Therefore, we have updated Socket and made it accessible to expert and nonexpert users alike.Protein–protein interactions are central to all biological processes. One frequently observed mode of such interactions is the α-helical coiled coil (CC). Thus, an ability to extract, visualize and analyze CC interfaces quickly and without expert guidance would facilitate a wide range of biological research. In 2001, we reported Socket, which locates and characterizes CCs in protein structures based on the knobs-into-holes (KIH) packing between helices in CCs. Since then, studies of natural and Socket2, which rectifies this oversight to identify CCs with any number of helices, and KIH interfaces with any of the 20 proteinogenic residues or incorporating nonnatural amino acids. In addition, we have developed a new and easy-to-use web server with additional features. These include the use of NGL Viewer for instantly visualizing CCs, and tabs for viewing the sequence repeats, helix-packing angles and core-packing geometries of CCs identified and calculated by Socket2.The original Socket only classified CCs with up to six helices. Here, we report Socket2 has been tested on all modern browsers. It can be accessed freely at http://coiledcoils.chm.bris.ac.uk/socket2/home.html. The source code is distributed using an MIT licence and available to download under the Downloads tab of the Socket2 home page. CCs accn design , 2021, lThe interactions between CC helices are tight and well-defined. These are known as knobs-into-holes (KIH) interactions as first proposed by iSocket, a Python-based application programming interface  3D coordinate file in PDB format .mmCIF files: In 2019, wwPDB made the use of mmCIF file format compulsory for the depositions of crystallographic methods. The webserver handles uploaded mmCIF files with Socket2 program to run smoothly.Modified residues: The MODRES record can be used to handle any modified residues or to rename a residue. The webserver searches for the presence of modified residues and, if not present, it adds a corresponding MODRES record to the input file allowing the Socket2. Each participating helix of the CC is initially displayed in different colours. Knob residues can be highlighted in ball-and-stick representation. Residues can then be rainbow-colour-coded according to their heptad register a-to-g.Visualization of CCs: Use of NGL Viewer allows an immediate inspection of any identified CCs, providing users an advantage over using the standalone version of Socket2 assigns a-to-g heptad registers to each chain of each identified CC. The webserver tabulates the name, number and heptad position for every residue (Data representation:  residue , allowin residue , and cor residue .Separate tabs for each CC: Structures may have one or more CCs. The webserver generates ‘Results’ tab for each CC to aid quick switching, inspection and analysis of these in large protein structures.Metadata: The ‘Results’ tab also provides links to text files giving the detailed Socket outputs. a PyMol script allowing off-line visualization of the annotated CCs in PyMol , and helSocket2 and data generated from it will be of use in gathering CC sequence statistics and structural parameters to improve sequence-to-structure relationships for CC-prediction (Socket2 webserver will provide a useful gateway to such studies for experienced and new users alike.We anticipate that ediction  and desiediction , 2021. ISocket2 to allow the identification of all possible CC architectures in multiple structure-file formats containing protein chains with proteinogenic or modified amino acids. The Socket2 program is freely available to download under an MIT licence from http://coiledcoils.chm.bris.ac.uk/socket2/home.html. In addition, a user-friendly, interactive, and freely available webserver has been designed to run the program, and to allow quick visual inspection of the identified CCs and associated structural and sequence data. We anticipate that these tools with be useful to new and experienced cell, chemical, structural and synthetic biologist interested in natural and designed CC domains.Socket has been upgraded to


Peripapillary hyperreflective ovoid mass-like structures (PHOMS) and dome-shaped macula (DSM) are 2 optical coherence tomography findings reported in 2018 and 2008, respectively. To date, there have been no ophthalmic case reports of concomitant PHOMS and DSM.A 19-year-old woman presented to our clinic with complaints of decreased vision in both eyes.The patient was diagnosed with PHOMS and a dome-shaped macula complicated by subretinal fluid in both eyes.A micropulse laser under the guidance of Indocyanine green angiography was applied to the hyperfluorescent areas and drugs to improve retinal microcirculation.No response to any intervention over the 41 months of follow-up, her visual acuity remained the same, and the subretinal fluid often recurred.PHOMS and DSM are associated with myopia; myopia may be a mediator between PHOMS and DSM. Dome-like structural changes may occur in different parts of the retina (optic disc and macula), caused by asymmetric myopic posterior scleral growth. PHOMSs are seen in many conditions, including papilledema, non-arteritic anterior ischemic optic neuropathy, central retinal vein occlusion, acute demyelinating optic neuritis, ODD, and tilted disks (myopic obliquely inserted disks), and in many cases resolve along with the underlying condition. For DSM, the normal shape of the macula detected on OCT is altered and inward bulging occurs in a dome-shaped formation. Choroidal neovascularization, serous retinal detachment, and retinal pigment epithelial (RPE) detachment are the most common macular complications that can occur during follow-up of dome-shaped macula.