Corynebacterium glutamicum and a newly created model of Phaeobacter inhibens.Genome-scale metabolic models are of high interest in a number of different research fields. Flux balance analysis (FBA) and other mathematical methods allow the prediction of the steady-state behavior of metabolic networks under different environmental conditions. However, many existing applications for flux optimizations do not provide a metabolite-centric view on fluxes. Metano is a standalone, open-source toolbox for the analysis and refinement of metabolic models. While flux distributions in metabolic networks are predominantly analyzed from a reaction-centric point of view, the Metano methods of split-ratio analysis and metabolite flux minimization also allow a metabolite-centric view on flux distributions. In addition, we present MMTB (Metano Modeling Toolbox), a web-based toolbox for metabolic modeling including a user-friendly interface to Metano methods. MMTB assists during bottom-up construction of metabolic models by integrating reaction and enzymatic annotation data from different databases. Furthermore, MMTB is especially designed for non-experienced users by providing an intuitive interface to the most commonly used modeling methods and offering novel visualizations. Additionally, MMTB allows users to upload their models, which can in turn be explored and analyzed by the community. We introduce MMTB by two use cases, involving a published model of  Genome-scale metabolic models are important tools for systems biology. They are used in various fields, e.g. in metabolic engineering, the identification of potential drug targets, and as knowledge libraries to understand the behavior of biological systems in detail . In thesFlux balance analysis (FBA) allows the prediction of the steady-state condition of the metabolic network of an organism under different environmental conditions . MetabolAs most applications for flux optimization focus on a reaction-centric point of view, they pay little attention to metabolite fluxes. Only a small number of previous studies showed the benefit of analyzing models from a metabolite-centric point of view, e.g. for the discovery of new drugs ,7. TherePhaeobacter inhibens DSM 17395, an ideal model organism for basic research and elucidation of stress responses because of its metabolic versatility. Experimental data for degradation pathways of different carbon sources based on metabolome and proteome measurements have been determined for P. inhibens DSM 17395 in previous studies by us and others [P. inhibens DSM 17395 are applicable for metabolic modeling. Metabolic modeling is used for a variety of applications, ranging from biotechnological applications to ecological questions . A well-d others ,12,13,14d others ,16. Protd others ,17,18. Dd others . More red others ,21. ThusCorynebacterium glutamicum DSM 20300, a widely used biotechnological production strain that was originally isolated as an l-glutamate-producing bacterium [C. glutamicum has been metabolically engineered for the production of other amino acids, organic acids, alcohols, and polymers [The second model system of this study is acterium  and is uacterium . Furtherpolymers . In this study, we present Metano, an open-source command-line toolbox for metabolic modeling, and MMTB, a web-based interface to Metano that comes with an integrative database of biochemical reactions and genome annotations. While Metano was developed for a more versed audience, MMTB was designed especially for inexperienced users or users without a strong background in bioinformatics. C. glutamicum to verify the accuracy or capability of the toolbox. In a second step, we used the TDA-negative mutant strains of P. inhibens DSM 17395, with optimal growth on three different amino acids to reconstruct a metabolic model for P. inhibens DSM 17395, based on genomic and experimental data. FBA was performed to analyze the carbon flux in the wild-type strain compared to the TDA-negative mutant strains with respect to carbon loss and growth inhibition by TDA. MMTB methods provided a metabolite-centric view on the model to determine changes in the intracellular carbon flux under different growth conditions.We applied Metano methods to the published model of Metano is a Python-based command-line tool for the analysis of stoichiometric models. Several features can be accessed online via the MMTB. Prominent examples of constraint-based metabolic modeling software include COBRA , FASIMU While flux distributions in metabolic networks are conventionally analyzed from a reaction-centric point of view, the Metano methods of split-ratio analysis and metabolite flux minimization (MFM) allow a metabolite-centric view on flux distributions . Split-rThe Metano toolbox includes several features for flux optimization and is optimized for processing speed. In addition to the common FBA algorithm, Metano implements the fastFVA algorithm for FVA . MetabolIn addition to the widely used SBML format, Metano models can be represented by simple lists of reactions that are readable by humans and can be easily modified by the user with any text editor. An additional parameter file sets the constraints for a simulation scenario so that the variables, e.g., substrate boundaries and objective function, are detached from the model itself. Easy exchange of models is ensured by offering export and import tools for the widely accepted standard format SBML .Metano Modeling Toolbox (MMTB) is a web-based tool for the generation and analysis of metabolic models. MMTB closes the gap between BKMS-react  and EnzyOn the one hand, MMTB assists during model creation. The key feature is an intuitive search tool that gives access to reaction and metabolite information. The user can search for reactions by either entering parts of the biochemical reaction, EC numbers, database IDs, or by selecting a BRENDA, MetaCyc, or KEGG pathway. The resulting reactions originate from the integrative database BKMS-react  that incOn the other hand, MMTB assists during model analysis via an interface to the Metano toolbox. The user can upload a metabolic model and apply one of the following analysis methods: (1) FBA, (2) FVA, (3) dead-end analysis, (4) split-ratio analysis, (5) metabolite flux minimization, (6) a metabolite-centric visualization that shows the network as an interactive bipartite graph with consuming and producing metabolite fluxes, (7) a model verification tool where all metabolites in the uploaded model are replaced by their recommended names from BKMS-react. Because misspelled metabolites or synonyms are not treated as identical metabolic nodes, this unique method helps to avoid mistakes. Additionally, MMTB has a model exchange platform, where users can upload and publish their own models. These models can be viewed, analyzed, visualized, and downloaded, thus promoting the reuse of models that are already published. A model conversion tool for SBML and JSON models allows the use of models that were generated with other software. C. glutamicum model iMG481 that consists of 550 reactions [The Metano modeling toolbox was evaluated using the published eactions . The onl−1, as well as key fluxes described in the paper. Furthermore, the MFM method revealed that of a total of 408 metabolites, 195 were not essential for biomass production of 95% of the optimal value. When the biomass function is restricted to 10%, 205 metabolites are non-essential. By using the Metano toolbox, we were able to reproduce the in silico growth on glucose as it was described by Graf and colleagues. When using maximal biomass production as objective function, Metano was able to reproduce the growth rate of 0.337 hThe model iPin571 was manually assembled with the assistance of the MMTB database of metabolic reactions and the integrated EnzymeDetector annotation . The modl-phenylalanine as the precursor for TDA biosynthesis, (2) l-alanine as an amino acid with immediate access to the central carbon metabolism, and (3) l-leucine as an amino acid with a more complex degradation pathway, slower growth, and a reduced TDA production compared to l-alanine. TDA-negative strains (Δ262-kb plasmid-cured and tdaE transposon mutant strains) were cultivated as a reference to compare optimal growth with inhibited growth, and furthermore, to analyze the influence of carbon loss due to secreted metabolites. Nine of the proteinogenic amino acids were previously analyzed with respect to growth physiology and degradation pathways . For theThe model iPin571 was able to simulate growth for the TDA-negative mutants on different carbon sources and the wild-type strain on leucine . l-phenylalanine, indicating reduced carbon yields due to TDA biosynthesis , 1.3-fold (l-leucine), and 1.6-fold  higher compared to that of the wild-type strain. The tdaE transposon mutant strain showed almost the same growth yields as the Δ262-kb mutant strain, indicating that the lower growth yields of the wild-type strain were connected to the inhibitory effect of TDA with a necessity for an increased respiratory activity resulting in more carbon loss by CO2 production [The wild-type strain showed the lowest growth yields on each of the amino acids as a nutrient, especially on ynthesis . Growth n source . The grooduction ,21.2 , and cells were transferred at least for one adaptation cycle in the respective amino acid before inoculating the main cultures. All main experiments were conducted with three biological replicates in 500 mL Erlenmeyer flasks with three baffles at 150 rpm and 28 °C in an orbital incubator as previously described [g for 5 min. Cells were re-suspended in 3.7% sodium chloride and split to get 1–3 mg cell dry weight (CDW) for DNA, RNA, protein and polyhydroxybutyrate (PHB) each, 10–30 mg for lipid and 10–30 mg for determination of CDW  as previously described . For detn of CDW .iMG481 was obtained from the The metabolic model iPin571 was reconstructed based on genome and experimental data [The metabolic model tal data ,17,18,46tal data . We inclMetano is a software toolbox for metabolic modeling implemented in the Python programming language. Metano is easily extensible by prospective functional extensions via well-documented interfaces in a structured object-oriented framework. This allows the adaptation of the software to different requirements by users with basic programming skills. Additionally, all functionalities of Metano can be accessed by standalone Python programs via the command line, without the need to write programs. The Metano toolbox implements many well-established analysis tools, including FBA, FVA, MOMA, knockout simulation, and dead-end analysis . AdvanceMFM first performs a standard FBA and then adds a variability analysis comparable to FVA by the following algorithm: (1) Set a constraint for the objective function (default 95% of FBA flux). (2) Generate coefficient vectors expressing the (producing) metabolite fluxes as linear combinations of the reaction fluxes. (3) Perform linear programming with the linear objective functions defined by these coefficient vectors to successively minimize each objective function.Split-ratio analysis computes the split ratios for the fluxes entering and leaving each metabolite as totals fluxes and percentage values. This method is used to calculate the network and label edges and nodes for the visualization available at MMTB.github.com/JuliaHelmecke/metano (accessed on 9 Febraury 2021).All methods are described in more detail on the software website and in the Metano includes interfaces to numerous freely available solvers for mathematical optimization problems. For linear programming, the supported solvers are lp-solve and the GNU Linear Programming Kit (GLPK), interfaced to Python via Swiglpk and PyMathProg, respectively. Quadratic programming problems are solved by using the quadratic cone program solver of CVXOPT, interfaced via CVXPY.mmtb.brenda-enzymes.org (accessed on 9 Febraury 2021)). Metano does not rely on commercial software packages and can be installed on various Linux distributions via the Python Package Index (PyPI) and the related package installation system pip. A current version of Metano is also available for OS-independent use as a Docker image on Docker Hub.The software is published under the GNU General Public License version 3 and is available via the MMTB website (


