Two recent meta-analyses have been conducted on the relationship between miR-146a polymorphism (rs2910164) and head and neck cancer (HNC) risk. However, they have yielded conflicting results. Hence, the aim of the present study was to conduct a quantitative updated meta-analysis addressing this subject. Eligible studies up to Sep 2016 were retrieved and screened from the bio-databases and then essential data were extracted for data analysis. Next, subgroup analyses on ethnicity, source of controls, sample size, and genotyping method were also carried out. As a result, a total of 9 publications involving 10 independent case-control studies were included. The overall data indicated a significant association between miR-146a rs2910164 polymorphism and HNC risk . Variant alleles of miR-146a rs2910164 may have a correlation with increased HNC risk. Future well-designed studies containing large sample sizes are needed to verify this result. Head and neck carcinoma (HNC) has ranked the sixth most frequent malignancy worldwide, which comprises a number of epithelial cancers originated from oral, nasal cavity, pharynx and larynx . The occThe etiology of HNC remains largely unclear. In recent years, microRNAs (miRNAs) have attracted much attention. MiRNAs are a series of single-stranded short non-coding RNAs that can inhibit gene expression by directly targeting specific mRNAs. They have been suggested to be involved in cellular processes such as cell proliferation, differentiation and apoptosis . Thus, aA popular miRNA, miR-146a, has been suggested to have an association with the development of a variety of disorders . It alsoPotential publications were retrieved from the databases. A total of 29 publications were originally obtained, among which 15 irrelevant papers were firstly excluded. Thus, 14 publications were eligible. Then, 2 review articles , 13 and All publications were written in English, except for one in Chinese . The relThe main results of the meta-analysis are listed in Table For the overall data, a total of ten case-control studies containing 4399 cases and 8777 controls were involved. The pooled ORs for the recessive model  failed to show an association. Nevertheless, borderline increased cancer risks could be shown in both the allelic contrast  and dominant model , implying that variant C allele of miR-146a rs2910164 may have a correlation with increased risk of HNC , suggesting that the publication bias was not evident . Published papers up to Sep 2016 were covered. The following keywords were used: For the literature inclusion, the following criteria were used: (1) papers should concern miR-146a rs2910164 polymorphism and HNC risk; (2) studies should be case-control designed; (3) papers should state adequate information for readers to calculate odds ratios (ORs) and their 95% confidence intervals (CIs). Accordingly, the following criteria were used for exclusion: (1) duplicate publication; (2) papers with insufficient information.The data were extracted by two of the authors independently. If the extracted information was conflicting, a discussion was conducted to reach an agreement. If the agreement could not be reached, another author was consulted and a final decision was made according to the majority of votes. When two or more studies shared the same group of population, only the study including the larger or the largest sample size was selected.The Hardy-Weinberg equilibrium (HWE) was assessed by Fisher's exact test for the controls in each study. The ORs and their 95%CIs were calculated to evaluate the strength of the association between miR-146a rs2910164 polymorphism and HNC risk. The pooled ORs were determined for an allelic contrast model , a dominant model (CC+CG vs. GG), and a recessive model (CC vs. CG+GG).P value for the Q-test greater than 0.05 indicates absence of heterogeneity, and then the ORs were pooled by a fixed-effect model (Mantel-Haenszel) [A chi-squared-based Q-statistic test was performed to assess between-study heterogeneity. A aenszel) ; otherwiaenszel) . The sigaenszel) . To miniaenszel) . All sta


Over the past decade, more interests have been aroused in engineering protein-based nanoformulations for cancer treatment. This excitement originates from the success of FDA approved Abraxane (Albumin-based paclitaxel nanoparticles) in 2005. The new generation of biocompatible endogenous protein-based nanoformulations is currently constructed through delivering cancer therapeutic and diagnostic agents simultaneously, as named potential theranostics. Protein nanoformulations are commonly incorporated with dyes, contrast agents, drug payloads or inorganic nanoclusters, serving as imaging-guided combinatorial cancer therapeutics. Employing the nature identity of proteins, the theranostics, escape the clearance by reticuloendothelial cells and have a long blood circulation time. The nanoscale sizet allows them to be penetrated deeply into tumor tissues. In addition, stimuli release and targeted molecules are incorporated to improve the delivery efficiency. The ongoing advancement of protein-based nanoformulations for cancer theranostics in recent 5 years is reviewed in this paper. Fine-designed nanoformulations based on albumin, ferritin, gelatin, and transferrin are highlighted from the literature. Finally, the current challenges are identified in translating protein-based nanoformulations from laboratory to clinical trials. HSA is a single-chain and non-glycosylated polypeptide with 66,500 Da in molecular weight, consisting of 585 amino acid residues, and heart-shaped with 80 × 80 × 30 Å in ca. dimensions , for synthesizing effective theranostic agents.T1 relaxivity of 4.82 mM−1 s−1. More recently, a gemcitabine functionalized HSA-IR780 agent was reported for chemotherapy and imaging-guided PTT of tumor  dyes, e.g., IR780, indocyanine green (ICG) and IR825, are broadly employed for cancer theranostics because of their relatively deep penetration and low interference. IR825 can be bound to the hydrophobic domain of HSA (the molar ratio of 1:1) via hydrophobic interactions, which fabricates a HSA-IR825 complex Figure  Chen et. The HSAin vivo circulation -probe@HSA) for theranostic application  effect  was selectively bound to hydrophobic domain of BSA via hydrogen bonding and hydrophobic interactions with 80-fold enhanced fluorescence intensity   salt to form nanomedicine with dual imaging modalities  theranostic agent , resulting in UCNP@BSA NPs possessing well stability and water-solubility in physiological environments  were developed, where BSA serving as the outer shell was further functionalized by the active targeted agent Anti-EGFR mab C225   (PEG) shell and anticancer drug DOX were presented for combined MR imaging diagnostics and chemotherapy  or basic pH (pH 10–12) and can be heated at 80°C exerting no deleterious effects , a potent hydrophobic photosensitizer, is well encapsulated into the Cys-Asp-Cys-Arg-Gly-Asp-Cys-Phe-Cys (RGD4C)-modified ferritins (P-RFRTs) with a loading rate as high as ~60 wt % for effective PDT  prodrug, was elaborated for fluorescence and MR imaging guided chemotherapy  have been designed to increase the tumor targeting efficiency, tumor retention and tumor penetration  and hydrophobic anticancer drug PTX for NIR/MR bimodal imaging guided chemotherapy  was developed, taking advantage of efficient NIR-to-visible up-conversion capability and increased tumor targeting ability and biocompatibility  conjugated magnetic NPs were proposed for PTT application  for targeted imaging and phototherapy of cancer  were fabricated for a targeted theranostics application through oral administration (Kamalapuram et al., With the exception of the foregoing proteins, several other proteins, e.g., silk fibroin (Bian et al., in situ polymerization was developed as an alternative strategies for protein modification (Ye et al., Although natural proteins were used in most studies, the disadvantages of these protein-based platforms were obvious, such as poor permeability, ease of degradation, and potential immune responses. Moreover, after functionalization or conjugation of other molecules, the protein properties and functions might be altered. In recent years, encapsulation of proteins by in vitro and in vivo. Despite these huge advances, the translation of natural protein nanoplatforms from laboratory to clinical trials remains an enormous challenge. More efforts should be made to improve the NP reproducibility, colloidal stability in biological environments, and drug-loading efficiency. Furthermore, live and spleen accumulation is a big barrier in clinical translation of all types of NPs. Accordingly, more understanding of bio-nano interactions is required, while more data of pharmacokinetics should be collected and analyzed. Long-term toxicity of nanoformulation is not well evaluated. In addition to mouse model, more animal models, e.g., beagle dogs, monkeys and gorillas, should serve for assessing the long-term toxicity and therapeutic effect. Engineering complex particles with multiple functions are currently achieved by chemists. Accurate diagnose of early stage of tumor and precision drug delivery to tumor site should be more considerable in the future developing of protein-based cancer theranostics.Natural proteins as biocompatible nanocarriers are broadly adopted in delivering therapeutic and diagnostic agents simultaneously. These nanoformulations are fabricated progressively complex and “smart” to employ multi functions in one platform. To increase the accuracy of diagnostic and the efficiency of cancer therapy, “all-in-one” nanoplatforms are designed with more than two imaging strategies and more than two therapeutic methods. Surface modification with targeted molecules and controlled drug release are employed to spatially control the localization of administered NPs. The improved efficiencies in tumor imaging and ablation are verified both YG, HZ, and GS: designed this work of review; DM, MZ, and LW: performed the literature search of the databases; YG: wrote the manuscript; HZ and GS: revised the manuscript. All authors approved the paper for publication.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.