–6 To date, there have been no ophthalmic reports of concomitant PHOMS and DSM. In this report, we present the case of a young woman with PHOMS and dome-shaped macula in both eyes, complicated by recurrent subretinal fluid in both eyes.Peripapillary hyperreflective ovoid mass-like structures (PHOMS) and dome-shaped macula (DSM) were 2 optical coherence tomography (OCT) findings in 2018 and 2008, respectively.2A 19-year-old woman presented to our clinic with complaints of decreased vision in both eyes. The patient had a history of high myopia. Best-corrected visual acuity was 20/32 in both eyes. Spheric equivalents were−7.50 in the right eye and−6.50 in the left eye, respectively. The intraocular pressure was 17 mm Hg in the right eye and 15 mm Hg in the left eye. Ocular axial lengths were 25.23 mm in the right eye and 25.05 mm in the left eye. The anterior segment was bilaterally normal. Fundoscopy revealed retinal pigment epithelial changes between the macula and optic disc in both eyes; the boundary of the optic disc was blurred, and temporal choroid atrophy and leopard fundus changed . A wide range of therapies have been used to treat subretinal fluid and CNV associated with DSM, including oral eplerenone or acetazolamide, focal laser, intravitreal injections of triamcinolone and anti-vascular endothelial growth factor agents, and half-fluence/half-dose photodynamic therapy; however, these have not been shown to be effective in achieving a significant anatomic or functional response. In our case, horizontal DSM related to high myopia, recurrent subretinal fluid secondary to DSM, DSM had no response to micro-pulse laser and drugs to improve retinal microcirculation, and visual function was not significantly decreased, so it is important to observe the development rate of high myopia and the occurrence of CNV.DSM was first described by Gaucher et al in eyes with high myopia, an anterior convex protrusion of the macula towards the vitreous cavity observable on OCT.4In summary, PHOMS and DSM are associated with myopia, and myopia may be a mediator between PHOMS and DSM. Dome-like structural changes may occur in different parts of the retina (optic disc and macula), caused by asymmetric myopic posterior scleral growth. Attention should be paid to monitoring possible decreased visual function due to progressive damage to the RPE complex. The treatment of PHOMS is mainly aimed at the primary diseases. When DSM occurs in the subretinal fluid and CNV, timely anti-Vascular Endothelial Growth Factor therapy and treatment of the RPE barrierData curation: Da-Guang Bi.Resources: Wei Gu.Supervision: Xiao-Yan Peng.Writing – original draft: Wei Zhang.


Three major medical electronic databases were searched with predefined search strategies and publications were systematically evaluated according to the Cochrane Review Methods. Continuous variables were tested for mean differences using the inverse variance method and 95% confidence intervals (CI) were calculated. Based on the assumption that intervention effects across studies were not identical, a random effects model was chosen. Assessment for heterogeneity was performed with the χ2 test and the I2 statistic. As primary endpoints, Ppeak, Pplateau, Pmean, Cdyn, PaO2, and PaCO2 were evaluated. Of the 725 publications identified, 17 finally met eligibility criteria, with a total of 929 patients recruited. Under supine two-lung ventilation, PCV-VG resulted in significantly reduced Ppeak (15 studies) and Pplateau (9 studies) as well as higher Cdyn (9 studies), compared with VCV . For one-lung ventilation (8 studies), PCV-VG allowed for significantly lower Ppeak and higher PaO2 compared with VCV. In Trendelenburg position (5 studies), this effect was significant for Ppeak only. This systematic review and meta-analysis demonstrates that volume-targeting, pressure-controlled ventilation modes may provide benefits with respect to the improved airway dynamics in two- and one-lung ventilation, and improved oxygenation in one-lung ventilation in adults undergoing elective surgery.For perioperative mechanical ventilation under general anesthesia, modern respirators aim at combining the benefits of pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) in modes typically named “volume-guaranteed” or “volume-targeted” pressure-controlled ventilation (PCV-VG). This systematic review and meta-analysis tested the hypothesis that PCV-VG modes of ventilation could be beneficial in terms of improved airway pressures (P Mechanical ventilation is a common perioperative requirement, and modern respirators enable mechanical ventilation in a variety of modes . New venFor the most common form of perioperative ventilation, i.e., continuous mandatory ventilation (CMV), there has been an ongoing debate whether PCV or VCV may offer advantages or disadvantages for the general patient or in certain subpopulations, for specific perioperative procedures  or patient positioning  ,3. Up toFor laparoscopy and the Trendelenburg position, research showed potential advantages for PCV-VG in the perioperative setting, e.g., in terms of improved oxygenation and reduced airway pressures . HoweverA systematic review and meta-analysis were performed according to the PRISMA guidelines  and the NCBI/PubMed (including MEDLINE), Cochrane and EMBASE were searched for eligible studies using the general search strategy given in In- and exclusion criteria were based on the PICOS model ,10 and d®  in a blinded fashion based on the abovementioned criteria. An additional, independent referee (J.H.) dissolved discrepancies regarding the question whether a study should be included. Three reviewers  independently evaluated all search results using the program AbstrackRn); mode of ventilation; tidal volume; reference for tidal volume; airway pressures Ppeak, Pplateau, Pmean, dynamic compliance Cdyn, positive end expiratory pressure (PEEP); blood gas analysis: pH, paO2, paCO2; hemodynamic variables: heart rate, mean arterial blood pressure (MAP), central venous pressure (CVP); patient positioning; type of surgery; reporting of adverse events.Two reviewers (F.D. and A.M.) independently extracted the data from the included studies; again, an additional, independent referee (J.H.) dissolved discrepancies regarding the question whether or how a set of data should be included and confirmed data extraction. Data extraction was based on the predefined outcome criteria. The following variables were collected: number of patients (Two reviewers (F.D. and A.M.) independently evaluated the risk of bias for each publication using the Cochrane Risk of Bias tool version 2  ; resultsn = 3), standard deviations were estimated using the formula described in Section 6.5.2.5. of the Cochrane Handbook for interquartile ranges [n = 1), means and standard deviations were estimated using the method described by Hozo [The parameters outlined above were obtained from the included studies at the given time points. For publications stating interquartile ranges and medians . Continuous variables were tested for mean differences using the inverse variance method and 95% confidence intervals (CI) were