Scheduled naps in the workplace are an effective countermeasure to drowsiness in safety-sensitive industries. This quasi-experimental study with a one-group, pre- and post-test design aimed to examine the effects of scheduled naps on nurses working 12-h shifts. Nurses in two pediatric intensive care units at a tertiary hospital were provided 30-min scheduled nap opportunities during their shifts. A total of 38 nurses completed pre- and post-test work diaries for sleepiness, fatigue, work demands and pace, and quality of nursing care at the end of each shift. The drowsiness of 13 nurses was continuously assessed during their shifts using infrared reflectance oculography. Nurses who reached naps reported improved levels of fatigue on the first night shift and better quality of nursing care the second night and day shifts post-test, while nurses who did not reach naps showed no significant improvements. The oculography successfully assessed drowsiness during 73% and 61% of the pre- and post-test total work hours, respectively. The total cautionary and cautionary or higher levels of drowsiness decreased. Nurse managers should consider scheduled naps in clinical settings to improve nurses’ alertness during their shifts. To provide patient care around the clock, hospital nurses often have nonstandard work schedules, including shift rotation and extended work hours. In Korea, many hospital nurses work traditionally in a rotating 8-h shift system . Due to Robust research indicates that extended work hours result in increased fatigue and drowsiness among nurses. Individuals working long work hours combined with rotating shift schedules experience more frequent sleep problems, which have detrimental effects on workers’ cognitive functioning and are well-known risk factors for decreased worker and patient safety . CurrentOne potential strategy to reduce workplace fatigue and drowsiness of nurses working 12-h shifts is to provide a scheduled nap opportunity . Since tTo prevent drowsiness-related injuries and accidents, it is essential to accurately assess drowsiness. Although previous research has successfully used subjective measures of drowsiness and sleepiness ,11, selfThe goals of this study were to conduct a scheduled nap intervention as a countermeasure of nurse drowsiness/fatigue in the middle of 12-h (day and night) shifts for intensive care unit (ICU) nurses and to examine whether there was an improvement in drowsiness and nursing care quality. We utilized both subjective and objective measures of drowsiness.This was a quasi-experimental study with a one-group pre- and post-test design. It was conducted in two pediatric ICUs at a tertiary hospital in Seoul, South Korea. Site one was a surgical ICU that primarily cares for children with congenital heart anomalies and those who have undergone heart surgery. Site two treats children with medical problems . The two units were selected because they have implemented 12-h shift schedules since 2012, unlike the traditional 8-h work schedule of most Korean hospitals.All participants provided written informed consent. The study protocol was approved by the Institutional Review Board of the study hospital (IRB number No. S2017-0696).Inclusion criteria were ICU nurses who provided direct patient care, had at least one year of experience as a registered nurse, and were working 12-h shifts, including nights . A total of 45 nurses  voluntarily participated in the study at baseline. After seven nurses withdrew from the study , 38 nurses completed the post-test measures . Among the participants, 13 nurses voluntarily agreed at baseline to wear infrared reflectance (IR) oculography  . None ofParticipants were asked to maintain normal sleep patterns and work behaviors during the study period, without restrictions on caffeine consumption or other sleep-related behaviors.The pretest measures were conducted from August–October of 2017. The study nurses were provided with a six-day work schedule of night-night-off-off-day-day at least once during the data collection period. All participants completed work diaries during their work schedule. The 13 nurses who volunteered to wear the oculography were monitored for their real-time drowsiness when working the two night- and two day-shifts of the six-day schedule.The scheduled napping began in November of 2017. The principal investigator met with all of the participants and each nurse manager and provided information about the risks of nurse drowsiness and sleepiness, the scientific basis for napping, and general sleep improvement strategies. This 30-min sleep education session was designed to help nurses recognize the importance of sleeping and resting, to correct personal sleep hygiene behaviors and habits, and to maximize intervention effectiveness .The post-test measures were conducted in January–March of 2018. All participants completed work diaries for the two night- and two day- shifts of the six-day work schedule , as did the 13 volunteers who wore the oculography. At the end of the post-test data collection, nurse managers and staff nurses were interviewed about their napping experiences.A total of 38 nurses completed the pre- and post-test work diaries. At the end of each shift, nurses were asked to report their levels of severe sleepiness and fatigue, physical and psychological work demands, work pace, and quality of nursing care provided during the shift. Each was measured using a range of scores from 1 (never) to 10 (extremely): “Please rate the highest levels of sleepiness/fatigue/physical work demands/psychological work demands/work pace/quality of nursing care provided that you perceived during the shift, respectively.” Single-item measures, often used in sleep and work diaries to reduce respondent burden, have an acceptable measurement validity ,19,20,21Using IR oculography, the 13 nurses’ drowsiness levels were continuously assessed during work. Oculography monitors eye and eyelid movements, which are controlled by the central nervous system. When people get drowsy, the central nervous system inhibits muscles and increases the velocity and duration of blinks and other eyelid closures. The participants wore a special pair of eyeglasses ) frames with IR transducers attached in the arm and positioned below and in front of the eye. These measured the duration of the separate components of eye blinks and other eye and eyelid movements. An oculography system can unobtrusively and continuously measure real-time drowsiness without electrodes or wires to infuse power. Johns Drowsiness Scale (JDS) scores were calculated and provided based on several variables, including the relative velocity and duration of blinks and other eyelid closures. JDS scores range from 0  to 10 (very drowsy), with a score of 4.5–4.9 indicating a cautionary level of drowsiness and a score of 5.0 or above indicating a critical level of drowsiness. Increased JDS scores are highly predictive of an increased risk of severe lane excursions on a driving simulator and hazardous driving events under real-world driving conditions ,22.Additionally, participant characteristics were assessed at the very end of the pretest work diary, including age, marital status, having children, religious affiliation, educational attainment, number of years of registered nursing (RN) experience, and the number of years working at the current unit.Data were managed and analyzed using Microsoft Excel 2016  and SPSS Statistics for Windows Version 25.0 . Descriptive analyses provided frequencies and percentages for categorical variables and means and standard deviations for continuous variables. Changes in self-reported sleepiness, fatigue, work demands, work pace, and quality of nursing care between pre- and post-testing were examined using paired t-tests. We stratified analyses by whether or not naps were reached to examine the effects of napping. We conducted separate statistical analyses for each outcome for each shift with the paired manner of the within-subject design. The time (in minutes) of when the Johns Drowsiness Scale scores were 4.5–4.9  and equal to or above 5.0  and 4.5  at work were calculated and compared pre- and post-test using the Wilcoxon Signed-Rank Test.Approximately half of the nurses reached naps during their shifts at the post-test. This includes 17 and 19 nurses on their first- and second-night shifts and 16 and 18 on their first- and second-day shifts, respectively.p = 0.04) and better quality of nursing care on the second night shift  and on the second day shift .When comparing differences in self-reported sleepiness, fatigue, physical and psychological job demands, work pace, and quality of nursing care, all significant beneficial findings were in those who reached naps . For exap = 0.04) and the total cautionary or higher level of drowsiness decreased from 297 to 76 min .For the 13 nurses whose drowsiness levels were continuously assessed during work, the Optalert systems successfully measured their ocular movements during 73% and 61% of the total work hours at the pre- and post-tests, respectively . The totThis study reports a nap intervention for 12-h shift nurses in Korea. We performed an innovative, objective assessment of the real-time drowsiness of nurses during their shifts and subjective measures of work on consecutive study days at both the pre- and post-tests. According to the ocular measures, cautionary or higher levels of drowsiness decreased after the nap intervention. Furthermore, we found significant improvement in work outcomes, e.g., fatigue and quality of nursing care, after the nap intervention mostly on the second night shift. When stratifying the analyses by whether or not naps were reached, significant beneficial effects were found among those who reached naps. Our findings suggest that napping could be adopted as an effective countermeasure to drowsiness in nursing units, where napping has been limitedly implemented.Extended work hours lead to increased fatigue and reduced alertness, which are all well-known risk factors for patient errors and occupational injuries and accidents . Nurses On-duty nap opportunities are reportedly effective for shift-workers and improve subjective sleepiness, fatigue, lapses, and reaction time post-nap through the end of the shift ,26. HoweOculography successfully measured the 12-h shift nurses’ real-time drowsiness during their shifts. As its small transducer is attached to glasses frames and it continuously monitors nurses’ eye and eyelid movements, the system minimally interferes with nurses’ work. However, while its wireless system allows nurses to move around without limits, its battery sometimes runs out before the end of the shift and requires an auxiliary power bank. Nonetheless, the oculography provides objective drowsiness data, which are presented as the JDS scale. The JDS is based on a combination of oculometric variables, including the relative velocity of eyelid movements during blinking . It doesn = 38) limits the generalizability of our results. However, the study nurses provided self-reported data at each pre- and post-test during a total of 304 shifts and objective data on the level of drowsiness during 104 shifts. Furthermore, this one group pre- and post-test design did not allow for control group comparison. Participant bias might affect the results, especially given that the sleep education session was provided after pretest measures were collected. Nevertheless, repeated measures during multiple days of work at the pre- and post-tests partially support study validity. Additionally, we did not include some potential factors that might affect drowsiness at work, such as history, comorbidities , health behaviors , and characteristics related to their commute. Lastly, due to the five-month gap between the pre- and post-tests, seasonal variation might have affected the study results. Nurses may have been less drowsy at the post-test because they were busier.Our study findings should be interpreted with caution. First, the relatively small sample of nurses (Nurses with extended work hours are often drowsy while working, leading to increased risk to their and their patient’s safety. Since the 1970s, napping has been implemented as an effective countermeasure to fatigue and sleepiness in many safety-sensitive industries, such as aviation, transportation, and manufacturing . HoweverFuture research on napping in a healthcare setting should include a larger sample size with a variety of work settings. Follow-up studies would be designed with a larger sample size and a control group to increase the reliability of the results. Further use of the oculography should be applied in nursing research to better understand healthcare workers’ drowsiness and work performance in safety-sensitive work settings.