MicroRNAs (miRNAs) have emerged as one of the crucial regulators of cancer progression. Some miRNAs are reported to be related to the response of breast cancer to tamoxifen (TAM). In this study, we investigated whether the levels of TAM response-related miRNAs translate to patient survival. The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) datasets were used and Gene Set Enrichment Analysis (GSEA) was performed. Four TAM response-related miRNAs, miR-221, miR-222, miR-342, and miR-451, were identified by literature search. Patients with high expression of miR-342, related to TAM sensitivity, were associated with better survival in TCGA cohort , p=0.02; Disease Free Survival (DFS), p=0.03, respectively), and in two other independent GEO cohorts . High expression of miR-342 was associated with significantly better survival in ER-positive patients (p=0.04), but not in ER-negative or triple-negative patients. Surprisingly, high expression of miR-451, reported to increase the sensitivity to TAM, was associated with worse survival (p=0.002). MiR-221 and miR-222 did not show any significance in survival. Lastly, GSEA demonstrated that lower miR-342 expression was significantly associated with the enrichment of TAM resistance-related gene expression, and higher miR-342 expression with TAM sensitivity-related gene expression, but miR-221, miR-222 and miR-451 were not. For the first time, we used “big data” from TCGA and GEO cohorts to analyze multiple miRNAs with respect to survival impact and TAM sensitivities. We demonstrated that TAM sensitivity-related miR-342 could be a promising biomarker, especially in luminal type breast cancer patients. Over 40,500 women in the US are still anticipated to die from breast cancer in 2017 , 4. SeleRecently, microRNAs (miRNA), which are noncoding RNAs consisting of 22-25 nucleotides, have emerged as crucial new players in epigenetic regulation through the targeting of messenger RNA sequences in breast cancer –9. Alterin vitro and/or in vivo systems or in a relatively small number of patient samples. Thus, in order to prove the utility of miRNAs as biomarkers, validation with larger clinical cohorts is needed.Many tumor-related miRNAs have been reported as clinical biomarkers in breast cancer –16. AlteTo address this limitation, we utilized The Cancer Genome Atlas (TCGA), one of the largest collections of genomic cancer data, possessing both genetic and molecular information for over 1000 breast cancer cases with full clinical profiles and survival data , 18. It The aim of this study is to use bioinformatics in a large clinical dataset to explore survival in patients with high expression of miRNAs reported to be related to TAM sensitivity or resistance. We conducted prognostic analyses using TCGA dataset, as well as other independent datasets retrieved from the GEO, to clarify whether TAM sensitivity- or resistance-related miRNAs show any survival impact in breast cancer patients. We also performed Gene Set Enrichment Analysis (GSEA) to validate whether each miRNA could be associated with known endocrine therapy response-related gene sets.A literature search was conducted using PubMed Central to identify miRNAs that were reported to relate to breast cancer TAM sensitivity or resistance. We identified several miRNAs of interest reported by multiple groups that lacked validation with a large patient cohort. Four miRNAs were selected for analysis; miR-221, miR-222, miR-342, and miR-451 –31 (Tablin vitro [p=0.02)    Figure . Patient) Figure . Remarka) Figure  and 1D.p=0.04)  Figure  and 2C. ) Figure .Interestingly, several previous reports demonstrated that expression levels of miR-342 are associated with ERα expression levels in breast cancer tissue , 32–34. p=0.002)  Figure . However) Figure  and 3C.p=0.005)  Figure  and 3F. In addition, miR-451 expression levels did not show any significant association with clinical or pathological factors in TCGA cohort .In the literature, miR-221 and miR-222 were reported to be associated with TAM resistance in breast cancer cells –28. In oIn addition, miR-221 and miR-222 expression levels did not show any significant association with clinical or pathological factors in TCGA cohort  and 3.p=0.0020)   was used . We foun) Figure . Next, w) Figure . These r) Figure . The resThe aim of our study was to examine whether expression of miRNAs reported to be related to TAM sensitivity or resistance is associated with patient survival in large clinical datasets. We expected that patients with high expression of miR-221 and miR-222, which was reported to be associated with TAM resistance, would have worse OS, whereas patients with high expression of miR-451 or miR-342, which was reported to be associated with TAM sensitivity, would have better OS. We used three large independent clinical datasets from TCGA and GEO to analyze survival with regards to these specific miRNAs. We found that high expression levels of miR-342 in breast cancer are associated with better OS, DFS, and OS in ER-positive subtypes. Through GSEA of two large TCGA gene sets, we also found that high expression of miR-342 enriched TAM sensitivity-related genes and low expression enriched TAM resistance-related genes. High expression of miR-451 unexpectedly demonstrated worse OS in our analysis of TCGA dataset, as well as decreased OS in the ER-positive subtype. We did not see the same trend in the GEO datasets, or through GSEA of TCGA. Expression levels of miR-221 and miR-222 did not show any significant association with survival in our analyses. To our knowledge, this is the first report to use TCGA or GEO to identify associations between miRNA expression levels and TAM sensitivity or resistance, and patient survival in large patient cohorts.Higher levels of miR-342 expression have been reported to be associated with TAM sensitivity in the literature. Cittelly et al. found that downregulation of miR-342 is associated with TAM-resistant breast tumors, using cell lines and tissues from 16 breast cancer patients primary breast cancer . Anotherin vitro analyses of cell lines. The result of our survival analysis of TCGA cohort was opposite to our expectation based on this report. Miller et al. demonstrated that breast cancer cells overexpressing miR-221 or miR-222 had greater viability in the presence of TAM, and postulated that this conferred resistance to TAM through downregulation and loss of the effector molecule p27Kip1 [in vitro data. Our study using large patient cohorts was unable to reproduce their results. Mechanisms for drug resistance remain difficult to elucidate, likely due to multiple concurrent mechanisms of action. Thus, it is difficult to explain why miR-221, miR-222 and miR-451 have shown some promise in pre-clinical studies, but not in our clinical dataset. With that said, given our data from large patient cohorts, it is safe to say that miR-221, miR-222 and miR-451 are not strong candidates for prognostic biomarkers at this time. On the other hand, miR-342 has shown promise as a biomarker both in preclinical studies from the literature, as well as in our analysis of 3 independent clinical datasets.Bergamaschi et al. demonstrated that downregulation of miR-451 expression promoted breast cancer cell recurrence and endocrine resistance, thus concluding that high expression of miR-451 leads to TAM sensitivity . This st p27Kip1 . Wei et  p27Kip1 . HoweverThe limitations of our current study include only using retrospective data from TCGA and GEO datasets. Also, as there are no known absolute cutoffs and ranges available in this newer genomic data, these were generated after statistical analysis was done on the distributions of gene expressions within the datasets. Further, TCGA lacks many traditional clinicopathologic data points, which may have added to the analysis. However, despite these limitations, we feel that the associations found within our study are strong and valid, as we used a large clinical database for analysis.In addition, we noticed that there was a large variation in the number of patients with high expression of miR-342.TCGA dataset had only 24.3% (255/1049) of breast cancer patients with high miR-342 expression out of 1,049 patients (24.3%), whereas 63.5% and 67.6% of patients showed high miR-342 expression in the GSE19536 and GSE2220 datasets, respectively. This difference may be attributed to multiple factors. First, the data originates from various populations in multiple countries, and therefore the outcomes data may be different. Also as described, the cutoff points between high and low expressions were determined by a running Cox proportional hazard statistic and not the number of patients or the absolute expression levels. Additionally, there was a lot of variation in the number of patients with high miR-451 seen among the datasets, as well as small numbers of patients with ER-negative or triple-negative tumors with high levels of miR-451. Despite the variation in numbers of patients in each group, we feel that by determining the threshold of dichotomization in the above manner , this stRecently there was a publication that stressed the importance of the translation of basic findings to clinical practice utilizing big data . That alIn conclusion, for the first time, we used “big data” from TCGA and GEO cohorts to analyze multiple miRNAs with respect to overall survival and sensitivities to TAM. We found that high expression of miR-342 is strongly associated with overall survival and TAM sensitivity. Therefore, we conclude that miR-342 is a strong candidate as a biomarker to predict TAM sensitivity in breast cancer patients, and would have a clear clinical impact for treatment recommendations. On the other hand, the predicted outcomes for miR-221, miR-222, and miR-451 were not validated in our study. Future studies using large clinical datasets such as TCGA are expected to become increasingly important as we seek further clinical correlations with gene expression, leading to more biomarkers and actionable targets.in vitro and/or in vivo in breast cancer; 2) the target mRNA or signaling pathway of the miRNA are identified in breast cancer; 3) the clinical relevance, including prognostic significance, of the miRNA has not been fully elucidated using large patient cohorts or multi-institutional clinical trials of breast cancer patients. Based upon this criteria, we analyzed the following miRNAs that have been reported to be related to tamoxifen sensitivity [We conducted a literature search using PubMed Central for articles from 2005 to 2016 that identified miRNAs that showed a relationship to TAM sensitivity or resistance in breast cancer. The criteria for selection were 1) the miRNA has demonstrated TAM sensitivity or resistance sitivity –16; miR-All data including miRNA-Sequence and clinicopathological data were retrieved from TCGA breast cancer cohort through the Genomic Data Common (GDC) portal, cBioportal, and Broad Institute Firehose. Survival data for the breast cancer patients in TCGA was obtained as previously reported . In TCGAOverall survival was defined as the time from date of diagnosis to the date of death by any cause, and disease-free survival was defined as the time from date of diagnosis to the date of diagnosis of a metastatic breast cancer. OS and DFS were compared using the Cox proportional hazard model between the high and low expression groups determined by each miRNA-specific thresholds as described below. Stratified analyses were also conducted and the covariates in the models included the ER and TNBC status. In TCGA dataset, the clinical data and histological subtypes were determined using TNM staging and pathological molecular subtyping , 40.Patients were placed into the low-expression or high-expression groups based on their miRNA expression levels in both TCGA and GEO cohorts. To determine the threshold of dichotomization, a running Cox proportional hazard statistic was applied . Differehttp://software.broadinstitute.org/gsea/index.jsp) [GSEA was conducted on each miRNA and RNA expression data from TCGA to see if there was any association with gene sets reported to correlate to drug sensitivity or resistance in breast cancer. This was done using software provided by the Broad Institute (dex.jsp) . GSEA wahttp:///www.r-project.org/) and Bioconductor (http://bioconductor.org/). Data of miRNA expression was normalized using DESeq2 package [All statistical analyses were performed using R software ( package  and log- package . To comp