calculated. Based on the assumption that intervention effects across studies were not identical, a random effects model was chosen . AssessmInitially, 724 publications in NCBI/PubMed, Embase, and Cochrane were identified. Additional records and manual search resulted in one study, for a total of 725 publications. After duplicates were removed, title and abstract of 372 publications were screened for selection according to the PICOS criteria specified above. Of those, 351 had to be excluded, resulting in 21 publications that were full-text assessed for eligibility. Four publications had to be excluded, finally resulting in 17 studies that underwent the following qualitative evaluation ,27,28. An = 10) were published within the last three years (2018–2020), and 94% of all studies (n = 16) were published within the last 7 years (2014–2020); no study was older than 10 years. Over 60% of the studies were performed in Asian countries (n = 11). There was no investigation from North or South America, Australia, Great Britain, or an EU country. For study characteristics, please see Within 17 publications included for this meta-analysis, a total of 929 patients were enrolled . Almost 60% of all investigations  was blinded with respect to the ventilation mode, or the study was explicitly not blinded in this regard. However, according to the Cochrane Risk of Bias methods, even if outcome assessors were aware of the intervention and if assessment of the outcome may—in theory—have been influenced by the knowledge of intervention received, it remains highly unlikely that assessment of the outcome was in fact influenced by the knowledge of the intervention received, as most endpoints were measured using objective, validated, or calibrated devices . Accordingly, risk of detection bias is only rated “high” for endpoints that are vulnerable to subjective evaluation , but not regarding measurements by calibrated devices. Therefore, the risk of detection bias (D4) was only moderate in this meta-analysis. Yet, for the same reason, risk of bias assessing adherence to intervention resulted in “some concerns” for a number of investigations included in this meta-analysis .peak, Cdyn, paO2, and paCO2) showed a significant heterogeneity by either I2 > 50%, a χ2 with a p < 0.10, or both. In the absence of relevant asymmetry, the random effects model was applied to all analyses. All included endpoints (Ppeak), 9 studies reported plateau airway pressures (Pplateau), and 13 studies reported mean airway pressures (Pmean) for supine two-lung ventilation without capnoperitoneum. Data for dynamic airway compliance (Cdyn) were available for nine studies. For all endpoints, data sets were chosen from the earliest time point under general anesthesia in supine position with sufficient equilibration for two-lung ventilation .Of the 17 studies included, 15 reported peak airway pressure  and arterial carbon dioxide pressure (PaCO2) for supine two-lung ventilation without capnoperitoneum. There was no significant difference between both ventilation modes with respect to arterial oxygen , 30 min (n = 3), and after 60 min (n = 4) of one-lung ventilation. As this set of data is different from the above with respect to time of measurement and patient position, these data are presented in a separate analysis below, and not included as a true subgroup. Peak airway pressures .Eight publications reported results for Ppeak was reported for 60 min of Trendelenburg positioning. Ppeak was significantly lower in patients ventilated with PCV-VG after 60 min in Trendelenburg position, compared with VCV under the same conditions .Five investigations presented various parameters for variable time points of Trendelenburg positions. In all studies, PHemodynamic parameters were reported only inconsistently or inhomogeneous and sometimes incomplete, and were therefore not evaluated further. In general, all investigators reported stable hemodynamic conditions for all patients. Further, no adverse events were detected with respect to the hemodynamic instability (see below).In eight publications, adverse events and various postoperative outcome parameters were explicitly reported . In all This systematic review and meta-analysis included 17 randomized, controlled trials that compared PCV-VG with VCV in 929 patients scheduled for elective major non-cardiac surgery under general anesthesia. PCV-VG aims at combining the advantages of VCV and PCV to ensure a target tidal volume with a decelerating flow. Depending on the previous breath, lung compliance is being calculated and the tidal volume is applied with the lowest inspiratory pressure possible [As this meta-analysis shows, peak airway and plateau pressures were significantly lower in patients ventilated with PCV-VG undergoing supine two-lung ventilation, compared with VCV. Regarding these endpoints, only three studies showed no difference for peak airway pressures, while the other twelve demonstrated moderately to significantly reduced peak airway pressures when using PCV-VG. These findings are in line with the previous meta-analyses comparing VCV and PCV—yet without volume targeting (“PCV-non-VG”)—resulting in significantly lower peak inspiratory pressures when using a PCV-non-VG mode, compared with VCV ,30. The peak and lower Pplateau than similar ventilation with VCV, this could have the potential to correspond with a decreased risk of ventilator-induced lung injury. This idea is supported by the (single) report on a significantly reduced neutrophil elastase after the use of PCV-VG [High airway pressures and large tidal volumes during mechanical ventilation are not part of a lung protective ventilation strategy and may therefore cause acute lung injury . As our f PCV-VG , as wellf PCV-VG . On the f PCV-VG . Yet, thThe clinical relevance of peak airway pressure for the development of barotrauma—especially in the course of intraoperative ventilation—is controversial. Some authors propose that peak airway pressure could not properly reflect the alveolar pressure ,32. On tEvaluation and interpretation of long-term effects using PCV-VG or VCV is challenging. Multiple postoperative outcome parameters were mentioned in eight out of the 17 publications. Only one study reported a significant difference for postoperative outcome parameters with reduced ICU and hospital stay in the PCV-VG group . Yet, whNo significant differences were seen for arterial oxygen pressure between VCV and PCV-VG. However, only