoperatively. If there were several biochemical results during the short/long-term follow-up, the latest result was adopted. The rate was calculated to divide the number of events by the total number of evaluable patients in each group.Two researchers (C.Y. & S.J.) extracted data of included studies independently. If there was any disagreement about the eligibility of data, a consensus was reached with the guidance of the senior authors (X.B. & R.W.). The outcomes of interest were short-term and long-term biochemical remission rates in all acromegaly patients (mainly macroadenomas), short-term biochemical remission rates in invasive macroadenomas, and postoperative complication rates. Biochemical remission is measured by one of following criteria: (1) nadir GH <1 ug/L during oral glucose tolerance test (OGTT) and normal levels of IGF-1 adjusted for age and sex; (2) nadir GH <0.4 ug/L during OGTT and normal levels of IGF-1 adjusted for age and sex8. Non-RCT studies with more than six stars and RCTs were considered as high-quality studies in this analysis. The statistical analyses of pooled data were conducted using Review Manager, version 5.3.5 . The odds ratio to compare dichotomous variables was calculated using the method of the Mantel-Haenszel test. The random-effects model was performed if there was heterogeneity between selected studies; otherwise, the fixed-effects model was performed. Study heterogeneity was determined using the Cochrane Q and I2 statistics. Heterogeneity was considered significant when the p value from Cochrane Q was <0.1 or I2 >50%. Publication bias was assessed by visually inspecting the funnel plots9.The methodological quality of randomized controlled trials (RCT) was assessed using the Cochrane Risk of Bias Tool. The methodological quality of non-RCT comparative studies was assessed using the nine-star Newcastle-Ottawa scale (NOS)21. The process of study selection is shown  were included for the final meta-analysisAmong the 12 eligible studies, there were five RCTs, two prospective studies, and five retrospective studies. In non-RCT studies, tumor classification was the most common matching factor in a comparative design, followed by preoperative growth hormone levels. As for tumor size, the study subjects were pituitary macroadenomas alone in six studies and a mixture of micro- and macroadenomas in six studies. The fraction of the included microadenomas was so small that it was negligible. Short-acting SSAs were daily used in five studies before 2008, while long-acting SSAs were used every one to four weeks in seven studies. Patients received the transsphenoidal surgery alone in 11 studies, and the remaining study also adopted the transcranial procedure in selected patients. The characteristic of the included studies are shown  in the SSA group and 129/367 (35.1%) in the non-SSA group. The pooled data showed a significantly higher short-term cure rate in the SSA group than that in the non-SSA group   or long-acting (n = 6) SSAs. A subgroup analysis was performed revealing the same result, which was in favor of preoperative medical treatment .Nine studies with a total of 688 patients mainly with macroadenomas evaluated the biochemical control within six months after pituitary surgery according to the widely-accepted remission criteria21. The meta-analysis was performed using the fix-effects model. The rate of long-term biochemical remission was 133/202 (65.8%) in the SSA group and 107/195 (54.9%) in the non-SSA group. The pooled data showed no significant difference regarding the long-term cure rate between groups   in the SSA group and 7/45 (15.6%) in the non-SSA group. The pooled data showed a significantly higher short-term cure rate in the SSA group than that in the non-SSA group   in the SSA group and 20/180 (11.1%) in the non-SSA group. The pooled data showed no significant difference regarding postoperative complications between groups  . However, when three RCTs were selectively analyzed, a significant effect was revealed to favor the impact of pretreatment on surgical results . However, Francisco et al.22 neither considered the relation between tumor features and surgical difficulties nor distinguished the short- and long- term cure rate. Nunes et al.23 performed a meta-analysis based on four RCTs with a total of 248 cases. The result showed that preoperative medical treatment increased the three-month postoperative biochemical remission rate in GH-secreting pituitary macroadenomas . Nevertheless, the three-month postoperative endocrine assessment was considered unpersuasive because of a carryover effect5. To explore more convincing evidence, Zhang et al.24 conducted another meta-analysis about the long-term effect of preoperative SSAs showing no significant difference .There is a great debate about the place of preoperative SSAs in acromegaly treatment. Three meta-analyses have been published to summarize the conflicting results of previous studies. Francisco