There is a growing demand for alternative fabrication approaches to develop tissues and organs as conventional techniques are not capable of fabricating constructs with required structural, mechanical, and biological complexity. 3D bioprinting offers great potential to fabricate highly complex constructs with precise control of structure, mechanics, and biological matter . 3D bioprinting is an additive manufacturing approach that utilizes a “bioink” to fabricate devices and scaffolds in a layer-by-layer manner. 3D bioprinting allows printing of a cell suspension into a tissue construct with or without a scaffold support. The most common bioinks are cell-laden hydrogels, decellulerized ECM-based solutions, and cell suspensions. In this mini review, a brief description and comparison of the bioprinting methods, including extrusion-based, droplet-based, and laser-based bioprinting, with particular focus on bioink design requirements are presented. We also present the current state of the art in bioink design including the challenges and future directions. Depending on the printing process, printability could potentially involve solution viscosity, surface tension, and cross-linking properties. Viscosity is a crucial parameter for a bioink formulation as it affects both the print fidelity and cell encapsulation efficiency. High viscosity polymer solutions are less likely to flow easily so that the printed structure could hold its shape at longer times post-printing. However, they require higher pressures to flow, limiting the gage size and smallest achievable print size (mainly for DIW). In this regard, Tirella et al.  investigThe most commonly used bioinks for tissue and organ printing are cell-laden hydrogels, decellularized extracellular matrix (dECM)-based solutions, and cell suspensions Figure . Cell-laCell-laden hydrogels are the most commonly used bioinks as they can be easily formulated for extrusion-based (DIW), droplet-based (inkjet), and laser-based (SLA and LIFT) bioprinting technologies. Cell-laden hydrogel bioink formulations utilize natural hydrogels such as agarose, alginate, chitosan, collagen, gelatin, fibrin, and hyaluronic acid (HA), as well as synthetic hydrogels such as pluronic (poloxamer) and poly(ethylene glycol) (PEG), or blends of both. Natural hydrogels offer inherent bioactivity except for agarose and alginate and display a structural resemblance to ECM. For instance, fibrin and collagen hydrogels with inherent filamentous structure display strain-stiffening property, mimicking the non-linear elastic behavior of the soft tissues in our body  and rapid cross-linking to develop self-supporting structures. There are two forms of cross-linking: physical and chemical cross-linking. Physical cross-linking is a non-chemical approach that utilizes hydrophobic interactions, ionic interactions, and hydrogen bonding. Chemical cross-linking relies on the formation of covalent bonds, which could be a radical polymerization (such as photo-cross-linking) or Michael-type addition reaction. The chemically cross-linked hydrogels form a mechanically robust network as compared to the physically cross-linked hydrogels, which is particularly important for the stem cell behavior including differentiation  to induce cell adhesion and biological activity -based hydrogel for DIW  in growth media  porous microspheres enabling cells to adhere and proliferate before printing.Modified inkjet printers have long been used to print cells into cellular assemblies. For instance, endothelial cells were printed from cell suspension (1 × 10Decellularized extracellular matrix-based bioinks involve decellularization of a tissue of interest by removing the cells while preserving the ECM. The ECM is then crushed into a powder form and dissolved in a cell friendly buffer solution to formulate the bioink. A carrier polymer could be used to increase the solubility, to tune the viscosity, or to induce/enhance post-cross-linking of the bioink. In this regard, Pati et al.  printed 3D printing has a strong potential to become a common fabrication technique in medicine as it enables fabrication of modular and patient-specific scaffolds and devices, and tissue models, with high structural complexity and design flexibility (Murphy and Atala, SJ and MG wrote the manuscript, and MG edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer, AA, and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


India is considering the scale-up of the Xpert MTB/RIF assay for detection of tuberculosis (TB) and rifampicin resistance. We conducted an economic analysis to estimate the costs of different strategies of Xpert implementation in India.Using a decision analytical model, we compared four diagnostic strategies for TB patients: (i) sputum smear microscopy (SSM) only; (ii) Xpert as a replacement for the rapid diagnostic test currently used for SSM-positive patients at risk of drug resistance (i.e. line probe assay (LPA)); (iii) Upfront Xpert testing for patients at risk of drug resistance; and (iv) Xpert as a replacement for SSM for all patients.The total costs associated with diagnosis for 100,000 presumptive TB cases were: (i) US$ 619,042 for SSM-only; (ii) US$ 575,377 in the LPA replacement scenario; (iii) US$ 720,523 in the SSM replacement scenario; and (iv) US$ 1,639,643 in the Xpert-for-all scenario. Total cohort costs, including treatment costs, increased by 46% from the SSM-only to the Xpert-for-all strategy, largely due to the costs associated with second-line treatment of a higher number of rifampicin-resistant patients due to increased drug-resistant TB (DR-TB) case detection. The diagnostic costs for an estimated 7.64 million presumptive TB patients would comprise (i) 19%, (ii) 17%, (iii) 22% and (iv) 50% of the annual TB control budget. Mean total costs, expressed per DR-TB case initiated on treatment, were lowest in the Xpert-for-all scenario .The Xpert-for-all strategy would result in the greatest increase of TB and DR-TB case detection, but would also have the highest associated costs. The strategy of using Xpert only for patients at risk for DR-TB would be more affordable, but would miss DR-TB cases and the cost per true DR-TB case detected would be higher compared to the Xpert-for-all strategy. As such expanded Xpert strategy would require significant increased TB control budget to ensure that increased case detection is followed by appropriate care. According to the 2015 World Health Organization (WHO) Global TB Report, India has the highest tuberculosis (TB) burden in the world. In 2015, an estimated 2.8 million people in India developed active TB, of which approximately 59% were diagnosed [The Xpert MTB/RIF assay (hereafter referred to as Xpert) for the diagnosis of TB and DR-TB offers great promise as a tool for TB control in India. The WHO-endorsed assay has greater sensitivity for TB detection than sputum smear microscopy (SSM) , high acAlthough Xpert has been shown to be easy to implement, and is potentially cost-effective and successful in increasing the detection of TB and MDR-TB in India ,7, XpertWe developed a decision analytical model to simulate a cohort of patients who report to public health facilities in India with symptoms or signs suggestive of TB and require diagnostic testing for pulmonary TB . We compThe simulated population represented adult patients requiring diagnostic testing for TB, rifampicin-resistant TB or both. In the primary analysis, the cohort characteristics were stipulated as observed in the implementation study , except The baseline scenario represents the recommended practice in India , with SSTo diagnose rifampicin resistance, the sputum of SSM positive TB patients at increased risk for MDR was tested by LPA. In the model, in all scenarios, patients at increased risk for MDR included TB patients who failed first-line treatment (DR-TB suspects) as well as patients with a history of TB treatment in the past. This was chosen to stay close to the RCNTP guidelines which define high-risk TB cases as those TB cases with previous history of anti TB treatment, TB cases on treatment with positive sputum smear result at any follow up smear examination, diagnosed TB cases with HIV-co-infection and all pulmonary TB cases who are contacts of a known MDR TB case . PatientThis scenario was identical to the baseline scenario, except that the Xpert assay replaced LPA for DST following SSM, and thus was only applied to SSM-positive TB patients at increased risk for MDR.In the third scenario, presumptive TB patients at increased risk for MDR-TB (as defined in scenario 1) received upfront Xpert testing, rather than SSM. New patients were tested with SSM as in the baseline scenario. Thus, if new patients were diagnosed with pulmonary TB, they were not subjected to drug resistance testing.In the upfront Xpert-for-all scenario, all presumptive TB patients were tested up-front by Xpert, instead of SSM, regardless of previous history of TB. This scenario is in line with WHO recommendations . If posiAfter a rifampicin-sensitive Xpert result, a first-line treatment regimen was started . In case of a rifampicin-resistant result for previously treated TB cases, second-line treatment was indicated without further diagnostic confirmation. In new cases, a sputum sample for confirmatory DST by LPA was required. Xpert MTB-positive, SSM-negative patients, assumed to be 36% , for whiAn observational micro-costing study (or ‘bottom-up’ approach) was conducted at seven study sites to determine the cost of each bacteriological test  per patient tested. The results are reported elsewhere . The cosThe outcomes calculated by the model were the number of TB cases detected and initiated on TB treatment, divided into true positive and false positive cases as determined by phenotypic methods. Similarly, MDR cases detected and initiated on treatment were divided in true positive and false positive cases. For the primary analysis, estimates for primary loss to follow-up between bacteriological TB diagnosis and treatment initiation were taken from the two arms of the Xpert implementation study . Loss to follow-up for DR-TB cases before treatment initiation was also estimated to be 10% based on the previous implementation study . To calcDeterministic sensitivity analyses were conducted to explore how assumptions and variations in the parameter estimates affected the total costs of different scenarios, including variation in the epidemiological parameters, assumptions about test accuracy, as well as the costs of diagnostic tests and treatment. Additionally, the assumptions about the use and interpretation (i.e. sensitivity and specificity) of CXR were explored in more detail, as little data is available regarding the proportion of patients receiving CXR in different diagnostic algorithms, despite the fact that the availability of CXR results could substantially affect clinicians’ decisions regarding empiric therapy and affect diagnostic costs. In the primary analysis, all patients with negative bacteriology (SSM) results were clinically evaluated, though only 4% of these patients received a CXR as part of their TB clinical assessment. This estimate was based on previous observations , and resEthical approval was not obtained for this study, as only secondary data were used in these analyses.The proportion of true pulmonary TB cases diagnosed and initiated on treatment among presumptive TB patients was 62% in both the SSM-only and LPA replacement scenarios, 67% in the SSM replacement scenario, and 81% in the Xpert-for-all scenario . The totThe diagnostic costs for the diagnosis of TB and rifampicin-resistant TB in a cohort of 100,000 persons  were: USst line treatment would increase minimally compared to SSM-only. However, cost for 2nd line treatment would increase by 59%, resulting in an overall expected 22% increase in total treatment costs. Compared to the SSM-only scenario, the Xpert-for-all scenario is predicted to result in a $253 million increase in total national costs for TB diagnosis and treatment.When applied to the whole country , the totThe mean diagnostic costs (for TB and rifampicin-resistant TB combined) per patient more than doubled for the Xpert-for-all scenario, from US$ 6.2 for SSM-only to US$ 16.4 , represeIn If all presumptive TB patients with negative bacteriological tests (SSM or Xpert) received CXR, the need for TB treatment, both for a true positive and false positive TB diagnosis, would increase in all scenarios Click here for additional data file.