four out of 15 included studies showed mild to moderate reductions in arterial oxygenation in the PCV-VG group, compared with the VCV group. Therefore, based on the reported data, serious disadvantages in respect of arterial oxygenation using PCV-VG cannot be postulated. In the same fashion, no significant differences were seen for arterial carbon dioxide pressure for both ventilation techniques. Data for airway compliance were extracted from nine studies. All of those included studies showed an improvement in compliances using PCV-VG compared to VCV. Accordingly, our analysis reveals significant superiority of the PCV-VG technique with respect to dynamic airway compliance as a functional lung parameter in mechanical ventilation. A subgroup analysis including nine studies for one-lung ventilation was carried out with regard to the parameters peak airway pressure, arterial oxygen pressure, and arterial carbon dioxide pressure. Comparable results for peak airway pressure were found, but a significantly higher arterial oxygen pressure was measured using PCV-VG. There were no significant differences in oxygen saturation. Changes in pressure conditions during one-lung ventilation, different measurement time, and patient positioning, however, were potential confounders that may blur these results. Most of the studies had excluded patients with poor preoperative pulmonary function or severe lung diseases. Assuming that this particularly critically ill patient group would benefit from PCV-VG, the effect of PCV-VG might have been underestimated. The mechanism for this beneficial effect of PCV-VG on oxygenation during one-lung ventilation remains to be established. It is tempting to speculate that PCV-VG might have an impact on the closing capacity during thoracic surgery. This could—in theory—be caused by the fact that the flow during PCV-VG is not fixed, potentially resulting in a higher ventilation of small airways in the environment of a higher extraluminal pressure. This meta-analysis has various limitations. First, PCV-VG is a relatively new mode of ventilation, and only 17 investigations fulfilled the inclusion criteria for our meta-analysis. Especially in subgroup analyses, a relatively small number of patients was included and the range of patients per study was 20–100, indicating that intervention effects could be significantly overstated in small study groups. Second, double blinding was not performed by all investigators due to the chosen study design and clinical needs. As discussed above, this should not have had a relevant impact on the results, as measurements of airway pressures and blood gases were performed using calibrated machines. Therefore, these data were not prone to subjective falsification. In accordance with the Cochrane Methods, the risk of bias due to this effect was consequentially only moderate, and we believe that the data are reliable. Third, all studies derived from selected regions of the world. This may theoretically have an impact on our findings, as loco-regional effects of a health-care system cannot be excluded completely. On the other hand, the objective measurement of the primary endpoints of this meta-analysis should not have been influenced by the origin of the studies.Fourth, regarding all primary endpoints as well as subgroup analysis for one-lung ventilation, measurements for airway pressures and blood gas analysis were taken at different time points . Therefore, for interpretation of the results, individual factors of each study member and surgical progress must be taken into account. Fifth, although data were generally symmetrical, most evaluations revealed a relevant heterogeneity of the studies included. To draw substantial conclusions for clinical practice, large-scale investigations with rigorous inclusion criteria would be needed. Due to the heterogeneity observed, the results need to be interpreted with caution.Finally, it was not possible to extract uniform long-term parameters as these were not reported regularly. Therefore, long-term effects due to different intraoperative ventilation strategies  cannot be assessed. However, this was not a primary endpoint of this investigation.Yet, this meta-analysis has also certain strengths: to our knowledge, this is the first systematic review of PCV-VG compared with VCV. Further, this investigation includes the data of over 900 patients from 17 prospective, randomized trials. Over 90% of the data is relatively new (2014+) and derives from relatively homogenous populations. All endpoints were obtained using strictly objective measurements with a very low risk of bias. Consequently, overall risk of bias in all studies was low to moderate and intervention effects were, to the best of our knowledge, properly estimated. Further, measurements for mechanical ventilation and gas exchange have been well reported. All recorded endpoints were related to the intraoperative or direct postoperative period. Therefore, this meta-analysis—despite some limitations—may add a significant amount to our knowledge on intraoperative ventilation regarding this new volume-targeting ventilation mode, PCV-VG. Our investigation raises an important clinical question: Based on our findings, should this new mode of ventilation, PCV-VG, be routinely used in the perioperative setting? From a historical perspective, many modern ventilation modes have failed to allow for significant, long-term improvements of clinical practice. Yet, PCV-VG has the potential to combine two former “opponents” of ventilation in a single mode of action. As Ball and colleagues have put it into words, PCV-VG appears to offer “undoubted clinical advantages” . WhetherThis systematic review and meta-analysis indicate that PCV-VG may provide benefits in terms of improved airway dynamics compared to VCV in adults undergoing elective non-cardiac surgery. PCV-VG appears to be a safe ventilation technique without relevant disadvantages or even inferiority, with respect to the evaluated endpoints. In two lung-ventilation in supine position, peak airway and plateau pressure were significantly lower and dynamic compliance was significantly higher for PCV-VG-ventilated patients. In one-lung ventilation, peak airway pressures and oxygenation were improved. Overall, the use of the PCV-VG technique for intraoperative ventilation appears to be beneficial, although valid data of long-term outcome parameters for distinct ventilation modes remain to be established.