In our view, tumor invasiveness is the most critical factor to influence the impact of pretreatment. Several recent publications provided further clinical data. Therefore, it is necessary to perform an updated meta-analysis to refine the clinical evidence, with particular attention to invasive macroadenomas.In this meta-analysis, we found that preoperative treatment of SSAs was associated with the elevated rate of short-term biochemical control in acromegaly, but no improvement was seen in the long-term cure rate. As for the acromegaly caused by invasive macroadenomas, which remained surgical challenges, preoperative treatment of SSAs could significantly improve the short-term cure rate as well. The data of long-term results were not available because radiotherapy, prolonged medical treatment, or both was commonly required in such cases with inoperable residual tumor. For safety, pretreatment exerted no impact on postoperative complications. Our results were consistent with guidelines and previous meta-analyses. Furthermore, this was the first study to report the value of preoperative SSAs in invasive macroadenomas achieving better short-term biochemical remission.et al.19. To elucidate the confusing phenomenon, we proposed the following potential reasons according to our experiences: (1) the included cases were a mixture of microadenomas and macroadenomas, whereas the pretreatment value was limited for microadenomas due to the high cure rate of approximately 90% by transsphenoidal surgery alone; (2) given that development of surgical techniques allows for more delicate resection of large and firm tumors, cavernous sinus invasion is the most significant predictor for surgical outcomes rather than preoperative hormone levels, tumor size and tumor consistency, which were considered as key therapeutic targets of preoperative SSAs. Thus, to clarify the impact of preoperative medical treatment more precisely, we recommend including patients with potentially-resectable invasive macroadenomas into a well-designed RCT.The effect of preoperative SSAs on surgical results was presumed to be multiple in terms of controlling GH, reducing tumor volume, softening tumor consistency, and lowering anesthetic risk. Theoretically speaking, these favorable results of pretreatment should improve the rate of gross total resection and biochemical control. Because the long-term result was unsatisfied, the favorable short-term result was questioned and thought to be due to a carryover effect. The results of unsatisfied long-term biochemical control were mainly from non-RCT studies except for the RCT study with a small sample conducted by Fougner The strengths of our meta-analysis are considered as follows. First, we made the most comprehensive literature search from three mainstream databases, including Pubmed, Embase, and Cochrane Library in order to find the updated clinical evidence. Second, before we performed the meta-analysis, we established a prospective protocol in terms of search strategies, data collection, dispute settlement, and statistical analysis, which was strictly followed in the whole procedure. Third, compared with previous studies, this meta-analysis included the largest number of cases from RCTs and non-RCTs, the qualities of which were relatively high after scale-based evaluation.However, the present meta-analysis has the following limitations. First, the therapeutic regimen of preoperative somatostatin analogues varied significantly among the included studies. Second, retrospective and prospective cohort studies were included in the final analysis. Randomization is recognized to eliminate the baseline difference between groups. The included retrospective and prospective cohort studies were distinguished from RCTs for not adopting randomization in assigning patients. In three retrospective studies, methods to balance the baseline data were not even reported. Though one or two matching factors were stated in some studies, the inherent drawbacks of the non-RCT design might cause potential selection bias between groups. Third, considering the extensive perioperative use of SSAs, a considerable number of observational studies with negative results might be not reported. The publication bias should not be neglected. Fourth, original data did not show the biochemical control related to individual preoperative imaging features in size and invasiveness, reducing the application value of our results.Preoperative medical treatment leads to better short-term cure rates in the acromegalics, but its impact on the long-term results is unclear. In acromegalics with invasive macroadenomas, preoperative medical treatment also shows great efficacy in the short-term cure rate. As for safety, preoperative somatostatin analogues do not increase the risk of postoperative complications. Despite some limitations, the present meta-analysis provides the latest evidence regarding the safety and efficacy of preoperative SSAs.