Takayasu arteritis (TA) is a rare, large vessel vasculitis that affects aorta, its major branches, and occasionally pulmonary arteries. Patients with TA can present with constitutional features and/or various symptoms and signs caused by morphological changes in the blood vessels affected by the inflammatory process. Corticosteroids (CS) and immunosuppressives (IS) are the first line treatment for active TA. Open surgery remains a treatment of choice for TA patients with moderate-to-severe aortic regurgitation (AR) and ascending aortic aneurysm (AAA). We present a 26-year-old female diagnosed with an advanced stage of TA, initially presented as congestive heart failure. Due to a progressive course of the disease , surgery of the Aortic valve and root , with total arch reconstruction and replacement of supra-aortic branches was performed. The patient has had an uneventful recovery during the postoperative course with no complications at one year follow-up. Normal left ventricle (LV) diameter, LV ejection fraction 67%, and a trace of AR were seen on the last echocardiography.


TP63 gene disorder and have similar features. In the present article, a R319H mutation in TP63 is reported, and the correlation between genotype and phenotype is discussed based on the current case and previous literature.Ectrodactyly ectodermal dysplasia-cleft lip/palate (EEC) syndrome, limb-mammary syndrome (LMS), and acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome are caused by a A 13-year-old Japanese boy had ectrodactyly in the right hand and left foot and syndactyly in the left and right foot, and tooth shape abnormalities.Peripheral blood samples were obtained, and mutation analysis was performed. A heterozygous G>A transition at cDNA position 956 of the TP63 gene was found. The patient was diagnosed with ELA (EEC/LM/ADULT) syndrome based on his clinical features and mutation analysis results.The patient underwent surgery to correct the left foot malformation at 1 year of age and the right foot syndactyly at 11 years of age.No complications were observed after the first and second operations. He can walk comfortably after them, and no additional interventions will be planned in him. We continued to follow up with him up to the present.The concept of ELA syndrome, which is the original concept of combining 3 syndromes (EEC syndrome/LMS/ADULT syndrome) into a unique clinical entity, can help clinicians to better understand TP63-related syndromes and improve the differential diagnosis of these syndromes. TP63 acts as a key regulator in limb development and other tissues, including epithelial and craniofacial tissues, not classical tumor-suppressor genes. Hence, ectrodactyly sometimes occurs along with other symptoms.Ectrodactyly or split hand/foot malformation is a rare congenital limb disorder with a prevalence of approximately 1 in 18,000 newborns.TP63 mutations have been identified in 6 different syndromes: ectrodactyly ectodermal dysplasia-cleft lip/palate (EEC) syndrome, acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome, limb-mammary syndrome (LMS), ankyloblepharon-ectodermal dysplasia-clefting (AEC) syndrome, Rapp–Hodgkin syndrome (RHS), and nonsyndromic split-hand/split-foot malformation (SHFM). EEC syndrome, LMS, and ADULT syndrome have traits along the same clinical spectrum and a similar pattern of p63 mutations; thus, the concept of ELA (EEC-ADULT-LM) syndrome has been reported to simplify the classification of TP63-associated disorders. In the present article, a case of R319H (described as R280H) mutation in TP63 with ectrodactyly, syndactyly, and tooth anomaly, is reported, and the correlation between genotype and phenotype is discussed based on the current case and previous literature.Causative 2The patient was a 13-year-old Japanese boy who was delivered normally, weighing 2954 g. He was found to have ectrodactyly in the right hand and left foot  syndrome based on his clinical features and mutation analysis results. His mother showed the same missense mutation at nucleotide 956, but she did not have any abnormalities related to the missense mutation. All relevant information was explained to the patient and his mother, and written informed consent was obtained from the patient and his mother for publication of this case report and accompanying images.After ethical approval by the ethics committee of Osaka Medical College  and written informed consent from the patient and his parents, peripheral blood samples were obtained. Whole exome sequencing was performed to screen for candidate causative mutations. Called mutations were validated by Sanger sequencing. The results showed no de novo, homozygous, and compound heterozygous mutations. Next, deleterious mutations  with a frequency <0.5% in the general population of p63 that were transmitted from one of the parents were analyzed, and a maternally transmitted missense mutation , ENST00000264731) was found  is the causative gene mutation in the present case, and it has been reported in both EEC syndrome and SHFM. This mutation also helps to rule out ADULT syndrome. For such cases, family history can aid in the diagnosis. In the present case, the patient's mother had the same missense mutation, but she did not have any symptoms or signs. The reason why she had no manifestations of the disease despite her missense mutation is unclear, but it may be related to somatic mosaicism or variable penetrance.TP63 is usually expressed in epithelial and mesenchymal structures; thus, TP63 mutations cause disorders in these tissues. At least 6 different syndromes have been linked to ns Table . However However, the phenotype exists based on the genotype, so that the genotype–phenotype correlation cannot be ignored when the origins of the syndromes are elucidated. This is the cause of confusion in understanding TP63-related syndromes. Prontera et al suggested the original concept of combining these syndromes into a unique clinical entity, ELA (EEC/LM/ADULT) syndrome. Establishment of a better classification system based on genotype–phenotype correlation can help clinicians to better understand TP63-related syndromes and improve the differential diagnosis of these syndromes.The concept of EEC syndrome was established before the detailed determination of its genetic causes. Therefore, EEC syndrome is defined by a combination of phenotypes.The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Conceptualization: Koichi Ueda.Data curation: Chisei Satoh, Ryuta Maekawa, Koh-ichiro Yoshiura.Methodology: Koichi Ueda, Koh-ichiro Yoshiura.Project administration: Koichi Ueda.Supervision: Koichi Ueda.Validation: Takashi Nuri.Visualization: Yuki Otsuki.Writing – original draft: Yuki Otsuki.Writing – review & editing: Yuki Otsuki, Chisei Satoh.