Bats have been increasingly gaining attention as potential reservoir hosts of some of the most virulent viruses known. Numerous review articles summarize bats as potential reservoir hosts of human-pathogenic zoonotic viruses. For European bats, just one review article is available that we published in 2014. The present review provides an update on the earlier article and summarizes the most important viruses found in European bats and their possible implications for Public Health. We identify the research gaps and recommend monitoring of these viruses. This might contribute to the lower number of viruses detected in Europe and North America. Nevertheless, the viral richness discovered in European bats is high. Bat viruses have been gaining worldwide attention following the outbreaks of SARS-Coronavirus (CoV), SARS-CoV-2, Nipah virus, Hendra virus, and Ebola virus. Worldwide sequences of 12,476 bat-associated viruses are available at NCBI Genbank and DBatVir (accessed on 31 March 2021) . . 219]. European bat species can be allocated to either one of three biogeographical groups, the Mediterranean, the Temperate, and the Boreal zone . CurrentAnother model by McCain found previously that the abundance of bats seems to be positively correlated with species richness; this suggests that bat species richness may also be related to productivity . This meBoyles et al. considered bats to be among the most economically important non-domesticated animal groups because of their important ecological roles as top predators and pollinators. Subsequently, in regions of bat diversity loss through climate change, the insect pest abundance would increase and pollination of food plants would be reduced . Miniopterus schreibersii, LLOV; Rhinolophus ferrumequium, SARS-like CoV) and would, according to climate models, thus be directly affected by climate change. The assessment of the risk of zoonotic spillover of bat-borne viruses is of major importance for public health ,227. OneBat research is not limited to virus discovery. Many disciplines study bats as one of the most special order of mammals. They are the subject of multifaceted studies investigating among others their bacteria, immunology, behavior, conservation, ecology, migration, echolocation, and evolution. They serve as model for e.g., the development of bionic aerodynamics and even mobility aid for the blind ,230. ForPteropid bats stress can result in higher virus-shedding rates, as was already shown for Hendra virus and Nipah virus [In the context of the origins of the SARS-CoV-2 pandemic the question has arisen if the examination of bat hosts will facilitate virus emergence. Investigation, whether invasive or non-invasive, is stressful for the bats. A study investigating the stress-induced hypothermia (SIH) of silver-haired bats found that SIH is effected by capture and handling of the bats . Followiah virus ,234,235.Bringing samples to the lab and propagating bat virus creates possibilities of human–bat–virus interaction that would most likely not have occurred in nature. It is unlikely for laboratory workers to get infected by a virus in the laboratory, although lab accidents are reported. Following the SARS-CoV epidemic, three possible accidental laboratory-acquired infections were reported in Singapore, Taiwan, and China ,238,239.Rousettus agyptiacus) assumed transient infections after intra-nasal infection of nine bats with 10 × 5 TCID50 of SARS-CoV-2 [Rousettus aegyptiacus bats were infected intranasally with a SARS-like CoV (WIV1-CoV), resulting in no signs of viral replication in the bats’ tissues [Eptesicus fuscus with SARS-CoV-2 in the US, did not find any evidence of successful viral replication in these bats [Rhinolophidae. So far, the bat CoV closest related to SARS-CoV and SARS-CoV-2 were detected in Rhinolophus sinicus and Rhinolophus affinis in China, respectively [Rousettus aegyptiacus and Eptesicus fuscus with SARS-CoV-2 have only limited significance as CoV are described as strongly host specific. The SARS-like CoV in Europe were predominantly detected in Rhinolophus hipposideros, R. ferrumequinum, and R. blasii. To determine whether European bats are susceptible to SARS-CoV-2, European bats of the family Rhinolophidae would have to be investigated in further studies. In this proposed study it should also be investigated whether the viral loads excreted by a SARS-CoV-2-infected person were sufficient for an air-borne infection of the bats. For SARS-CoV-2 an average viral load in sputum of 7.00 × 10 × 6 copies per ml is reported [Rhinolophus spp. are related to the Asian Rhinolophidae and host jumps may result in only lower evolutionary pressure. Phylogeographical reconstruction of the evolutionary history of the greater Horseshoe bat (Rhinolophus ferrumequinum) across Europe and west Asia revealed that nearly all of the European Rhinolophus ferrumequinum species were made up by a single haplotype spread from west Asia throughout Europe approximately 40,000–60,000 years ago [Vice versa, especially during the current pandemic, we also have to discuss the possibility of anthropozoonoses. Human-to-animal transmissions of SARS-CoV-2 have already been described for minks, cats, and dogs ,243,244.RS-CoV-2 . Three nRS-CoV-2 . This is tissues . Anotherese bats . As alreectively . The desreported . Neverthreported . During reported ,255,256.ears ago . On the https://www.fledermausschutz.de/2020/12/29/fledermausschutz-empfehlungen-zur-kontrolle-von-winterquartieren-in-zeiten-von-corona/, accessed on 22 June 2021).As long as no further data are available to rule out a potential risk of anthropozoonotic transmission, it is good practice that bat volunteers and researchers wear FFP2 masks and gloves to prevent air-borne zoonotic and anthropozoonotic transmission, as is