Cardiac auto-regulation involves integrated regulatory loops linking electrics and mechanics in the heart. Whereas mechanical activity is usually seen as ‘the endpoint’ of cardiac auto-regulation, it is important to appreciate that the heart would not function without feed-back from the mechanical environment to cardiac electrical  and mechanical  activity. MEC and MMC contribute to beat-by-beat adaption of cardiac output to physiological demand, and they are involved in various pathological settings, potentially aggravating cardiac dysfunction. Experimental and computational studies using rabbit as a model species have been integral to the development of our current understanding of MEC and MMC. In this paper we review this work, focusing on physiological and pathological implications for cardiac function. In addition, in cardiac pathologies associated with changes in myocardial mechanical properties and function, MEC in particular can have deleterious effects on rhythm, contributing to atrial and ventricular arrhythmogenesis . Cardiaiewed in ), or intiewed in ). By thehythmias ).2Cardiac MEC and MMC occur at multiple levels of structural and functional integration in the heart (from subcellular to whole organ), in numerous cardiac cell types  cells, and – at least for MEC – fibroblasts), and are present in vertebrates spanning the scale from zebrafish to humans. The rabbit is a particularly relevant small animal model, as its regional patterns of myocardial deformation , cardiac3Studies in rabbit have been integral in forming our understanding of the relevance and mechanisms of cardiac MEC. MEC is thought to be important in both physiological and pathophysiological settings, with its role dependent on the region of the heart in which it occurs.3.12+ currents, and sodium (Na+)/Ca2+ exchanger current) and sarcoplasmic reticulum (SR) membranes  Caembranes . The resembranes .ex situ, confirming that intra-cardiac  mechanisms are involved.The ability of the SAN to respond rapidly to the heart’s haemodynamic status is the clearest  example of the physiological relevance of MEC in cardiac auto-regulation. This was recognised over one hundred years ago by Francis Arthur Bainbridge, who observed an acute increase in heart rate upon right-atrial volume-loading in anaesthetised dogs , an effeex situ preparation from various other mammalian species  to demonstrate that the instantaneous increase in beating rate (BR) was accompanied by an increased rate of diastolic depolarisation and a reduction in action potential (AP) amplitude, caused by a decrease in absolute values of maximum diastolic and maximum systolic potentials , stretch-sensitive ATP-inactivated potassium (K+) channels , cation non-selective stretch-activated channels , or to interfere with intra-cellular Ca2+ handling   . That starations .swell . Furthermore, cell inflation is mechanically different from axial stretch . Subsequent studies using hypo-osmotic swelling of spontaneously beating rabbit SAN cells showed that this intervention actually causes a reduction, rather than the anticipated increase, in BR (m dynamics) , a slowing of BR was seen with stretch . With ae, in BR . In conte, in BR B of spone, in BR , resultse, in BR . This inynamics) C, similaynamics) . Subsequr −11 mV  . The ro studies  demonstr GsMTx-4 . Of note stretch . This sp stretch .Vice versa, if BR is reduced by vagal stimulation , the chronotropic response to stretch is enhanced .While rabbit isolated SAN cell and tissue experiments suggest that humoral and extra- or intra-cardiac neuronal signalling may not be pre-required for the cardiac BR response to stretch, interactions between mechanical and autonomic rate control matter. In intact rabbit , as wellenhanced . It shouenhanced . At the enhanced . Even som is moving towards the threshold for AP initiation. Stretch-induced activation of depolarising currents, such as SACNS, could allow mechanical ‘priming’ of the SAN to adjust heart rate on a beat-by-beat basis in line with diastolic load. This would contribute to the matching of cardiac output to venous return (via beat-by-beat changes in instantaneous cycle length). Moreover, it appears that physiological loading may be essential to SAN automaticity, as slack or excessively stretched rabbit isolated SAN preparations tend to show no or irregular rhythms, respectively, while moderate preloads restore normal activity , which is the very time when SAN Vactivity . Interesactivity , as chanactivity .Evidence commensurate with these rabbit-derived insights into variation of heart rate with haemodynamic demand has been documented in humans. Heart rate fluctuates with the respiratory cycle, rising during inspiration (when reduced intra-thoracic pressure favours venous return) and declining during expiration (when venous return is impeded), a phenomenon known as ‘respiratory sinus arrhythmia’ . While generally considered to be a consequence of autonomic  nervous input, respiratory sinus arrhythmia continues to exist  in the transplanted (and thus denervated) heart . Experim3.2e.g., acute pulmonary embolus or myocardial ischaemia), transient , and chronic  settings . The most common sustained arrhythmia encountered in humans is atrial fibrillation (AF) – in no small part because, in contrast to ventricular fibrillation (VF), it is not instantaneously lethal . While settings .Atrial stretch is thought to be involved in both the initiation and maintenance of AF . The isoUsing high-density mapping during acute right atrial dilatation by balloon inflation in isolated rabbit hearts, a global decrease of conduction velocity with stretch has been observed . This slNS)   , suggestptomycin  . The sostretch) . Alternas TREK-1 ), cause s TREK-1 .+ channel block by flecainide  or ranon rabbit  suppress sotalol ).The importance of atrial stretch in the genesis of AF, as demonstrated in the rabbit, translates to humans, as large clinical trials established left atrial enlargement as an independent risk factor for the development of the disease . The fac3.3As in the atria, MEC responses described in the ventricles mostly have been pro-arrhythmic, with stretch altering conduction and refractoriness, causing premature ventricular excitation (PVE) and contributing to sustained arrhythmias. This may be important in a host of cardiovascular diseases where alterations in myocardial mechanical properties may, through MEC, contribute to the electrophysiological changes responsible for arrhythmogenesis. Thus, ventricular tachyarrhythmias are frequently encountered in pathologies associated with volume or pressure overload, or changes in tissue mechanics, such as valve disease, cardiomyopathy, heart failure, hypertrophy, ischaemia, and infarction . Conceptm in ventricular tissue), ventricular tachycardia or VF may be induced .In the context of intra-ventricular balloon inflation, it is important to note that even in the setting of a global increase in volume there may be spatially heterogeneous mechanical effects, as myocardial stiffness varies throughout the ventricles with anisotropy of structure, active contraction, and passive viscoelasticity. This is apparent from isolated rabbit heart studies demonstrating that an increase in intra-ventricular volume results in non-uniform stretch, which is associated with heterogeneity of depolarisation . As a coIn pathological states, this spatio-temporal dependence may be enhanced by heterogeneous changes in electrical and mechanical properties. In the ischaemic ventricle, arrhythmogenic effects of balloon inflation are increased during acute regional, but not global, ischaemia , again hNS in mechanically-induced excitation has been demonstrated by SACNS block with GsMTx-4 (+ channel block with flecainide has a similar effect on conduction during stretch). The increase in the frequency and complexity of VF with stretch is similarly attenuated by block of SACNS with streptomycin , which ulations . These ‘ulations  and impaulations .via eradication of the excitable gap by SACNS-induced depolarisation  can temporarily restore sinus rhythm . These o cordis  or by loo cordis , suggest4While rabbits have been important in investigating the sub-cellular basis of passive tension and stiffness with myocardial stretch , they ha4.1via BR), but for each side of the heart individually as well. Left and right ventricular output must be matched precisely to their individual input , as otherwise blood would be pooled in the pulmonary or systemic circulation. This should by no means be taken for granted, yet it works perfectly fine even in heart transplant recipients.The FSL, by which stretch of myocardium results in an immediate increase in myofilament interactions and contractile force on the beat immediately following a mechanical stimulus , allows2+-sensitivity, crossbridge- and Ca2+-cooperativity, inter-filament spacing, and titin-mediated strain-effects on spatial interrelations of thick and thin filaments  and Na+/Ca2+ exchanger activity, angiotensin-II receptors 1 and 2, and protein kinase C (This immediate positive inotropic response to stretch A appearsilaments . Importa stretch ). While  stretch . It has esponses . Intact esponses . Rabbit esponses . Furtherkinase C , althougkinase C . For in-kinase C .4.22+ transient amplitude and contractile force, seen over a period of minutes after the initiation of sustained stretch. Based on studies in various species, numerous ion currents and signalling molecules have been implicated in the SFR   . Rabbit 2+ released on each beat, in rabbit papillary muscle inhibition of SR Ca2+ release (by ryanodine) (2+ release and uptake (by cyclopiazonic acid) . It has been shown in rabbit isolated ventricular muscle that the SFR is reduced by block of the Na+/H+ exchanger (by HOE 642 (N-methyl-N-isobutyl)-amiloride  (NS (by gadolinium), angiotensin-II receptor 1 (by CV 11974), or endothelin-A receptors (by BQ123) were shown to have no effect in one study (While the SR is the major source of intra-cellular Caanodine)  or combiic acid)  has no e HOE 642  or 5-(N-miloride ). The SFntration  or inhibnthidin) . In contne study , while bne study  or protene study  reduced ne study  and attene study .2+ secondary to altered flux via the Na+/Ca2+ exchanger, in part resulting from increases in intra-cellular Na+ concentration mediated by the Na+/H+ exchanger (by as yet poorly defined mechanisms). There may, however, be effects acting beyond modifications in Ca2+ handling at the level of the myofilaments, similar to that proposed for the FSL. It has been show in ultra-thin, intact right ventricular trabeculae from rabbit that the increase in myofilament Ca2+ with stretch results in part from increased phosphorylation of tropomyosin, troponin I, and myosin light chain-2, on a time scale that would implicate it in the SFR (rather than in the FSL)  .2+ spark rate . Experiractions ). This we.g., changes in posture or exercise) and with numerous pathologies , and requires the heart to respond with a rapid increase in cardiac output. For instance, the enhanced venous return that occurs with exercise  leads to increased volume of the cardiac chambers , as welexchange ) – may bexchange . This isIn this process, we expect to see improvements in the delineation of therapeutically-targetable subcellular structures and of mechanisms underlying pathological effects, such as mechano-transduction pathways  and the


Diffusion tensor imaging (DTI) experiments were performed and tract-based spatial statistics (TBSS) was used for data analysis. Fractional anisotropy (FA) was quantified across the whole brain. Profoundly reduced FA on the right side of sagittal striatum, posterior thalamic radiation (PTR), retrolenticular limb of the internal capsule (RLIC) and superior longitudinal fasciculus (SLF), and on the left side of PTR, middle temporal gyrus and inferior frontal gyrus were observed in the ketamine group compared to controls. Diminished white matter integrity found in either fronto-thalamo-temporal or striato-thalamic connections with tracts including the SLF, PTR, and RLIC lends support to similar findings from DTI studies on schizophrenia in humans. This study suggests that chronic ketamine exposure is a useful pharmacological paradigm that might provide translational insights into the pathophysiology and treatment of schizophrenia.Acute and repeated exposures to ketamine mimic aspects of positive, negative, and cognitive symptoms of schizophrenia in humans. Recent studies by our group and others have shown that chronicity of ketamine use may be a key element for establishing a more valid model of cognitive symptoms of schizophrenia. However, current understanding on the long-term consequences of ketamine exposure on brain circuits has remained incomplete, particularly with regard to microstructural changes of white matter tracts that underpin the neuropathology of schizophrenia. Thus, the present study aimed to expand on previous investigations by examining causal effects of repeated ketamine exposure on white matter integrity in a non-human primate model. Ketamine or saline (control) was administered intravenously for 3 months to male adolescent cynomolgus monkeys ( N-methyl-D-aspartate (NMDA) receptor antagonist, can be used to model aspects of positive, negative, and cognitive symptoms of schizophrenia in humans  study, it was reported that effects of chronic ketamine use on resting-state functional connectivity are coupled to increased activity in the frontal gyrus and decreased activity in the anterior cingulate cortex  were purchased from Yunnan Laboratory Primate Inc. and all experiments were conducted in full compliance with license from the Ethics Committee of Shandong University. The animals were bred from a colony of natural-habitat-reared M. fascicularis and were kept at Hongli Animal Center  in a room maintained at temperature of 25°C with a 12:12 h light-dark cycle. Monkeys were individually housed in stainless steel cages  with water available ad libitum and were allowed to have visual and auditory contact with each other. They were fed twice daily with whole grains diet , supplemented with fresh fruits each day. Rearing procedures had been reviewed and approved by the Animal Care Committee of Shandong University.Male adolescent cynomolgus monkeys (M. fascicularis at 4.12 ± 0.65 (mean ± standard deviation) years old . Based on studies by our group and others  or saline (control) was administered intravenously for 3 months to male adolescent 2) was performed in 25 non-collinear directions with 1 non-diffusion weighted image.DTI experiments were performed on a 3-T Signa Magnetic Resonance System (GE Company). Briefly, monkeys were anesthetized by intramuscular injection with ketamine (10 mg/kg) and xylazine hydrochloride . Tract-based spatial statistics  algorithm. TFCE method was adopted with a non-parametric approach of permutation test of 500 permutations . To locate the actual anatomical regions of those significant clusters in monkey, a diffusion tensor based white matter brain atlas for rhesus macaques was applied  was derived from diffusion data which quantifies how strongly directional a local tract structure is. In order to localize brain changes, group comparison of FA-value was performed between control group and ketamine group  between ketamine group and controls in the right side of sagittal striatum , posterior thalamic radiation , middle temporal gyrus white matter , inferior frontal gyrus WM , retrolenticular limb of the internal capsule , and superior longitudinal fasciculus .Group comparison between chronic ketamine administration group and controls revealed seven different anatomical regions, where the ketamine group had FA-values significantly lower than that of the control group. The anatomic location and size of these clusters with peak p < 0.005, TFCE-uncorrected) in right SS in the ketamine administration group when compared with controls. In addition, the significant regions were located in the posterior region of the thalamic radiation. Both right and left PTR showed reduced FA (p < 0.005) in the ketamine administration group  in the right RLIC in the ketamine group compared with controls. SLF, the largest association bundles, connects to the cortex of the frontal, parietal, occipital and temporal lobes  in left side of IFG  and inferior frontal gyrus WM (IFG-WM), and also reduced FA in the right side of sagittal striatum (SS), RLIC, and SLF. More importantly, reduced integrity of fronto-thalamo-temporal or striato-thalamic white matter connectivity observed in this study is consistent with, and extend the previous clinical findings in chronic ketamine users.Our current DTI findings of abnormality in the IFG-WM and MTG-WM with chronic ketamine exposure in non-human primate are largely consistent with white matter tract patterns observed in previous clinical imaging studies of schizophrenia in humans , GL, DY, FP, DW, and PS contributed to design, acquisition, analysis, and interpretation of data for this work. QL wrote the draft for the manuscript. GL, HY, LS (7th author), and FP performed the experiments. LS (2nd author), FY, KL, QL, and DW prepared all figures and image analysis. NW, GL, HY, LS (2nd author), and PS revised and edited the manuscript. PS approved the final draft of the manuscript. All authors reviewed the manuscript for intellectual content and approved submission.Research reported in this publication was supported by a National Natural Science Foundation of China (NSFC) grant (NO. 81300987).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.