Continuing geographic spread of chronic wasting disease (CWD) poses a serious threat to the sustainable future of cervids and hunting in North America. Moreover, CWD has been detected in captive cervids in South Korea and, in recent years, in free-ranging reindeer in Europe (Norway). Management of this disease is limited by logistical, financial, and sociopolitical considerations, and current strategies primarily focus on reducing host densities through hunter harvest and targeted culling. The success of such strategies in mitigating the spread and prevalence of CWD only upon detection is questionable. Here, we propose a proactive approach that emphasizes pre-emptive management through purposeful integration of virtual experiments  with the aim of evaluating their effectiveness. Here, we have used a published agent-based model that links white-tailed deer demography and behavior with CWD transmission dynamics to first derive a CWD outbreak trajectory and then use the trajectory to highlight issues associated with different phases of the CWD outbreak (pre-establishment/transition/endemic). Specifically, we highlight the practical constraints on surveillance in the pre-establishment phase and recommend that agencies use a realistic detection threshold for their CWD surveillance programs. We further demonstrate that many disease introductions are “dead ends” not leading to a full epidemic due to high stochasticity and harvesting in the pre-establishment phase of CWD. Model evaluated pre-emptive (pre-detection) harvest strategies could increase the resilience of the deer population to CWD spread and establishment. We conclude it is important to adaptively position CWD management ahead of, rather than behind, the CWD front. Odocoileus virginianus, mule deer Odocoileus hemionus, and elk Cervus canadensis) that has been detected in free-ranging and captive cervids in 26 U.S. states and three Canadian provinces as well as in free-ranging reindeer Rangifer tarandus in Norway and in captive cervids in South Korea. The seemingly inexorable spread of CWD presents both short- and long-term threat to free-ranging cervids and to wildlife conservation in general. Field data show that CWD can markedly reduce cervid populations (Chronic wasting disease (CWD) is an emerging prion disease of North American cervid populations , detection of CWD using hunter-harvested deer (non-probabilistic sampling) is difficult, if not practically impossible, because the overall prevalence remains very low and cases are clustered, not randomly distributed –20. Nevepre-establishment phase is the early stage of the outbreak characterized by low CWD prevalence (below 1%) and sample size requirements that are either difficult to achieve and unsustainable  or unreliable ; (b) transition phase follows the pre-establishment phase, characterized by an increasing prevalence  and a considerable decrease in the sample size requirement even with realistic assumptions; and (c) endemic phase characterized by rapidly increasing CWD prevalence and a corresponding decrease in sample size requirement for CWD detection using realistic assumptions. Thus, surveillance strategies at each phase necessitates different sample sizes to confidently detect the existence of CWD. Among other factors, environmental contamination likely plays an increasingly important role in CWD transmission in the endemic phase, further complicating disease management  will be particularly useful for determining realistic sample size requirements for confidently detecting CWD in the pre-establishment phase. Better still, such a tool can be used to set a realistic detection threshold to economize surveillance efforts for efficient management of CWD.Other model approaches, such as Bayesian weighted surveillance  and riskOvCWD explicitly simulates these stochastic processes, and therefore can be used to derive “CWD persistence probability” .https://github.com/anyadoc/proactiveCWDmgmt. Model codes are openly available for download here: MIOvPOP (Version 1.1.0) https://doi.org/10.25937/kv07-3e08; MIOvCWD (Version 1.0.0) https://doi.org/10.25937/6qeq-1c13; MIOvPOPsurveillance (Version 1.0.0) https://doi.org/10.25937/fdke-rp28.Publicly available datasets were analyzed in this study. This data can be found here: AB: conceptualization, model simulation and model output analysis, writing—original draft, writing-review and editing, prepared, and reviewed the manuscript. JJM, JRM, JS, HV, and AM: conceptualization and writing-review and editing. All authors contributed to the article 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 determine differences among multi-race (MR) American Indian and Alaska Natives (AIAN), single race (SR) AIANs, and SR-Whites on multiple health outcomes. We tested the following hypotheses: MR-AIANs will have worse health outcomes than SR-AIANs; SR-AIANs will have worse health outcomes than SR-Whites; MR-AIANs will have worse health outcomes than SR-Whites.Behavioral Risk Factor Surveillance System data were used to examine general health, risk behaviors, access to health care, and diagnosed chronic health conditions. Those identifying as SR-White, SR-AIAN, and MR-AIAN were included in multinomial logistic regression models.Compared to SR-AIANs, MR-AIANs had more activity limitations, a greater likelihood of experiencing cost as a barrier to health care and were more likely to be at increased risk and diagnosed with more chronic health conditions. Both SR and MR-AIANs have worse health than SR-Whites; MR-AIANs appear to be at increased risk for poor health.The current study examined access to health care and nine chronic health conditions, neither of which have been considered in prior work. MR AIANs are at increased risk compared to SR groups. These observations beg for further inquire into the mechanisms underlying these differences including stress related to identify, access to care, and discrimination. Findings support the continued need to address health disparities among AIANs regardless of SR or MR identification. American Indian/Alaska Native (AIAN) people are disproportionately burdened by poor health and comprise one of the largest multi-race (MR) groups in the US . IdentifIn addition to stress related to identity, other factors may contribute to poor MR-AIAN health outcomes such as access to care and discrimination. The Indian Health Service (IHS) provides health care to federally recognized AIANs in the US . AlthougGrowing evidence supports the association of MR identity with poor health outcomes. One study that aggregated MR people together regardless of racial combination observed, MR people were more likely to smoke and drink alcohol compared to SR groups  . AnotherWe examined differences between MR-AIANs, SR-AIANs, and SR-Whites on health outcomes across four categories: general health, behavioral risk factors, health care access, and chronic health conditions. Drawing upon the existing literature summarized above, we posited three hypotheses: 1) MR-AIANs will have worse health outcomes compared to SR-AIANs; 2) SR-AIANs will have worse health outcomes compared to SR-Whites; and 3) MR-AIANs will have worse health compared to SR-Whites.The BRFSS survey is recognized as a leading source of health data. It is the largest continuously conducted survey in the world that focuses on non-institutionalized adults aged 18 or older and inquiries about health practices, health risks, and chronic health conditions . Its nathttps://www.cdc.gov/brfss/annual_data/annual_2012.html. Our team used the publicly available data accessible at this location. We did not request or use data that required special approval or access.BRFSS data were used for these analyses. The data analyzed for this study are publicly and freely available at the BRFSS website located here, We drew upon responses from the BRFSS 2012 core questions asked of all respondents. Our analyses included self-reported demographics, general health variables, risk behaviors, access to health care, and diagnosed chronic health conditions.The question, “Which one or more of the following would you say is your race?  White, Black or African American, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and Other (specify)”, was used to construct the MR variable. We developed three categories, SR-AIAN, MR-AIAN, and SR-White. Respondents selecting White only or AIAN only from among these options comprised the SR groups. Those indicating AIAN in combination with any other race or combination of races comprised the MR-AIAN category.General health assessments included poor health, frequent distress, and activity limitations. We constructed these variables similarly to other studies –27. PoorWe considered five behavioral risk factors: obesity, lack of exercise, current smoker, binge drinking, and heavy drinking. Respondents with a body mass index (BMI) ≥30 were designated as obese . Lack ofTwo access to health care variables were also included. Respondents answering “no” to the question, “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare or Indian Health Service?” were identified as lacking health care coverage , 24. ThoNine chronic health conditions were included in our analyses. Yes, to the question “Has a doctor, nurse, or other health professional EVER told you that you had any of the following?” defined the presence of: 1) cardiovascular disease  , 21; 2) East , Northern Plains , Southwest , Pacific , Southern Plains , and the state of Alaska comprised the Alaska region. Metropolitan statistical area (MSA) status was operationalized as either not in an MSA or county with an MSA. MSA was defined as in the center city of an MSA, outside the center city of an MSA but inside the county containing the center city, inside a suburban county of the MSA, or in an MSA that has no center city.We controlled for demographic variables which included Hispanic ethnicity, sex , six age categories , marital status , children less than 18 years of age in the home , education , in the labor force, income , and region of residence . To examine AIAN regional variation we constructed a region of residence variable similar to other studies using BRFSS data . We defiThe Colorado Institutional Review Board determined these analyses were not human subjects research. The University of North Dakota did not require a review since Dr. Running Bear’s analyses were completed at the University of Colorado Anschutz Medical Campus, prior to employment at the University of North Dakota.All analyses were weighted and Stata was used to produce estimates . DescripThe income and MSA variables displayed large proportions of missing data, 13% and 41% percent, respectively. The MSA variable was collected for respondents that had a land line. Individuals completing the survey by cellphone are missing the MSA variable which accounts for the large amount of missing data. We chose to create a missing category for the MSA variable because a larger proportion of AIANs both SR and MR appear to have participated by cell phone. The indicator variable for missing MSA data was used as a covariate in all analyses. Following the approach of others we created a missing data category for income that was included in all analyses . Once acOf the 475,687 respondents in the BRFSS 2012 data, we identified 393,681 (82.7%) who were either SR-AIAN, MR-AIAN, or SR-White and lived within the 50 states or DC. Of these, 7,976 (2.0%) identified as SR-AIAN, 5,512 (1.4%) as MR-AIAN, and 380,193 (96.6%) as SR-White. Approximately, two-thirds (64%) of the MR-AIAN group chose White as the race that best represented them; 818 (15%) selected AIAN; the remaining 1,236 (21%) selected one of the other races .SR-AIANs were 38% more likely to report poor health, 41% more likely to experience frequent distress, 36% more likely to have activity limitations, 27% more likely to be obese, 15% more likely to lack physical activity, and 43% more likely to currently smoke than SR-Whites. SR-AIANs were also 54% more likely to report CVD, lung disease (48%), arthritis (30%), diabetes (50%), and have two or more chronic health conditions (42%) but 55% less likely to report skin cancer compared to SR-Whites.Compared to SR-Whites, MR-AIANs were 50% more likely to report poor health, 70% more likely to report frequent distress, 85% more likely to have activity limitations, 31% more likely to be obese, 49% more likely to be a current smoker, and 61% less likely to want to see a doctor but couldn’t because of cost. MR-AIANs were also more likely to report CVD (78%), other types of cancer (26%), lung diseases (90%) arthritis (75%), depressive disorders (57%), diabetes (49%), and 2 or more chronic conditions (84%) compared to SR-Whites.These analyses investigated differences in health outcomes between SR-AIANs and MR-AIANs as well as differences between these two groups and SR-Whites. Our first hypothesis, that SR-AIANs have better outcomes than MR-AIANs, was supported for seven of the 19 health conditions examined, five of these were chronic health conditions. No statistically significant differences were found between SR-AIANs and MR-AIANs in behavioral risk factors. Fewer differences in health outcomes were evident among SR and MR-AIANs, than for the other race comparisons.Our second hypothesis was SR-AIANs will have worse health outcomes compared to SR-Whites. SR-AIANs had worse health outcomes for all general health variables, three of the five behavioral risk factors, and over half of the chronic conditions. However, fewer SR-AIANs reported skin cancer and lacked health care coverage compared to SR-Whites.The last hypothesis postulated that MR-AIANs would report worse health outcomes than SR-Whites. Thirteen of the 17 indicators differed significantly between MR-AIANs and SR-Whites. Ten health outcomes were statistically significant when we compared both SR-AIANs and MR-AIANs to SR-Whites. They were poor health, frequent distress, activity limitations, obesity, current smoker, CVD, lung disorders, arthritis, depressive disorders, diabetes, and two or more chronic conditions.Four differences emerged when comparing SR-AIANs and MR-AIANs to SR-Whites. SR-AIANs were more likely to lack exercise, though this was not statistically significant for MR-AIANs. This difference may be due to the lack of available and accessible physical activities on reservations . WantingOur findings are consistent with previous studies that found MR-AIANs are at increased risk for poor health, frequent distress, smoking, and respiratory illnesses compared to SR-Whites. Clearly, failing to measure MR status in studies of AIAN health likely limits the insight to be gained into the differential risks, outcomes, and subsequent disparities . AdditioWhile there is good reason to suspect stress related to MR identity may contribute to poor health, the biological stress response has yet to be carefully considered. Similar to studies that show discrimination is associated with conditions like high blood pressure or CVD, stress related to MR identify may also impact health. Comparisons of the biological stress response among MR-AIANs and SR-AIANs may help to clarify the contribution of stress related to racial identity.Although no difference was observed between MR-AIANs and SR-Whites with respect to lack of health care coverage, MR-AIANs were more likely to have difficulty paying to see a doctor. SR-AIANs had lower incomes, were less likely to report higher education levels and were also less likely to have difficulty accessing a doctor than MR-AIANs. SR-AIANs also had slightly better health than MR-AIANs with respect to several outcomes. We can only theorize this is in part due to IHS access. IHS is underfunded, understaffed, has an aging infrastructure, and receives less per capita funding than other US federal health care services . We suspThere are limitations to this study. First, we were unable to use the most current BRFSS data because detailed MR data is not available in the public use datasets after 2012. Second, though we used an MSA variable in the analyses to control for urban and rural differences, the MSA variable is only reported for individuals responding to BRFSS via landlines; consequently, there is no way to determine urban/rural residence for cell phone users. Inclusion of the MSA variable without indicating a missing category would have limited our sample to landline users potentially introducing bias since more SR-AIANs had missing MSA data. Additionally, we acknowledge that cell phone users and nonusers residing in urban and rural locations are likely heterogenous which can lead to bias. SR-AIANs had slightly more missing data on the income variable than MR-AIANs and SR-Whites. Excluding those with missing income would have excluded slightly more SR-AIANs than the other two groups, we therefore created a missing data category for non-responders. However, we do recognize that individuals who chose to report and chose not to report income are also heterogenous which may bias results. We recognize there may be many unmeasured factors that potentially contribute to the observed health differences between SR and MR-AIANs such as identity stress, discrimination related to health care access, culture, and environment contributions. Despite these limitations, our findings are consistent with and extend the literature related to the role of MR identification regarding risks, outcomes, and resulting health disparities.MR-AIANs are at greater risk for poor outcomes compared to SR-AIANs on several chronic conditions. Both are at greater risk than their SR-White counterparts for poor health across many identical health outcomes. Regardless of AIAN-SR or MR identification, these findings support the continued need to address health disparities among AIANs. We must also carefully consider national statistics that report SR-AIANs only in results. These analyses mirror the results of our earlier work on the burden of mental health problems associated with MR and SR identity. The underlying dynamics are not simple and must consider a wide range of lifestyle and environmental factors, some of which are undoubtedly linked to the social and psychological aspects of racial identity. Research on stress related to MR identity, discrimination in the health care systems, along with differences is access to care is needed to understand the complex health disparities that exist between SR and MR-AIANs.


Self-testing for STIs such as HIV and syphilis may empower sexual minorities and expand uptake of STI testing. While much is known about HIV self-testing (HIVST), less is known about syphilis self-testing, particularly in low-income settings. The objective of this study is to determine context-specific facilitators and barriers for self-testing and to assess the usability of syphilis self-testing in Zimbabwe among men who have sex with men (MSM).This mixed methods study was conducted in Harare as part of a larger syphilis self-testing trial. The study included in-depth interviews (phase I) followed by usability testing and a second interview (phase II). In-depth interviews were conducted with MSM and key informants prior to syphilis self-testing. The same MSM then used the syphilis self-test, quantitatively assessed its usability and participated in a second in-depth interview. Phase I data were analysed using a thematic approach, guided by an adapted social ecological model conceptual framework. Phase II interviews were analysed using rapid assessment procedure methodology, and usability was assessed using a pre-established index, adapted from existing HIVST scales.Twenty MSM and 10 key informants were recruited for phase I in-depth interviews, and 16 of these MSM participated in phase II by completing a syphilis self-test kit. Facilitating factors for self-testing included the potential for increased privacy, convenience, autonomy, and avoidance of social and healthcare provider stigma. Barriers included the fear to test and uncertainty about linkage to care and treatment. Data from the Usability Index suggested high usability  among the men who received the self-test.MSM in Zimbabwe were willing to use syphilis self-test kits and many of the barriers and facilitators were similar to those observed for HIVST. Syphilis self-testing may increase syphilis test uptake among sexual minorities in Zimbabwe and other low-income and middle-income countries. In 2016, the WHO estimated 19.9 million cases of syphilis worldwide, with the highest prevalence in the WHO African region.MSM are often prevented from accessing sexual health services because of lack of funding, lack of testing, legal and cultural barriers, and stigmatisation, particularly in low-income and middle-income countries (LMICs).One way to expand MSM syphilis test uptake is self-testing. Syphilis self-testing is an approach whereby a person performs a rapid test and interprets the result in private. Self-testing may overcome some of the barriers associated with facility-based testing, promoting early diagnosis and interrupting disease progression.HIV self-testing (HIVST) is recommended by the WHO to expand test uptake among stigmatised key populations.This study aims to understand how syphilis self-testing can create opportunities to test for MSM in Zimbabwe. The purpose of this study was to determine facilitators and barriers for syphilis self-testing and to assess the usability of syphilis self-testing as reported by Zimbabwean MSM.A two-phased mixed methods study was conducted among MSM in Harare due to the strong network of MSM community-based organisations in the city. The first phase was prior to testing, and the second phase was after syphilis self-testing. Formative data from both phases informed a trial protocol comparing syphilis self-testing to facility-based testing in MSM in Zimbabwe.In phase I, in-depth interviews were conducted among MSM and key informants, by trained researchers from the Pangaea Zimbabwe Aids Trust (PZAT), between March and April 2020. We recruited participants using snowball sampling until we reached saturation of themes. Participants had to be 16 years or older, living in Harare, ever had anal or oral sex with another man, born biologically male and able to provide informed consent.Interviews lasted 30 min and were audio-recorded. The MSM interview guide was developed to collect sociodemographic data, explore prior syphilis-testing and HIV-testing experiences, facilitating and deterring factors, and self-testing intervention preferences . The key10.1136/sextrans-2020-054911.supp1Supplementary dataInterviews were translated and transcribed by PZAT researchers. Transcripts were entered into Dedoose 8.3.17. The Framework Method was used to guide our analysis.In phase II, the syphilis self-test distributed to MSM consisted of a Standard Q Syphilis Ab treponemal blood-based rapid test, adapted for individual use and interpretation. SD Biosensor reports 100% sensitivity and 97.5% specificity of the antibody test, with a result appearing within 5–20 min. This is a lateral flow immunochromatographic assay similar to blood-based HIVST kits. Individual lancets and buffer samples were packaged into sealed pouches, with an individual test device and infographic, detailing step-by-step use, disposal and procedure for confirmatory testing. An instructional video was created and disseminated to facilitate independent use. Tests were distributed by researchers from PZAT to the same MSM who had completed phase I.In phase II August 2020), PZAT researchers interviewed a sample of 16 MSM who successfully completed a self-test. Interviews were conducted under COVID-19 social distancing measures. An exit interview guide was developed to qualitatively assess specific facilitators and barriers for syphilis self-testing. Participants also completed a 15-item Usability Index (UI) to assess the usability of the test, adapted from a study of HIVST usability in South Africa. The index includes dichotomous questions about specific items related to the process of self-testing. Like in the HIVST study, we tracked all successful steps in completing the self-test, in order to quantify a UI, expressed as a percentage.20, PZAT 10.1136/sextrans-2020-054911.supp3Supplementary dataTwenty MSM and 10 key informants were recruited for phase I in-depth interviews. In phase II, 16 MSM were invited to conduct the self-test and were subsequently interviewed. Four were lost to follow-up due to relocation or communication difficulties. Upon testing, it emerged that insufficient quantities of buffer were provided in some kits. This was resolved through community-based distribution of additional buffer samples.In phase I, 18 of 20 MSM had previously used HIVST . All parIn phase I, 18 MSM had experienced HIVST before using the oral HIV test. Ten participants stated they used HIVST every 3–6 months. In addition, 13 of the 18 HIVST-experienced MSM had then attended a facility and were empowered to seek facility-based services. Key informants confirmed that syphilis testing is usually reserved for pregnant women, and only three underwent training on how to work with MSM, suggesting MSM are largely neglected by STI services. Some providers recommended syphilis testing should be mandatory for key