already recommended by most bat rehabilitation foundations . All of these methods aim to find structures and genes related to human-pathogenic viruses. Virus isolation enables animal experiments, cell culture experiments, metatranscriptomics, and serostudies. Especially the availability of cell cultures of potential reservoirs is increasing which can be used for receptor studies and provide opportunities to examine species barriers. Proteomics, modeling, and many more techniques are more comprehensively available. Serosurveys in human and bat hosts are of importance, as they can give a retrospective picture of infection occurrence. However, the only indubitable proof of a zoonotic infection is the repeated isolation (persistence) of a virus from animal host and human. Numerous general factors contribute to a potential risk of spillover, ranging from the abundancy of potential bat vectors to the innate immune response of the human hosts ,257. We We have compared available data for those viruses which in our opinion may pose a potential threat to public health, based on their virological properties like relatedness to known human-pathogenic viruses . We fillSummarized, criteria used were (1) relatedness to a viral species known to induce severe diseases in humans; (2) viral RNA load shed by host species in copies/µL; (3) successful virus isolation; (4) infectious virus shedding; (5) potential route of transmission; (6) hints of epizootic or zoonotic transmission; (7) migration behavior of bat host; (8) IUCN threat; and (9) synanthropic behavior. These criteria were selected in accordance with the available literature ,257,260.Miniopterus schreibersii in Spain and Hungary. As most Filoviruses are described to be highly pathogenic for humans, the occurrence of LLOV should be carefully monitored. Miniopterus is a seasonally migrating species with flying distances between a few hundred and 800 km. There must be more Miniopterus schreibersii colonies in between Spain and Hungary that could serve as potential reservoirs of LLOV. It is assumed that the Spanish and French bats migrate from Africa through the Rhône valley and the Hungarian bats migrate over the eastern route through Turkey. However, the colonies of Miniopterus schreibersii have exchanges at a certain level. This would be a great opportunity to bundle ecological and virological expertise and skills throughout Europe to monitor and evaluate the occurrence of LLOV in Miniopterus schreibersii. Bat researchers of all countries participating could sample Miniopterus schreibersii colonies in their respective geographical research area. All samples could be investigated with the same coordinated methods, allowing to get a picture of LLOV prevalence in Europe. Furthermore, LLOV has been associated with mass mortality in Miniopterus schreibersii; raising awareness for this phenomenon across Europe could improve the timely investigation of LLOV emergence. This is just one example [Survey of European wildlife  should be increased because the risk of zoonotic emerging diseases in Europe seems neglected. So far, several studies have enlightened the virome of European bats, many of which are comparable. However, research is also competitive in publishing the first sequences of certain viruses. Maybe it is time to overcome this because so much more could be achieved with a collaborative initiative. If bat researchers combined their skills and finalized a certain strategy it would become possible to address the missing gaps collaboratively. For example, a bat Filovirus (LLOV) was detected in  example ,69.People are increasingly concerned about the risk posed by synanthropic bats . Viruses have been detected in numerous synanthropic species, therefore a potential for transmission is given , though preventable by simple measures: No touching or handling of bats or bat excrements without gloved hands and, in the case of a bat bite, immediately proceeding to the appropriate facility for post-exposure prophylaxis . Based oThe intensified research effort on bat CoV after the emergence of SARS-CoV allowed for the rapid identification of SARS-CoV-2 and its potential reservoir host. This is an excellent example of the importance of knowing viruses harbored by bats for preparedness against emerging infectious diseases . In most


A 58-year-old male was admitted to our hospital due to lasting fever, progressive lymphadenopathy and bicytopenia, with a previously histological diagnosis of follicular lymphoma grade 3a with Epstein–Barr virus-encoded RNA positive one month ago. A second biopsy of axillary lymph node revealed concurrent diffuse large B-cell lymphoma with Epstein–Barr virus-encoded RNA positive. Another diagnosis of hemophagocytic lymphohistiocytosis secondary to Epstein–Barr virus positive diffuse large B-cell lymphoma was further concluded by clinical manifestation, laboratory test and atypical lymphocytes in peripheral-blood smear. After a pulse of steroid pre-phase treatment, the patient’s clinical condition deteriorated and died in two weeks. The presence of Epstein–Barr virus infection in patients with follicular lymphoma is associated with more aggressive clinical course and increased risk of high-grade transformation. Hemophagocytic lymphohistiocytosis in response to Epstein–Barr virus infection or lymphoma remains fatal. Early diagnosis and initiation of treatment may improve the outcome. It is fs (LCLs) . It has Follicular lymphoma (FL) is the most common indolent and second most common non-Hodgkin lymphoma subtype. EBV-positive follicular lymphoma is a poorly characterized disease and is only rarely reported. It was described to share some similarities with EBV-positive diffuse large B cell lymphoma (DLBCL), especially in EBV positivity predominantly within large