The success of prevention of mother to child transmission programs over the last two decades has led to an increasing number of infants who are exposed to human immunodeficiency virus (HIV), but who are not themselves infected . Although the morbidity and mortality among HIV-exposed, uninfected infants is considerably lower than that among HIV-infected infants, they may remain at increased risk of infections in the first 2 years of life compared with their HIV-unexposed peers, especially in the absence of breastfeeding. There is some evidence of immunological differences in HIV-exposed, uninfected infants, which could play a role in susceptibility to infection. Cytomegalovirus (CMV) may contribute to the increased immune activation observed in HIV-exposed, uninfected infants. Infants born to HIV-infected women are at increased risk of congenital CMV infection, as well as early acquisition of postnatal CMV infection. In infants with HIV infection, CMV co-infection in early life is associated with higher morbidity and mortality. This review considers how HIV infection, HIV exposure, and CMV infection affect infant responses to vaccination, and explores possible immunological and other explanations for these findings. HIV-infected infants have lower vaccine-induced antibody concentrations following tetanus, diphtheria, pertussis, hepatitis B, and pneumococcal vaccination, although the clinical relevance of this difference is not known. Despite lower concentrations of maternal-specific antibody at birth, HIV-exposed, uninfected infants respond to vaccination at least as well as their HIV-unexposed uninfected peers. CMV infection leads to an increase in activation and differentiation of the whole T-cell population, but there is limited data on the effects of CMV infection on infant vaccine responses. In light of growing evidence of poor clinical outcomes associated with CMV infection in HIV-exposed, uninfected infants, further studies are particularly important in this group. A clearer understanding of the mechanisms by which maternal viral infections influence the developing infant immune system is critical to the success of maternal and infant vaccination strategies. Immunization is essential to global strategies to reduce infant mortality, especially in low-resource settings where infectious morbidity and mortality remain high , 2. In rIn 2015, there were 1.4 million pregnant women living with HIV , and an The expansion of PMTCT programs in the last two decades, and continued high numbers of HIV-infected women who become pregnant, have led to an increase in the number of HIV-exposed, uninfected infants, who now represent up to 30% of births in some parts of Southern Africa . CompareCytomegalovirus is the most common congenital infection worldwide, affecting up to 1.2% of live births in developing countries. Although CMV infection is thought to lead to immune senescence and a poor response to the influenza vaccine in the elderly , it is nThis review summarizes the evidence for alterations in infant vaccine responses associated with exposure to maternal HIV and CMV infection, and explores possible immunological and other explanations for these findings.A literature search of English language publications was performed using Medline. Key search terms included: maternal, fetal, neonate, HIV, CMV, vaccination, and immunization. The full search strategy is detailed in Table S1 in Supplementary Material. A formal systematic review was not undertaken; how-ever, we sought to carry out a comprehensive review of the published literature. We screened titles and abstracts, selecting all articles with outcomes that included infant immune responses to routine Expanded Program on Immunizations vaccinations following antenatal exposure to either maternal HIV or CMV infection, or both.Studies of HIV-infected infants in which the majority of participants received ART were selected when possible, for three main reasons: (1) ART is associated with increased magnitude and quality of infant antibody responses to vaccines –10; (2) The published literature shows some heterogeneity in the differences in concentrations of specific immunoglobulin (Ig) G and proportion of infants protected following primary and booster doses of routine vaccines in HIV-infected infants receiving ART compared with HIV-unexposed infants Table .Following primary immunization, HIV-infected infants aged 20 weeks had significantly lower specific antibody concentrations to tetanus, diphtheria, pertussis and hepatitis B surface antigen (HBSAg), than HIV-unexposed infants in a South African study . HoweverPneumococcal conjugate vaccine (PCV) antibody concentrations were lower in HIV-infected infants after the first and second PCV doses , but aftp < 0.01), and a lower proportion had protective antibody levels than HIV-unexposed infants   had 42% lower neutralizing antibody responses at 18 months ( < 0.01) .Following measles vaccination at age 9 months, there was no significant difference in measles-specific IgG levels at 24 months in HIV-infected infants compared with HIV-unexposed infants in a study from South Africa, and no difference in the proportion of infants with protective antibody levels .p < 0.001), HBsAg , and pertussis  (p ≤ 0.008) and measles  , 10. Sim measles , 10.In a study in South Africa, in which mothers received PMTCT and infected infants (diagnosed at 6 weeks) were not breastfed and did not receive ART, T-cell responses to BCG in HIV-infected infants were compared with those in HIV-unexposed infants . After BBoth maternal and infant factors are likely to be involved in the observed differences in antibody and cellular responses to vaccines seen in HIV-infected compared with HIV-unexposed infants . In HIV-p < 0.01). Differences in breastfeeding duration in HIV-infected and unexposed groups were not stated in the other studies described earlier, although in four of the studies, infants were co-enrolled in the CHER trial in South Africa, a randomized controlled trial evaluating antiretroviral treatment strategies, in which only 14% of infants were breastfed  at 18 months of age, increasing breast-feeding duration was associated with increasing poliovirus antibody level . In thisreastfed . Short dreastfed –33.A recent review of the effects of maternal nutritional status on infant vaccine responses concluded that maternal macro- and micronutrient deficiency during pregnancy is likely to impair infant responses to vaccines, even in the presence of nutrient supplementation .Increased exposure to opportunistic infections through breastfeeding  or close contact with HIV-infected mothers who may have co-infection may affect immune responses in HIV-infected infants. In HIV and CMV co-infection, infants have accelerated HIV progression, increased mortality, growth delay and cognitive impairment, compared with HIV-infected infants without CMV . In MalaIn summary, HIV-infected infants receiving ART may have impaired ability to mount quantitatively and qualitatively ade-quate antibody responses to vaccines compared with HIV-unexposed infants. The clinical effect of impaired vaccine responses on morbidity from vaccine-preventable disease is not known. Shorter breastfeeding duration, poorer nutritional status and increased exposure to co-infections in HIV-infected infants may be contributing factors, and their impact requires further investigation to fully understand the mechanisms underlying the changes in vaccine responses in HIV-infected infants. CMV infection is almost ubiquitous in low-resource settings, and its clinical effects on infants with HIV suggest it is having an important effect on the immune system, and could be an important modifiable factor in reducing morbidity and mortality of HIV-infected infants.Detailed studies in HIV-exposed, uninfected infants have demonstrated differing patterns of antibody responses to vaccines compared with HIV-unexposed infants Table , and revAfter three doses of pertussis-containing vaccine, antibody levels in HIV-exposed, uninfected infants were two to seven times higher than in unexposed infants , 29, 37.p < 0.05)  . One stu < 0.05) , 39.In studies in South Africa, HIV-exposed, uninfected infants who received all three doses of PCV had significantly higher antibody concentrations at 16 and 20 weeks , 29, altThe increased antibody responses to the initial doses of Hib, tetanus, and other vaccines can be explained by reduced interference from maternally derived antibody in HIV-exposed, uninfected infants. Before vaccination, HIV-exposed, uninfected infants consistently had lower antibody concentrations against PCV (seven serotypes), pertussis, Hib, and tetanus in a number of studies , 29, 37.p = 0.002)  . The oth= 0.002) . Pre-vac= 0.002) , 37.2 10.93, df = 1) and very good responders  at 7 months, compared with HIV-unexposed infants in Brazil   . The res< 0.001) .In summary, typically vaccines for which the antibody concentration is lower before vaccination result in higher concentrations after vaccination. This is true for only the first one to two doses of Hib and tetanus vaccines, but persists to the end of the course of PCV and pertussis. For all four vaccines there is reduced maternal trans-placental transfer of antibody . There aMycobacterium tuberculosis (M. tb) sensitization at time points between 6 weeks and 12 months  in one study, even after adjusting for differences in birthweight, breastfeeding, and gestational age . HoweverHuman immunodeficiency virus-exposed, uninfected infants are exposed to antenatal factors that might affect both their antibody and T-cell responses to vaccines. There is compelling evidence that in mothers with HIV infection, less IgG is transferred across the placenta than in HIV-uninfected mothers, resulting in lower pre-vaccination levels of IgG specific to several vaccines , 29, 37.in utero and early infancy. HIV-exposed, uninfected infants may have a smaller thymus, which has been associated with immune abnormalities in early infancy  infects B-cells, and EBV-infected infant IgG responses to measles vaccine and meningococcus A and C polysaccharide vaccine are reduced by approximately one third . In infap = 0.06), but not in HIV-exposed, uninfected infants. In HIV-infected infants antibody responses were reduced in CMV seropositive compared with CMV seronegative infants, although these results did not reach statistical significance (Gambian infants who acquired CMV antenatal or postnatally had no significant differences in anti-Hib or anti-tetanus toxoid IgG concentration measured compared with uninfected infants at 18 months . A studyificance .Human immunodeficiency virus-infected mothers in this study had a mean breastfeeding duration of 6 months compared with 15 months in HIV-uninfected mothers, and longer breastfeeding duration was associated with increased mean poliovirus antibody titers in infants . The autCytomegalovirus-infected infants show alterations in responses to measles and possibly polio vaccines, which are live vaccines, and no significant differences have been found in the responses to Hib or tetanus vaccines. Overall the ability to mount effective and lasting responses is preserved in otherwise well infants, at least in the short term, and responses to SEB indicate that some T-cell responses are increased in CMV infection. Interactions may occur between CMV and HIV or EBV to produce further alterations in vaccine responses, but there is still no significant impairment compared with CMV-uninfected infants. There is limited data on the effects of CMV infection on infant vaccine responses, and in light of growing evidence of poor clinical outcomes associated with CMV infection in HIV-exposed, uninfected infants, further studies are particularly important in this group.Human immunodeficiency virus-infected infants have some impairment in their humoral and cellular responses to routine immunizations. However, as many of the infants in the studies reviewed were born to mothers who started ART a short time before delivery as part of PMTCT programs, and were not exclusively breastfed, future studies will be needed to determine whether the same changes in immune responses are present when mothers and infants undertake optimal HIV treatment, PMTCT, and feeding practices. The clinical importance of these findings is unknown, as the risk of vaccine-preventable infection in HIV-infected infants compared with HIV-unexposed infants has not been determined.Human immunodeficiency virus-exposed, uninfected infants and those with CMV have alterations in their vaccine responses, but the evidence does not support changes to the vaccine schedule in these groups. Protecting infants from infection before their first vaccines, for example, by maternal immunization, is important in all infants, even more so in HIV-exposed, uninfected, and HIV-infected infants, who are less likely to be protected than HIV-unexposed infants. Maternal immunization is a key part of global efforts to reduce neonatal and infant infectious morbidity and mortality. A better understanding of the mechanisms by which maternal infection and immune responses influence the developing infant immune system are critical to ensuring the success of new vaccines.The theme and concept were designed by M-LN and CJ. OF undertook the literature review and wrote the original draft of the paper, which was reviewed and revised by CJ and M-LN.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.