populations.Of the 16 participants in phase II, two (13%) tested positive for syphilis. One had a history of previous treatment and was offered a confirmatory non-treponemal test that was negative. The other had a new syphilis diagnosis and received a positive non-treponemal test, followed by a course of benzathine penicillin. Fifteen participants reported the clarity of explanations provided in the infographic and video was instrumental to successful test completion. Overall, MSM reported 89.6% usability for the syphilis self-test on a 0–100 scale. This is described in detail in Phase II participants felt that the syphilis and HIV self-test kits had many similarities, including the potential for privacy and convenience. The major challenge cited was that syphilis self-testing uses a blood sample, while most HIVST kits use oral samples. Two MSM reported a preference for HIVST compared with syphilis self-testing because of this issue. However, 15 (94%) participants felt that they trusted the syphilis test result more because it was blood-based. They also preferred the syphilis self-test because of the clarity of instructions compared with HIVST instructional material.Facilitating and deterring factors for self-testing were categorised into individual-level, community-level and structural-level factors . ConveniThe following factors were facilitators for both HIVST and syphilis self-testing: privacy, autonomy and empowerment, convenience, user-friendliness, high perceived trust in blood-based tests, avoidance of social and healthcare provider stigma, monetary and time savings, and reduced contact with facility-based services in the COVID-19 context. All MSM participants felt comfortable testing alone and stated they would prefer doing their next test at home, in order to be the first to see their results. In comparison, three participants stated that facility-based testing did not provide adequate levels of privacy. MSM liked that they could conduct their test without the involvement of a healthcare provider and the convenience of it.MSM highlighted that the lengthy waiting periods for in-facility testing are an important deterring factor. A rapid self-test could contribute to speeding up diagnosis, reducing treatment delay and interrupting more syphilis transmission. Seven participants mentioned that HIVST empowered them to test more frequently and to take control of their sexual health. All phase II participants stated that the blood draw increased their trust in the syphilis self-test. Two MSM noted the blood draw for syphilis facility-based testing is more painful than the self-test due to the nature of the self-testing lancets provided, and thus would opt for the self-test. Participants explained that they preferred the pressure-activated lancets provided in the study self-test kits, in comparison to the twist-top universal lancets used in-facility.Participants liked that they were able to avoid being identified at a facility and stigmatised by members of their own community. Additionally, several MSM observed that self-testing prevented hostility from providers or other society members, therefore decreasing test-associated stigma. Key informants in phase I explained they valued self-testing because of the potential to reduce contact with clients, especially in the context of the COVID-19 pandemic.Themes related to barriers included the following: the challenge of self-sampling blood, reluctance to test due to poor awareness, stigma at community-level following at-home testing, indefinite linkage to care and treatment availability. Twelve participants experienced difficulty with the blood draw that they attributed to inexperience. One participant was concerned about the biohazard potential with test kit material disposal. Some MSM mentioned that self-test uptake is jeopardised among the wider community of MSM by poor awareness and the perception that they do not have STIs. MSM also expressed concerns over the fact they could be profiled or stigmatised within their own community following at-home self-testing. Participants reported that they would seek confirmatory testing if trusted information was provided on where to go and what to expect in-facility. These are legitimate concerns that align with phase I qualitative data, which showed that provider discrimination and treatment shortages exist at structural level. Key informants also reported occasional unavailability of the facility-based syphilis tests required for confirmatory testing, as these are reserved for antenatal care.Our study expands on the limited literature on syphilis self-testing, includes qualitative and quantitative data, and follows MSM prior to and after self-testing. We found that syphilis self-testing was feasible and highly acceptable among MSM in Zimbabwe. The high UI (89.6%) suggests that syphilis self-testing would be acceptable in this subgroup of MSM. Overall, 12.5% of phase II MSM tested positive for syphilis, a high proportion considering the small number of participants. Participants reported self-testing was a convenient method that provided increased privacy, autonomy and diminished vulnerability in comparison to facility-based testing. The testing challenges associated with the amount of test buffer were transient and were improved by increasing the quantity of buffer provided.Study findings are consistent with HIVST data in Zimbabwe, as well as syphilis self-testing data from ChinaOur qualitative data suggest that syphilis self-testing can empower MSM to test when, where and with whom they wish. This is consistent with global HIVST qualitative literature showing how self-testing gives agency to those who test.One barrier to syphilis self-testing was the uncertainty of linking to confirmatory testing and treatment within health facilities. Key informants noted that Zimbabwe hospitals have variable access to non-treponemal tests and stock-outs of penicillin occur. While similar concerns existed for HIVST, linkage to care rates have been excellent.This study has a number of limitations. First, as a mixed methods study, qualitative results should be interpreted as only an indication of the preferences of the men interviewed. The MSM participants all had at least secondary-level education, were educated about STIs and were able to access community-based services. They may therefore be early adopters within the MSM population, more likely to take up health innovations due to heightened awareness and contact with community organisations.This study has implications for research and policy. It has revealed that more research is needed on how we can integrate syphilis self-testing into established networks of HIVST services to facilitate implementation. Syphilis self-testing cannot effectively contribute to interrupting syphilis transmission if facility-based confirmatory testing, and treatment is not made accessible to MSM. Clinical trials are needed to assess the effectiveness and risks of syphilis self-testing in practice. From a policy perspective, many of the existing HIVST policies could be expanded to cover syphilis self-testing. Further policy development will help national leadership to embrace syphilis self-testing as a tool for expanding syphilis testing. Improving testing among key populations can reduce the bridging of syphilis into the general population, likely having an impact on the overall prevalence of syphilis, with the potential of reducing mother-to-child transmission.In conclusion, the findings from this study suggest that syphilis self-testing may decrease user perceived test-associated stigma and empower MSM in an area where same sex relations are condemned. Innovative tools such as syphilis self-testing are needed to expand syphilis test uptake, especially for marginalised populations of MSM.Syphilis self-testing is an empowering, innovative tool that can be used to expand uptake of STI testing among sexual minorities in Zimbabwe.Facilitators and barriers for syphilis self-testing are similar to those observed for HIV self-testing in Zimbabwe and other low-income and middle- income countries.Participants reported high self-test usability and found that self-testing provided increased privacy, convenience and autonomy in comparison to facility-based testing.10.1136/sextrans-2020-054911.supp2Supplementary data10.1136/sextrans-2020-054911.supp4Supplementary data


There has been an increase in older rural-to-urban migrant workers (aged 50 and above) in mainland China, little known about their depressive symptoms. The aim of this study was to identify depressive symptoms among older rural-to-urban migrant workers, as well as explored the factors leading to differences in depressive symptoms between older rural-to-urban migrant workers and their rural counterparts  and urban counterparts (older urban residents) in mainland China. The results provided a comprehensive understanding of the depressive symptoms of older rural-to-urban migrant workers, and had great significance for improving the depressive symptoms for this vulnerable group.Data were derived from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2015, and coarsened exact matching (CEM) method was employed to control confounding factors. This study employed a Chinese version 10-item short form of the Center for Epidemiologic Studies-Depression Scale (CES-D 10) to measure depressive symptoms, and used the Social-Ecological Model as a framework to explore influential factors related to depressive symptoms. Specifically, the approach of Fairlie’s decomposition was used to parse out differences into observed and unobserved components.After matching, our findings indicated that the prevalence of depressive symptoms in older rural-to-urban migrant workers was lower than older rural dwellers; and the prevalence of depressive symptoms in older rural-to-urban migrant workers was higher than older urban residents. Fairlie’s decomposition analysis indicated that type of in-house shower, sleeping time at night and ill in the last month were proved to be major contributors to the differences in depressive symptoms between older rural-to-urban migrant workers and older rural dwellers; self-reported health and sleeping time at night were proved to be major contributors to the differences in depressive symptoms between older rural-to-urban migrant workers and older urban residents.Differences in depressive symptoms between older rural-to-urban migrant workers and their rural and urban counterparts did exist. Our findings contributed to a more reliable understanding in depressive symptoms among older rural-to-urban migrant workers. Our findings would be of referential significance for improving older rural-to-urban migrant workers’ depressive symptoms. There has been a dramatic increase in rural-to-urban migrant workers in mainland since the 90’s of last century. At the same time, a number of rural-to-urban migrant workers are facing the situation of aging, and they are developing older rural-to-urban migrant workers (aged 50 and above), as National Bureau of Statistics (NBC) mentioned . AccordiEvaluating the mental health differences between older rural-to-urban migrant workers and their rural counterparts and their urban counterparts is essential for the mental health plans proposed to benefit older rural-to-urban migrant workers in mainland China. Mixed, sometimes contradictory mechanisms through which migration may potentially influence the mental health have been presented. However, there are still no consistency conclusions. On one hand, migration may cause disadvantages in many aspects, which had negative implications for rural-to-urban migrant workers’ depressive symptoms. Much research had demonstrated that migration was associated with an increased risk for poor mental health , 4. OldeFollowing the accelerated speed of population aging, older rural-to-urban migrant workers’ depressive symptoms should be taken seriously. Previous studies , 11 had Limit studies on older rural-to-urban migrant workers in mainland China has primarily focused on their health; however, research regarding the comparison between older rural-to-urban migrant workers in mainland China and their rural and urban counterparts is scarce. To our best of knowledge, only Dan et al. had specially focused on the health of older rural-to-urban migrant workers in mainland China, and their study showed that older rural-to-urban migrant workers had higher self-assessed health status, compared with older rural dwellers . A growiSocial-Ecological Model provided a good framework to identify factors influencing the outcome at various levels . VariousAlthough there is increasing recognition of older rural-to-urban migrant workers in mainland China, their mental health evaluation associated with migration is still in its infancy. As there were no consistency conclusions about mental health mechanisms about older rural-to-urban migrant workers. Our paper aimed to show the differences in depressive symptoms at multiple levels of the Social-Ecological Model between older rural-to-urban migrant workers versus older rural dwellers, and between older rural-to-urban migrant workers versus older urban residents. Therefore, based on the Social-Ecological Model, our study aimed to reveal the differences in depressive symptoms between older rural-to-urban migrant workers and older rural dwellers, and the differences between older rural-to-urban migrant workers and older urban residents. Our study further quantified the impact of biological characteristics and perceived susceptibility, life-style and health behavior, social interpersonal, living and working conditions; and social system on the depressive symptoms of older rural-to-urban migrant workers and their urban and rural counterparts. Then Fairlie’s decomposition was applied to deeply analyze the source of the differences in depressive symptoms. Accordingly, we provided insights into the issues of depressive symptoms among older rural-to-urban migrant workers, to deepen our understanding of this vulnerable group in mainland China.We adopted a dataset from Chinese Health and Retirement Longitudinal Study (CHARLS) conducted in 2015, and the data was issued by the China Center for Economic Research at Beijing University. By using the PPS Method , `28 provinces in mainland China were randomly selected in the first stage, and 150 county-level units were selected in the next stage. Thirdly, 450 village-level units were chosen. Then, 12,400 households were interviewed. Finally, 23,000 individuals who were aged 45 and older were interviewed. These samples can be tracked every two to 3 years in the future, and a detailed description of the questionnaire had been published . The CHAIn our study, older rural-to-urban migrant workers included met the following inclusion criteria: (1) aged 50 ~ 65; (2) with rural hukou (Chinese household registration system); (3) their permanent was cities and towns; (4) employed for more than 6 months. Older rural dwellers included met the following inclusion criteria: (1) aged 50 ~ 65; (2) with rural hukou; (3) their permanent was village; (4) not employed, or employed for less than 6 months. Older urban residents included met the following inclusion criteria: (1) aged 50 ~ 65; (2) with urban hukou; (3) their permanent was cities and towns. In our study, we restricted the age from 50 to 65 , to elimFor the response variables of depressive symptoms, a Chinese version 10-item short form of the Center for Epidemiologic Studies-Depression Scale (CES-D 10) had exhibited a good internal consistent reliability and good construct  , 29. PerIn our study, we followed the construction of some variables in previous research on ecological models of mental health , 30–32. First, biological characteristics and perceived susceptibility: age group , gender , have you been ill in the last month , self-reported health  and chronic diseases .Second, life-style and health behavior variables: smoking, drinking, sleeping time at night  and nap after lunch .Third, social interpersonal variables considered in the study were living arrangement , education level  and social activity .Four, living conditions and economic status: type of in-house shower , clear in this house , geographic characteristics reflecting the potential regional heterogeneity  and expenditure. Expenditure was measured by yearly personal expenditure, and then was divided into five quintiles, from the poorest expenditures quintile and the richest quintile.Five, social system considered in the study were type of health insurance {basic health insurance [including new cooperative medical insurance (NCMS )], no} aBy using comparative analysis approach, our study analyzed the differences of depressive symptoms among older rural-to-urban migrant workers and their urban and rural counterparts. As Mark  put it, L1 can be used to test the imbalance before and after CEM. L1 ranged from 0 to 1 . A higher value meant a larger imbalance between comparison groups. A lower value meant more perfect global balance. A substantial reduction in L1 indicated a well-balanced matching [The multivariate imbalance measure matching . If a sumatching . Detailsmatching . CEM is Decomposition method was used to decompose the mental health differences into the contribution of various factors. If the mental health outcome was a continuous variable, Oaxaca-Blinder decomposition method was extensively adopted to analyze the contributions of health differences in different groups –45. In mFollowing Fairlie , the decj was the sample size for group j. In our study, j presented these two groups of w and B. This alternative expression for the decomposition was used because Y did not necessarily equal. To calculate the decomposition, we defined mentclass2pt{minimThe descriptive statistics analyses showed the details, and the chi-square test was used to examine categorical variables. The logistic regression was applied with weighted data to estimate the association between influencing factor and depressive symptoms. Multicollinearity was quantified by variable inflation factors (VIF); and the cut-offs of 5, 10, and sometimes 30 would indicate problematic levels of multicollinearity . All resTables L1 statistics. After matching, L1 between older rural-to-urban migrant workers and older rural dwellers was actually close to zero, which was much lower than that before matching (0.478), indicating good matching performances; L1 between older rural-to-urban migrant workers and older urban residents was all actually close to zero, which was much lower than that before matching (0.456), which also indicated good matching performances.Table Table Table To the best of our knowledge, this was the first large-scale comparative study in mainland China in depressive symptoms between older rural-to-urban migrant workers versus older urban residents, and between older rural-to-urban migrant workers versus older urban residents. The issue of older rural-to-urban migrant workers in mainland China has attracted widespread attention among the whole society . Our stuAfter matching, we found a lower prevalence of depressive symptoms in older rural-to-urban migrant workers than older rural dwellers, and a higher prevalence of depressive symptoms in older rural-to-urban migrant workers than older urban residents. Older rural-to-urban migrant workers had lower prevalence of depressive symptoms than older rural dwellers, in agreement with previous studies on “healthy migrant hypothesis” . It may Our regression analyses further showed differentials in correlates of depressive symptoms among older rural-to-urban migrants, older rural dwellers and older urban residents in mainland China. As highlighted by other researchers, age, sleeping time, gender, ill in the last month, chronic diseases, type of in-house shower, clear in this house, social activity and region were key indicators for depressive symptoms –55. WhilOur results suggested that there were strong differences in depressive symptoms between older rural-urban migrants verse urban and rural counterparts. Depressive symptoms detrimental to older rural-urban migrants was clearly observable here for both base populations verse urban counterparts. It’s probably because older rural-urban migrants had lower socio-economic position, and poorer living conditions in the city. However, their mental health advantage stood out when they were compared with their rural counterparts. Improved economic conditions experienced by older rural-urban migrants might explain their better mental health relative to their rural counterparts. Though continuous progress has been made in mental health services in mainland China, a huge gap in depressive symptoms remained wide between older rural-to-urban migrant workers and their counterparts.Our study provided convincing evidence that priority should be given to improving depressive symptoms for older rural-to-urban migrant workers. A large proportion of the differences still cannot be explained by the observed differences. On one hand, the differences already seem to reveal that some discrimination was taking place, particularly the large gap between older rural-to-urban migrant workers and older urban residents. Owing to the unobservability of social policies and social integration, we can’t estimate the influence of social policies and cultural factors in our study. It reminded us of the need to reduce discrimination in policy setting and social integration. On the other hand, although variables had been included as many as possible in our study, our study can’t include all factors that influence depression caused by data limitations. Our study did not make a detailed introduction about the unexplained part of the decomposition in lines with other studies –58, becaThe most important contribution of our study did not only evaluate risk factors for depressive symptoms among older rural-to-urban migrant workers, older rural dwellers and older urban residents, but also explored the explanatory source of the differences in depressive symptoms by Fairlie’s decomposition analysis. As many studies had mentioned, the significance of sleep loss and sleep deficiency were drivers of depressive symptoms , 60, andOur study also reminded that type of in-house shower was a key contributor to eliminate the potential differences in depressive symptoms between older rural-to-urban migrant workers and older rural dwellers. Many older rural dwellers can’t take a warm bath or shower, because of the lack of hot bath facilities, so we stressed the importance of mainland China’s rural residential solar hot water heating system programs. Given that ill in the last month and self-reported health appeared to be important contributors for differences in depressive symptoms between older rural-to-urban migrant workers and older urban residents, it was suggested that physical health was an important factor for depressive symptoms. Therefore, it is very essential to recognize different risk-factor profiles of different older groups and make different policy approaches on depressive symptoms.Although a substantial amount of evidence had investigated associations between economy status and depressive symptoms , 62, ourSeveral limitations still required our attention. First, because of the cross-sectional design of our study, our study cannot provide causal inferences. We can get a very small sample size if we matched the data from 2011 to 2015. Therefore, we didn’t use the panel data of CHARLS. The aging of older rural-to-urban migrant workers is a dynamic process, and a longitudinal study using other data should be investigated in our future research to emphasize causal relationships. Second, the unexplained part from decomposition analysis still accounted for a big percentage of total differences. This unexplained part revealed that some discrimination was taking place, and it may be due to the contribution by unobserved variables such as social norms and culture. More factors should be put into the model in our further study, to warrant a better understanding of differences in depressive symptoms. Third, older rural-to-urban migrant workers were highly selected sample groups, and small sample sizes meant that some estimates lacked precision. Pooled estimates were used to address it; however, it may mask heterogeneity between groups. Although CEM was more effective and convenient than tendency score matching method, the poor representativeness of the study population still existed . FinallyThe comparative analysis showed that significant differences in depressive symptoms between older rural-urban migrants verse urban and rural counterparts did exist. Moreover, we also found that type of in-house shower, sleeping time, ill in the last month and self-reported health were key factors of differences in depressive symptoms. Based on the contributing factors which may result in the differences in depressive symptoms, more efforts are urged to improve the mental health condition of the older rural-urban migrants. Therefore, Chinese government should adopt countermeasures to improve depressive symptoms and narrow differences in depressive symptoms to achieve a stable and sustainable urbanization process.