lymphoma cells, presence of EBV in latency II or III, lack of morphological or immunophenotypic features that predict EBV positivity, and lack of history of immunosuppression . BesidesEBV is also the most common infection highly associated with HLH, which is a rare syndrome of severe, life-threatening hyperinflammation. The underlying pathophysiology of HLH is the impaired activity of cytotoxic T lymphocytes and natural killer (NK) cells, leading to uncontrolled immune activation, hypercytokinemia, and macrophage proliferation. EBV-associated HLH is thought to be particularly prevalent in Asia with a fatal rate of up to 50% . This maHere, we reported a very rare case of a patient with EBV-positive DLBCL accompanied with HLH may involve from EBV-positive FL within one month. This is a rare case of EBV-driven FL histological transformation as well as HLH in an immunocompetent patient.A previously healthy 58-year-old man presented with a 2-month history of generalized lymphadenopathy, fatigue, night sweat, and weight loss. The Computed Tomography (CT) of the upper abdomen showed splenomegaly, multiple lymph nodes in the retroperitoneum and hilar region. An excisional biopsy of the left cervical lymph node was performed and histopathologic examination reported high-grade B cell lymphoma. The bone marrow involvement was excluded by flow cytometry and histology. The patient has no human immunodeficiency virus (HIV) viremia or evidence of immunosuppression.2 copies/ml) and cellular EBV DNA (3.81 × 104 copies/ml) were detected by quantitative PCR. A complete work-up was done including routine blood tests which showed leukocytosis, anemia, thrombocytopenia, coagulopathy, hypertriglyceridemia, hypoalbuminemia, hyperferritinemia, and elevated lactate dehydrogenase, and so on .EBV-associated follicular lymphoma is poorly characterized and only rarely reported. A recent retrospective study of 382 follicular lymphoma patients suggested that the prevalence of EBV infection in the FL is about 2.6% in Western populations . The pat2 copies/ml from zero and lymphoma cells spread quickly to the bone marrow. Elevated levels of EBV DNA in the blood of transplant recipients were reported to be associated with an increased risk of developing post transplanted lymphoproliferative disorders (PTLD). Some studies have certified that EBV infection was implicated as an etiologic risk in the Ritcher’s transformation of CLL to Hodgkin-like lymphoma, and the presence of EBV-EBER-1 and EBV-encoded latent membrane protein-1 (LMP1) mRNA in patients with CLL was associated with poor outcomes (versus EBV-negative) in the same patient may be a useful method.In our case, the initial diagnosis was grade 3A FL with EBER and CD30 expression and without evidence of immunodeficiency. Within a month, this patient followed an unusually aggressive clinical course with lasting high fever, rapidly enlarging lymphadenopathy, and cytopenia. Another biopsy is in urgent need and the result led to another diagnosis of EBV-positive DLBCL, while cell-free EBV-DNA raised to 5.42 × 10outcomes –10. Mackoutcomes Figure 3outcomes . Dereguloutcomes . In addioutcomes . Kim et outcomes . Ma et aoutcomes . These fA clinical diagnosis of HLH was suspected when our patient developing symptoms of hepatosplenomegaly, cytopenia besides persistent fever, while the EBV DNA in the plasma was significantly high. This diagnosis was further confirmed by laboratory examinations according to revised diagnostic criteria of HLH-2004 . The maiBone marrow involvement of lymphoma appears to be another risk factor for developing HLH in our case. Prior studies had noticed that bone marrow involvement is related to increased risk of developing HLH in patients with T-cell lymphoma and extranodal NK/T-cell lymphoma . Yeh et The management of HLH remains challenging. Once EBV-positive DLBCL was diagnosed, a pre-phase treatment comprising steroid was initiated to reduce tumor burden and facilitate the clearance of viruses residing in these cell populations. However, the patient died of multiple organ failures in two weeks. Currently, in addition to HLH-directed therapies, treatment of underlying triggers is recommended. The anti-CD20 antibody rituximab can deplete EBV-harboring B cells and improve the outcome of EBV-associated HLH . ChellapThese findings remind us of the significance of the identification of EBV infection, histological transformation, as well as bone marrow involvement in patients with high-grade follicular lymphoma who experience a very aggressive clinical course. Further studies are required to solve these questions regarding whether there is a prognostic or therapeutic significance of identifying EBER, AID, and CD30 expression in FL, and whether identifying if an EBV-positive DLBCL has derived from another EBV-positive lymphoma especially FL has clinical significance. The presence of Epstein–Barr virus infection in patients with follicular lymphoma is associated with a more aggressive clinical course and increased risk of high-grade transformation. Hemophagocytic lymphohistiocytosis in response to Epstein–Barr virus infection or lymphoma remains fatal . Early dThe original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The patients/participants provided their written informed consent to participate in this study.HX composed the manuscript and literature review. XX, WC and MX provided figures and pathology interpretation. GC, JF, RJ, HC, LZ and YH had the acquisition, analysis or interpretation of data for the work, and final approval of the version to be published. All authors contributed to the article and approved the submitted version.The project was supported by the National Natural Science Foundation of China (No.81400172).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.