Previous studies have confirmed that serum concentrations of actin-free Gc globulin (Af-Gc globulin) may provide prognostic information in patients withacute liver failure (ALF). However, until now the relation between plasma Af-Gc globulin levels and chronic or acute-on-chronic liver failure (CLF or ACLF) caused by HBV is unknown.Plasma Af-Gc globulin in 56 patients with liver failure, in 23 patients with compensated liver cirrhosis (CR), and in 25 healthy controls were measured using enzyme-linked immunosorbent assay (ELISA). Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), choline esterase (CHE), Albumin (ALB), total bilirubin (TBIL), palsma international normalized ratio of prothrombin time (INR), and platelet (PLT) were also detected. The Child-Pugh score was calculated for each patient on admission.Plasma Af-Gc globulin levels in CLF, ACLF and CR were significantly lower than that of healthy controls . The median (range) Af-Gc globulin level at admission for the liver failure (CLF or ACLF) was significantly reduced compared with that of CR group (P ≤ 0.001); additionally, there was significant difference between CLF and ACLF patients (P < 0.001). In liver failure cohort, plasma Af-Gc globulin was significantly positive correlated with ALB, ALT, AST and CHE . Meanwhile, there was significantly negative correlation between plasma Af-Gc globulin and Child-Pugh score (P = 0.02). The level of Af-Gc globulin in ascites or hydrothorax-infected liver failure patients were markedly lower than that of non-infected (P = 0.015), the levels of Af-Gc in encephalopathy presence were lower than in encephalopathy absence. No significant difference of Af-Gc was noted between non-survivors and survivors during the follow-up period in liver failure patients.Plasma Af-Gc globulin levels in liver failure patients are significantly reduced compared with compensated liver cirrhosis patients and healthy controls, however, it might not be used in the prognosis of liver failure. Liver failure is a severe end-stage liver disease, it always progress to multiple organ dysfunction (MOF) and is associated with high mortality -3. ResenGc globulin is a hepatically synthesized multifunctional protein, involved in scavenging of actin released from necrotic cells, binding and transporting vitamin D metabolites , 8 and nHowever, the pathophysiological process of chronic or acute-on-chronic liver failure (CLF or ACLF) is different from that of acute liver failure (ALF), the levels of plasma Gc globulin in these patients are not clear. In this study, we aimed to test a new fast enzyme-linked immunosorbent assay (ELISA) for determining actin-free Gc-globulin(Af-Gc globulin), we intended to investigate the association between the reductions of Af-Gc globulin and liver dysfunction in patients with chronic or acute-on-chronic liver failure.Fifty-six patients with liver failure , and 23 patients with compensated cirrhosis  between October 2007 and April 2008 at Tianjin Third Central Hospital were recruited. The study was approved by Tianjin Third Central Hospital Ethics Committee.The diagnosis of liver failure was made according to the Chinese Diagnostic and Treatment Guidelines for Liver Failure 2006) [06 [20], All the blood samples were collected in the morning when patients were admitted to our hospital. Blood collected in heparin was spun at 3000 r/min for 15 minutes, and the plasma obtained was immediately stored at -80 °C until Af-Gc globulin measurement was performed.The data of clinical investigations were collected when patients were referred to the hospital. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), choline esterase (CHE), Albumin (ALB), total bilirubin (TBIL), palsma international normalized ratio of prothrombin time (INR), platelet (PLT) were detected. Meanwhile, Child-Pugh scores were calculated on admission.Af-Gc globulin levels were determined in triplicate by use of a sandwich enzyme-linked immunosorbent assay technique that used a standardized protocol . Inter- and intra-assay variation coefficients were less than 5%.Data were presented as mean (range). To identify differences between groups, ANOVA and Mann-Whitney U tests were used. Correlations were analyzed by Spearman rank test. A P value of less than 0.05 was considered statistical significant. All analysis was performed by the Statistical Program for Social Sciences (SPSS 13.0 for Windows).The demographic data of the study populations were listed in Af-Gc globulin levels for the groups of CLF, ACLF, CR and healthy controls were shown in P = 0.015); No significant difference were noted in encephalopathy and GI bleeding . But a trend toward lower Af-Gc levels was seen in encephalopathy compared with non-encephalopathy in liver failure patients.Comparisons were examined in the liver failure patients (n = 56) to investigate the influence of complications to the levels of Af-Gc globulin . The levOf the 56 patients, the survival rate was 57.14% (32 patients) during 30 days follow-up. Liver failure is viewed as a net loss of functioning hepatocytes to the point that surviving hepatocytes cannot maintain adequate metabolic functions. This represents either a failure to regenerate after partial hepatectomy or accelerated destruction of hepatocytes from necrosis or apoptosis . AccordiGc globulin  belongs to the albumin superfamily of binding proteins, which includes Gc-globulin, albumin, α-fetoprotein, and afamin . Apart fACLF is defined as acute deterioration in liver function in a patient with preexisting chronic liver disease; CLF is different from ACLF, it develops into dysfunction gradually based on the liver cirrhosis. It is difficult to discriminate them in clinic. By this purpose, we compared the Af-Gc levels between CLF and ACLF, the result showed a statistically significant lower levels of Af-Gc in CLF than ACLF. For this, it can be seen that the measurement of Af-Gc may further help us to discriminate them.ALB, ALT, AST, choline esterase (CHE) is highly expressed in hepatic cells or synthesized by hepatocytes, and their levels or activities can directly reflect the state of liver function. Our study found that the levels of Af-Gc globulin in liver failure patients had a significantly positive relationship with ALB, ALT, AST, CHE, that is to say, the level of Af-Gc can also be used to evaluate the degree of hepatic injury.Child-Pugh score is the most widely-used liver functional assessment system for patients with liver disease. Our results showed Af-Gc globulin had a strong negative correlation with Child-Pugh score, so it can also be used as predictor of liver function. Antoniades et al  demonstrAscites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal bleeding and other serious complications will happen when the liver diseases progress to end-stage. In our study, we identified that some complications could influence the levels of Af-Gc globulin in liver failure patients. For example, we found that the Af-Gc levels were significantly lower in the ascites or hydrothorax-infected patients (60.96 mg/L) than that in the non-infected patients (104.47 mg/L). It was reported that the response of Gc-globulin involve in nonspecific immune defense function and it is markedly decreased in inflammatory . The aboThe distribution of Af-Gc levels in survivors and non-survivors during the follow-up period showed there was no significant difference between them in liver failure cohort. To better validate our finding, we chose to divide the liver failure patients into 2 subgroups (CLF and ACLF) on the basis of Diagnostic and treatment guidelines for liver failure in 2006 , 31, 32.In conclusion, to some extent, the measurement of plasma Af-Gc globulin can reflect the degree of hepatocellular necrosis, and it can be used to discriminate liver failure and non liver failure patients. Whereas the prognosis of liver failure patients were affected by many factors, and our data do not favor the levels of Af-Gc globulin as an independent predictor of mortality in liver failure patients (CLF and ACLF).The next step we can combine with other known prognostic markers to evaluate its role in the prognosis of liver failure. It is likely that deficiency of this protein plays an important role in the pathophysiology of liver failure and should be further studied in the future.


South Africa has one of the highest burdens of TB worldwide, driven by the country’s widespread prevalence of HIV, and further complicated by drug resistance. Active case finding within the community, particularly in rural areas where healthcare access is limited, can significantly improve diagnosis and treatment coverage in high-incidence settings. We evaluated the potential health and economic consequences of implementing community-based TB/HIV screening and linkage to care. Using a dynamic model of TB and HIV transmission over a time horizon of 10 years, we compared status quo TB/HIV control to community-based TB/HIV screening at frequencies of once every two years, one year, and six months. We also considered the impact of extending IPT from 36 months for TST positive and 12 months for TST negative or unknown patients (36/12) to lifetime use for all HIV-infected patients. We conducted a probabilistic sensitivity analysis to assess the effect of parameter uncertainty on the cost-effectiveness results. We identified four strategies that saved the most life years for a given outlay: status quo TB/HIV control with 36/12 months of IPT and TB/HIV screening strategies at frequencies of once every two years, one year, and six months with lifetime IPT. All of these strategies were very cost-effective at a threshold of $6,618 per life year saved (the per capita GDP of South Africa). Community-based TB/HIV screening with linkage to care is therefore very cost-effective in rural South Africa. South Africa has the highest incidence of TB/HIV co-infection in the world . Recent Studies have shown that community-based HIV testing with point-of-care CD4+ cell count testing is very cost-effective for HIV control in settings with high incidence, and can effectively link eligible HIV-positive individuals to ART , 8. HoweTo determine the cost-effectiveness of community-based TB and HIV screening and linkage to care in rural South Africa, we developed a mathematical model that incorporates the dynamics of both TB and HIV infection and treatment, as well as economic resource utilization and health burden. We parameterized the model with clinical and epidemiological data from South Africa to predict the number of TB, HIV, MDR-TB, and XDR-TB cases averted, as well as the number of life years saved, as a result of the screening program over a 10-year time horizon. We considered TB/HIV screening frequencies of once every two years, one year, and six months. Analyzed from the perspective of the South African Department of Health, we found that community-based TB/HIV screening with linkage to care was very cost-effective.To examine the potential impact of community-based TB/HIV screening and linkage to care over a 10-year period, we extended our previous model of TB and HIV transmission in a rural area of South Africa  to incluIn line with other models of TB infection , latent We modeled the early and late stages of HIV disease, mortality, and prevalence-dependent behavior change, as well as ART initiation and default. HIV-negative individuals can become infected with HIV at a rate proportional to the prevalence of HIV in the population , 22. ConWe take into account both the effect of HIV and ART on TB disease, as well as TB disease on HIV pathogenesis, such that disease progression and mortality rates depend on whether an individual is co-infected . OverallWe compared the impact of community-based TB/HIV screening and linkage to care over a 10-year time horizon on the disease incidence, mortality, and healthcare costs arising from drug-sensitive TB, MDR-TB, XDR-TB and HIV. Specifically, we compared a total of eight mutually exclusive strategies .e.g. cough lasting longer than