Antiretroviral therapy (ART) improves the health and well-being of people living with the human immunodeficiency virus , and reduces their risk of transmitting the virus to sexual partners. However, patterns of sexual risk behavior among HIV-positive patients taking ART in Vietnam remain largely unknown. In this study, we sought to examine sexual risk behaviors and their associated factors among HIV-positive patients receiving ART in northern Vietnam. The socio-demographic characteristics, ART use, health status, and sexual behaviors of 1133 patients taking ART in the Hanoi and Nam Dinh provinces were explored through face-to-face interviews. There were 63.5% of patients who had one sex partner, while 3.6% and 5.6% of patients had sexual intercourse with casual partners or sex workers, respectively, in the previous 12 months. Most participants tended to use condoms more often with commercial sex partners (90.2%) and intimate partners (79.7%), and less often with casual partners (60.9%). Higher age  or suffering pain/discomfort  were factors more likely to be associated with multiple sex partners. Patients who were self-employed were more likely to have sexual intercourse with casual partners/sex workers . Meanwhile, a higher score on the EuroQol visual analog scale (EQ-VAS), an unknown HIV stage, and a longer duration of ART were adversely associated with not using condoms with casual partners/sex workers. Patients with longer durations of ART had a lower likelihood of not using a condom with casual partners/sex workers . Our study underscored a relatively high rate of unsafe sexual behaviors among HIV-positive patients. Continuing to improve the physical and psychological well-being of HIV-positive patients in Vietnam is important in reducing the spread of HIV via risky sexual behaviors. In addition, safe-sex education should be provided to older people, and to those who are self-employed.  Antiretroviral therapy (ART) is used to improve the lives of people living with the human immunodeficiency virus and acquired immune deficiency syndrome  ,2, and tThe HIV epidemic in Vietnam is concentrated in most-at-risk populations, namely people who inject drugs, female sex workers, and MSM. To date, there are upwards of 300,000 PLWH nationwide, and 120,000 PLWH receiving ART, with the viral suppression rate ranging from 90% to 95% ,11,12,13Understanding risk behaviors of patients on ART can inform the operation of HIV/AIDS programs. Currently, harm-reduction activities are targeting most-at-risk populations using mainly peer-outreach interventions, and mass media. Meanwhile, care and treatment services are facility-based, and not necessarily linked with community-based harm reduction. Therefore, preventive services are not sustained, especially for those patients on long periods of ART. In this study, we sought to examine factors associated with sexual risk-taking behaviors among HIV-positive patients taking ART in the Hanoi and Nam Dinh provinces, two HIV epicenters in northern Vietnam.This was a sub-analysis of the 2013 HIV Services Users Survey (HSUS) dataset collected between February and July in 2013. Overall, the HSUS examined various aspects of the access, quality, and outcomes of HIV/AIDS services, from the perspectives of providers and users. Basically, a total of eight outpatient clinics located in Hanoi and Nam Dinh—2 epicenters of HIV/AIDS—were selected, including a national hospital (Hanoi), a provincial hospital (Nam Dinh), a provincial center (Nam Dinh), three district health centers from Hanoi, and two district health centers from Nam Dinh. Some articles using the same dataset and methods were published elsewhere ,18.A convenience-sampling technique was performed to recruit participants from selected clinics. Patients were chosen if they met the following eligible criteria: (1) 18 years old or older; (2) having a HIV-positive result from the confirmatory test; and (3) agreeing to participate in the survey. Patients with cognitive impairment were excluded from the survey. Firstly, the patients were invited to a private counseling room to ensure a pleasant atmosphere, and to protect the patients’ privacy. Then, the interviewer introduced the purposes of the study, and what benefits and drawbacks patients might experience if participating in the study. We also mentioned that patients’ confidentiality would be kept, and we did not collect any data that could disclose their identity. After that, we asked patients if they would participate in the study. If the patients agreed, they were asked to give their written informed consent. A total of 1133 participants agreed to participate in the study.Participants were interviewed face-to-face using a structured questionnaire. An interview lasted 20 min in a private room, to ensure the comfort and privacy of participants. Data collectors were master’s students in public health at the Hanoi Medical University. They were consistently trained to ensure the quality of data. Socioeconomic information: We collected information about the general characteristics of participants, including living area , age, gender, education level, marital status, and employment status.Health status: In this study, we employed two items from the EuroQol five-dimension five-level (EQ-5D-5L) questionnaire, including (1) pain/discomfort, and (2) anxiety/depression with five levels ranging from “no problem” to “extreme problems” . People ART status: Data about the ART status of participants including HIV stages , cluster of differentiation 4 (CD4) cell count, ART duration, whether or not they were using ART, and frequency of attending peer-to-peer meetings  were collected.Sexual behaviors: We asked patients whether or not they had sex. Among those who had sex during their lifetime, we asked them to report the number of sexual partners  they had in the previous 12 months. We also asked whether or not they used condoms with intimate partners, casual partners, and commercial sex workers in their previous sexual intercourse.p-value < 0.2 for the log-likelihood-ratio tests.We analyzed data using STATA 12.0 . Socio-economic information , health-related quality of life (HRQOL), ART status, and sexual behaviors were described. These variables were considered potential covariates in the regression models. Multivariate logistic regression was conducted to identify associated factors with sexual behaviors of patients, including having more than one partner, having sexual intercourse with casual partners/sex workers (both variables for people ever having sex during their lifetime), using a condom with spouses/intimate partners (for people having sex with intimate partners), and not using a condom with casual partners/sex workers . The results were displayed by adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Stepwise strategies with forward selection were used to develop reduced multivariate models, which included variables in the models based on a The ethical application of this study was reviewed, and the approval was obtained by the Institutional Review Board (IRB) of the Vietnam Authority of HIV/AIDS Control’s Scientific Research Committee (28/QD-AIDS). Participation was voluntary, and patients had the right to stop the interview at any time.Female patients  and people having anxiety/depression  were less likely to use a condom with spouses/intimate partners. Meanwhile, a higher EQ-VAS score, an unknown HIV stage, and a longer duration of ART were adversely associated with not using a condom with casual partners/sex workers. Noticeably, patients with a longer duration of ART had a lower likelihood of not using condom with casual partners/sex workers .The current study explored the sexual risk behaviors among HIV-positive patients taking ART. In this study, we highlighted that a minority of patients had multiple sexual partners (10%); however, the prevalence of individuals using a condom with casual partners was low. We found that HIV-positive patients’ sexual behaviors were associated with some socio-demographic and clinical factors. Our results revealed important findings about the sexual practices of this vulnerable population, and ways to create interventions that can increase safe-sex practices.Rates of condom usage with intimate partners (79.7%) and with commercial sex workers (90.2%) mirror those that found in other countries , and in While there were some studies suggesting that patients on ART may engage in more sexual risk-taking behaviors ,8, ART wInterestingly, our findings revealed that people who did not know their HIV status were less likely to have sexual intercourse with casual partners/sex workers without a condom. This suggested that perhaps those who did not know their HIV status were more worried about transmitting the virus to their sexual partners. Previous work in Uganda with patients initiating ART found that patients with lower CD4 counts were more likely to transmit HIV to their partners . PatientParticipants who were physically and psychologically impaired were more likely to engage in sexual risk-taking behaviors, as evidenced by their increased likelihood of having more than one partner, or their reduced likelihood of using condoms with intimate partners, while having a higher VAS scale leading to reduced sexual risk-taking behaviors. These findings correlated with some studies that found that depression and reduced well-being were linked to higher sexual risk-taking behaviors among patients living with HIV ,31, but Being self-employed was a risk factor for sexual promiscuity. Self-employment was associated with an increased likelihood of having sexual intercourses with casual partners/sex workers. Perhaps individuals who are self-employed have a wider social network, which can facilitate more casual sexual events . In addiSeveral implications can be drawn from our work. Similar to what was found among patients taking ART around the globe , in VietThis study looked at sexual behaviors of HIV-positive patients taking ART in northern Vietnam on a large scale. However, there were a few limitations to our study. Our study methods relied on patients’ ability to recall their sexual behaviors, the duration of their ART therapy, and other elements of their health and well-being. This method of data collection is susceptible to recall bias. Our method of convenience sampling possibly led to bias, and reduced the generalizability of our results. Because we used a cross-sectional study design, we could not draw causal conclusions between ART duration and sexual behaviors; additional longitudinal data would be required for this. Several potential factors, such as duration of HIV infection, and virologic failure, were not collected, which were potential confounders affecting the results of this study. Further research is warranted to investigate the effects of these factors on the sexual behaviors among HIV-positive patients.Our study underscored the importance of ART therapy in reducing sexual risk-taking behaviors of HIV-positive patients in northern Vietnam. Increasing the availability of ART, and continuing to improve the health and psychological well-being of HIV-positive patients in Vietnam are important areas of focus in reducing the spread of HIV via risky sexual behaviors. In addition, safe-sex education should be provided to older people, and to those who are self-employed.