Tuberculosis (TB) appears to afflict men more than women, but the underlying reasons for this disparity and whether there are sex-based differences in TB treatment responses are unknown. Based on a knowledge gap in previously published studies, a pertinent research question is being asked: Are there sex-specific differences in response to adjunctive host-directed therapy (HDT) for TB? Using statins as a prototype, we also highlight the incorporation of appropriately designed studies on sex differences in HDT.Mycobacterium tuberculosis-infected mice and prevent acute mortality, while decreasing pulmonary bacillary loads, tissue necrosis, and type I IFN levels  to the alternative phenotype . Early secreted antigenic target of 6-kDa of M. tuberculosis induces M1 phenotype in the early stage and then polarizes to M2 phenotype in the later stage of TB infection  reductase inhibitors (statins) have been shown to have broad anti-inflammatory and immunomodulatory properties , 23, andnfection . Heat-She damage in vitro and better anti-TB activity in the standard BALB/c mouse model and in the C3HeB/FeJ mouse model of human-like necrotic TB lung granulomas   a murine model of chronic TB infection with human-like necrotic lung granulomas; and (ii) s (MDMs) . M. tubeherapies , 39. An ND and BS have made substantial, direct and intellectual contribution to the work, critically reading an earlier version of this manuscript, and approved it for publication. All authors contributed to the article 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.


Convalescent plasma therapy holds promise as a transient treatment for COVID-19. Yet, blood products are important sources of HIV infection in low- and middle-income nations. Great care must be taken to prevent plasma therapy from fueling HIV epidemics in the developing world. Their effectiveness has been based on small studies and massively inflated by the media, only to later show limited to no benefit in larger studies and, sometimes, even cause severe side effects. The reality is that, to date, there is no proven drug to treat COVID-19. A potential vaccine will take at least 1 year to be developed and tested. Yet, a promising strategy to hold down the fort has arisen: convalescent plasma therapy. Trials to treat COVID-19 using this method are being initiated in many countries, including low- and middle-income nations in Africa, Southeast Asia, and Latin America.The COVID-19 pandemic has inspired rapid research towards medications and vaccines to prevent the spread of the disease. Many drugs have been promoted as potential treatments for the disease, including hydroxychloroquine, azithromycin, Remdesivir, Avifavir, ivermectin, chlorine dioxide, among others2. Collecting plasma, the liquid component of blood, from someone who has recently recovered from COVID-19 and infusing it into someone with an ongoing infection would confer the plasma recipient with antibodies to combat the virus3. Of note, this is an immediate transient treatment and does not replace the long-lasting immune memory generated by a vaccine. Indeed, high-affinity IgG antibodies have a half-life of up to three weeks in blood4. Nevertheless, the hope is that the infusion of convalescent plasma enriched in antibodies will substantially boost the recipient’s immediate immune response to clear the virus.Convalescent plasma therapy is based on the concept of passive immunity. Individuals who recover from SARS-CoV-2 infection have, in principle, developed neutralizing antibodies against the virus3. Yet, convalescent plasma therapy is not without its perils, especially in low- and middle-income nations with suboptimal healthcare infrastructures and less strict regulations. Blood transfusions can transmit blood-borne pathogens5 and lead to conditions such as transfusion-related acute lung injury and transfusion-associated circulatory overload6. In fact, blood transfusions have been shown to represent an important source of HIV infection in many low- and middle-income countries, being associated with positive HIV status7. It is unlikely that most low- and middle-income countries will be able to secure the blood supply by universal HIV testing7. Even when funding is provided, access to medical materials and supplies in the international market remains difficult for the developing world8.The infrastructure for collecting and administering plasma exists. The risks are known and rather low when the healthcare infrastructure is optimal. More than 16,000 patients at hundreds of US hospitals have received convalescent plasma therapy for COVID-19. A study in New York City found that convalescent plasma recipients had improved survival and less-supplemental oxygen requirements than control patients9. This technology has recently been approved for COVID-19 testing, although with significant delays in the delivery of reagents and supplies10. Importantly, this platform has a higher cost and lower throughput than other PCR-based approaches. It allows the processing of only up to four samples per run, severely limiting its utility for COVID-19 and HIV PCR-based testing in larger communities. Moreover, governmental laboratories with RNA testing capabilities are currently saturated in many low- and middle-income countries11, leaving administrators to decide between testing for COVID-19 or HIV.For years, the United Nations Development Programme (UNDP) and the World Health Organization (WHO) have subsidized molecular testing in the developing world. One such program, the introduction of “all-in-one cartridge” systems for RNA sample isolation and PCR-based testing, has been used for HIV and tuberculosis diagnosis12. The reality of plasma donations is similar. In Bolivia, for instance, although law 1716 forbids any kind of payment for tissue donation, advertisements requesting paid plasma donations are common, even in prime time TV and national newspapers13. Such strategy is likely to be successful, as media coverage has been shown to positively impact organ and tissue donation rates14. Some regions have circulating lists of infected individuals. Plasma donations are compensated with thousands of dollars, several times the local average monthly salary, and can be performed once a week. Patients who recover following convalescent plasma infusion are then encouraged to donate their plasma. In addition to resembling a pyramid-type scheme, such practice does not have a solid scientific rationale, as these patients are highly unlikely to have developed any neutralizing antibodies against SARS-CoV-2. In fact, even among individuals who recover from SARS-CoV-2 on their own, one-third have low or undetectable neutralizing antibody titers2. Such a plasma black market is reminiscent of events in the 1990s in China, where an HIV epidemic began with local pay-for-plasma schemes15.Regulations worldwide have forbidden paid organ and tissue donations for decades. Yet, these measures remain far from effective, particularly, in the developing world10. Centers with a proven track record of testing for endemic contagious diseases in the developing world exist, some of them resulting from multinational collaborations with developed nations16. Furthermore, antibody-based tests generated in-house may be more accurate and cost-effective than commercial ones17, so sharing parts and reagents  may be more desirable than already assembled testing kits. Importantly, conventional antibody-based HIV testing may miss early infection18. Hence, methods to detect viral nucleic acids directly remain desirable. Recently developed CRISPR-based methods to detect specific viral RNA sequences amenable to lyophilization, long-term storage, and reconstitution on paper represent a promising approach to detect the presence of SARS-CoV-2 and HIV, both RNA viruses, in locations with little to no healthcare infrastructures20. More bilateral and multilateral scientific collaborations between high- and low- and middle-income countries should be encouraged to gradually foster productive scientific collaboration and build local biomedical infrastructure21.Rapid and affordable antibody-based HIV and COVID-19 testing capacity must be escalated in the developing world. One possible strategy is to share plasmids with biomedical facilities in low- and middle-income countries, which could then locally produce the reagents for antibody-based testing, circumventing the high costs and waiting times associated with importing such tests from abroadIn summary, convalescent plasma therapy holds promise as an emergency transient treatment for critical COVID-19 patients. Nevertheless, it is of utmost importance to emphasize that, unlike chemicals, such as hydroxychloroquine, which can only harm the individual taking them, plasma therapy can endanger entire communities. In scenarios of scarce blood-borne pathogen testing capacities, few enforced regulations, and widespread misinformation and disease stigma, unregulated convalescent plasma therapy may well become a recipe for a new HIV epidemic in the developing world.