two weeks, fever, night sweats, and/or weight loss), Xpert MTB/RIF , sputum smear, and/or chest x-ray. We assume the status quo TB case detection rate to be 72.5% [i.e. the percentage of suspected TB patients who receive microbiologic testing) for KwaZulu-Natal is estimated to be 80% [We evaluated the effectiveness of community-based TB/HIV screening and linkage to care relative to status quo TB and HIV control currently implemented in rural South Africa. In the baseline scenario, individuals with TB and/or HIV symptoms self-present to a healthcare facility for symptom detection  , 41, 42 We model a community-based TB/HIV screening and linkage to care program that combines HIV testing and counseling with TB testing . TB/HIV Individuals not yet eligible for ART (with a CD4+ cell count greater than 500 cells per milliliter) are linked to their local ART clinic for IPT, as well as regular CD4+ cell count monitoring , 8. We cThe WHO states that there is not sufficient evidence to conclude that IPT administration increases MDR-TB incidence via the generation of isoniazid mono-resistance , so we aEach modeled TB/HIV screening team consists of a professional nurse, two field health workers, and three counselors who screen between 1,800 and 4,800 individuals annually at community sites , costingWe considered the lifetime costs of TB and HIV detection and treatment among 90,000 adults in a rural South African setting. We performed the analysis over a 10-year time horizon from the perspective of the South African Department of Health, which is typically responsible for all medical costs in rural settings. Health burden was estimated with regard to the number of life years saved by an intervention strategy over the course of the lifetimes of the individuals in the population modeled. Costs and life years were discounted at an annual rate of 3%, following WHO guidelines . Costs wi.e. not optimal) if it costs more than an alternative strategy that is as or more effective.We calculated the incremental cost-effectiveness ratio (ICER) of the community-based TB/HIV screening and linkage to treatment strategies detailed above. The ICER of each strategy measures the additional cost per life year saved as the frequency of TB/HIV screening and/or the duration of IPT is increased. In accordance with WHO guidelines, we classified an intervention strategy as “very cost-effective” if its incremental cost-effectiveness ratio (ICER) was less than the South African per capita GDP in 2015  and as “cost-effective” if the ICER was less than three times the per capita GDP  , 57. Stri.e. life years saved) and the average intervention and healthcare costs, divided by the threshold cost-effectiveness ratio [i.e. was optimal at a given willingness-to-pay threshold).To assess the impact of parameter uncertainty on our cost-effectiveness analysis and to estimate the likelihood that a strategy would be optimal at a given willingness-to-pay threshold, we performed a probabilistic sensitivity analysis . We assiss ratio . We calcConsidering South Africa’s goal of screening all individuals once per year, we also performed a one-way sensitivity analysis to determine the impact of parameters on the cost-effectiveness ratio of annual TB/HIV screening. Specifically, we calculated the ICER of annual TB/HIV screening with 36/12 months of IPT and lifetime IPT at the minimum and maximum value of each parameter  to deterUnder status quo TB/HIV control—including Xpert implementation, 36/12 months of IPT for HIV-infected individuals on ART, and MDR-TB care decentralization—annual total TB incidence would be reduced from 868 per 100,000 to 298 cases per 100,000 population  after 10When the community-based TB/HIV screening and linkage to care intervention was implemented under current 36/12 months IPT guidelines, annual total TB incidence was reduced to between 274 per 100,000 to 233 cases per 100,000 population, for screening frequencies between once every two years and every six months . Annual We first estimated the additional discounted costs associated with community-based TB/HIV screening and linkage to care, as well as the discounted life years (LYs) saved, at screening frequencies of once every two years, one year, and six months, relative to status quo . Under si.e. strategies which conferred the maximal benefit for a given outlay): status quo with 36/12 months of IPT; TB/HIV screening every two years with lifetime IPT; TB/HIV screening every year with lifetime IPT; and TB/HIV screening every six months with lifetime IPT. All three TB/HIV screening strategies involving 36/12 months of IPT were dominated relative to the TB/HIV screening strategies with lifetime IPT (i.e. they cost more and conferred fewer life years than the combination of lifetime IPT strategies), as was status quo detection with lifetime IPT relative to status quo detection with 36/12 months of IPT. ICERs estimated for the four efficient strategies were all significantly below the South African per capita GDP of $6,618, suggesting that even the most frequent program of TB/HIV screening with lifetime IPT would be very cost-effective by South African standards. When considered separately from strategies with lifetime IPT, all three screening strategies involving 36/12 months of IPT were very cost-effective at a threshold of $6,618.Cost-effectiveness analysis  identifii.e. maximizing net health benefits and number of life years saved for a given outlay) relative to the other strategies at different willingness-to-pay thresholds . The ICER of annual TB/HIV screening was not sensitive to variation in TB or IPT parameters, including status quo TB incidence or linkage to TB care. We found that even if expanded IPT coverage increased isoniazid resistance or the sensitivity of Xpert for detecting XDR-TB was improved, community screening interventions would remain cost-effective. Finally, TB/HIV screening remained very cost-effective when ART eligibility was expanded to all HIV-infected individuals.Using one-way sensitivity analysis, we investigated the extent to which the ICER for annual TB/HIV screening and linkage to care was impacted by variation in parameters Figs  and 4. FWe found that community-based TB/HIV screening with linkage to care is a very cost-effective approach for reducing the burden of both diseases in South Africa. When the intervention was implemented over 10 years, total TB incidence was reduced to as low as 298 cases per 100,000 population and HIV incidence to 0.8%, while simultaneously decreasing both MDR and XDR-TB incidence. For the country as a whole, this integrated community-based intervention could save as many as 31.8 million life years.The intervention remained very cost-effective even when status quo guidelines extended IPT from 36/12 months to lifetime or expanded ART eligibility from CD4+ cell count below 500 cells per milliliter to all HIV-infected individuals. Although we found that screening strategies of once every two years, once every year, or once every six months were all cost-effective, annual screening is most practical for implementation in rural settings. Accordingly, an aim of the South African Department of Health is to screen individuals for TB on an annual basis.Although the intervention remained very cost-effective across entire ranges of plausible values, its cost-effectiveness was most influenced by variation in cost per person screened, as well as status quo HIV prevalence and ART coverage. In such settings where ART coverage is high or HIV prevalence is low, a smaller pool of untreated individuals is available in the community. Therefore a lower return for screening effort would be expected, thus increasing the cost per HIV positive or TB positive diagnosed and linked to care. In general, community-based TB/HIV screening is best suited to settings with high prevalence of both diseases, and where treatment coverage is suboptimal, as is the case currently in South Africa and many parts of sub-Saharan Africa.Although increasing the cost per person screened unsurprisingly reduced the efficiency of the intervention, the ICER remained below the cost-effectiveness threshold for cost-effectiveness even if screening costs were doubled beyond our base costs parameterized from pilot implementation in rural South Africa. It is not until screening costs exceed 10 times the base cost that the intervention would no longer be cost-effective. We found the cost-effectiveness of annual TB/HIV screening to be robust to variation in TB incidence or treatment parameters, as well as IPT efficacy and adherence parameters. Because TB treatment costs constitute a fraction of total TB/HIV related healthcare costs, even when accounting for expensive drug resistant TB diagnosis and treatment costs, the costs of integrated TB/HIV healthcare will not be substantially affected by changes in TB costs alone. Furthermore, the cost-effectiveness of the community-based TB/HIV screening and linkage to care program was also unaffected by changes in status quo XDR-TB detection. While a smaller pool of undetected XDR-TB cases would be expected if improved Xpert technology were available for status quo XDR-TB diagnosis, overall status quo health care costs would also rise as additional XDR-TB cases are treated and the relative increase in cost per XDR-TB case diagnosed by the intervention would not push the ICER past the South African cost-effectiveness threshold.Overall, screening strategies with lifetime IPT dominated strategies of the same frequency shorter IPT duration, supporting a South African policy change to extend IPT to lifetime. The benefit of lifetime IPT with status quo TB/HIV control can be attributed to the reduction in drug-sensitive TB incidence achieved by extending IPT duration. Furthermore, lifetime IPT also improves the impact of the community-based TB/HIV screening intervention in two ways. Firstly, TB incidence is reduced via expanded IPT coverage in a population with higher CD4+ cell counts who would otherwise not receive IPT. Secondly, patients with high CD4+ cell counts are identified and engaged in HIV care at an earlier stage of disease, minimizing the delay in initiating ART after becoming eligible. This reduces HIV incidence, because patients successfully treated with ART are much less likely to transmit HIV. Although this benefit was slightly diminished when status quo ART eligibility was extended to all HIV-infected individuals, community-based TB/HIV screening remained very cost-effective.As with other modeling studies, the validity of our analysis is limited by the data available from epidemiological and clinical studies for parameterization. Nonetheless, sensitivity and uncertainty analyses where all model parameters were varied across plausible ranges demonstrated that our cost-effectiveness results are robust to parameter uncertainty. TB and HIV control in South Africa has also been rapidly evolving over the past decade, so “status quo” control strategies, guidelines, and technologies are likely to continue improving. Therefore, we evaluated the two most likely scenarios for South African policy change: increasing the duration of IPT administration to lifetime and expanding ART eligibility to all HIV-infected individuals, as have been recently recommended by the WHO. We additionally explored the impact of high status quo TB and HIV treatment coverage on our cost-effectiveness results in the sensitivity analysis.Our results support community-based TB/HIV screening with linkage to TB and HIV care. This intervention has the potential to substantially reduce TB and HIV incidence simultaneously by expanding ART, IPT, and both first- and second-line TB treatment coverage. A number of recent studies have shown that home or community-based HIV testing and counseling is very effective and cost-effective in rural South Africa, with the potential to substantially reduce HIV incidence and associated mortality , 60–64. S1 TextSupplementary methods, figures, and tables.(DOCX)Click here for additional data file.