We present NCBI-taxonomist—a command-line tool written in Python that collects and manages taxonomic data from the National Center for Biotechnology Information (NCBI). NCBI-taxonomist does not depend on a pre-downloaded taxonomic database but can store data locally. NCBI-taxonomist has six commands to map, collect, extract, resolve, import and group taxonomic data that can be linked together to create powerful analytical pipelines. Because many lifescience databases use the same taxonomic information, the data managed by NCBI-taxonomist is not limited to NCBI and can be used to find data linked to taxonomic information present in other scientific databases.https://gitlab.com/janpb/ncbi-taxonomist and via PyPi (https://pypi.org/project/ncbi-taxonomist/), as a Docker container (https://gitlab.com/janpb/ncbi-taxonomist/container_registry/) and Singularity (v3.5.3) image (https://cloud.sylabs.io/library/jpb/ncbi-taxonomist). NCBI-taxonomist is licensed under the GPLv3.NCBI-taxonomist is implemented in Python 3 (≥3.8) and available at  Retrieving and managing taxonomic information is central to many biological studies. Taxonomic information is often crucial metadata that helps in the organization of other biological datasets and represents a simple way to navigate and search the ever-increasing amount of data generated by genome-sequencing studies. Here, we present NCBI-taxonomist, a Python command line tool for the retrieval and handling of taxonomic information from the ‘Taxonomy Database’  and to construct more advanced taxonomic queries using boolean operators. These queries can be performed on the NCBI website or via the E-Utilities . The forhttps://ftp.ncbi.nih.gov/pub/taxonomy/). The current size of the compressed taxonomic database download is approximately only 50 MB (Megabytes). However, the download consists of several files, together producing ∼354 MB of data, and contains dumps of the taxonomy database tables. These files need to be updated with every new release of the Taxonomy Database. This necessarily increases complexity because of the need to parse and maintain local taxonomy databases. In contrast, NCBI-taxonomist can retrieve taxonomic information on-demand and does not require the user to download the entire taxonomic database; rather, it can locally store taxonomic information. NCBI-taxonomist implements all operations that can be performed in NCBI’s Taxonomy Database, in addition to creating user defined groups for selected taxa and a more versatile sub-tree command. NCBI-taxonomist is written in Python 3 (≥3.8) and the only dependency outside of the Python standard library is entrezpy. All interactions with Entrez, such as the use of NCBI API keys or control of the request frequencies are handled by entrezpy and described in further detail in its documentation. Because we developed and maintain entrezpy, which itself has no external dependencies, NCBI-taxonomist is less prone to suffer ‘dependency hell’ (https://en.wikipedia.org/wiki/Dependency_hell) and remain stable and available.Existing software that requires taxonomic data, for instance ETE3 (https://pypi.org/). The source code is available at https://gitlab.com/janpb/ncbi-taxonomist and the documentation at https://ncbi-taxonomist.readthedocs.io/en/latest/. In addition, a Docker container and Singularity image (https://stedolan.github.io/jq/) are available. The Docker container can be obtained using the command docker pull registry.gitlab.com/janpb/ncbi-taxonomist: latest and the Singularity container using the command singularity pull library://jpb/ncbi-taxonomist/ncbi-taxonomist.NCBI-taxonomist is licensed under the GNU General Public License v3 (GPL v3) and can be downloaded from PyPi (https://stedolan.github.io/jq/). For convenience, we also added XML output formats for each command. Because processing tab or comma separated outputs  are widely used, we show examples on the online manual how to use jq to select attributes from the JSON output and convert them into TSV or CSV. Individual NCBI-taxonomist commands can be chained together using pipes to create powerful, taxonomy-related pipelines for automated taxonomic retrieval and management; for instance, a collect command can be directly linked to create a local database and add the fetched taxa into a user specified group for later retrieval  as input (as input .ncbi-taxonomist map maps taxids to taxon names, and vice versa. In addition, it can map sequence and protein accessions to taxids. Currently, accessions from the following Entrez databases are supported: assembly, bioproject, nucleotide and protein ( protein .ncbi-taxonomist resolve resolves the lineages for taxids and taxon names (on names . To resoon names .ncbi-taxonomist subtree extracts all lineages for specific ranks from given taxids or taxon names. If only one rank is given, only the taxonomic information for this rank is extracted. If an upper, that is, closer to the root, rank is specified, all lineages from the given rank to the lowest rank are returned. If a lower—further from the root—rank is given, all lineages from the lower rank to the root are returned. If an upper and lower rank are given, all lineages between these two ranks are returned (returned .ncbi-taxonomist group adds taxa obtained from a query to a user-specified group. Each taxon can belong to several groups. This allows the user to create specific collections based on non-taxonomic relations (elations .ncbi-taxonomist import reads query results from standard input and stores the taxa locally in an SQLite database. This allows the creation of experiment-specific taxonomy databases. It also stores the parsed taxa while printing the received input to standard output and therefore does not need to be the last step of a NCBI-taxonomist pipeline (pipeline .The versatility of NCBI-taxonomist allows it to be used for quick look-ups or to be integrated into more complex pipelines to manage or create experiment-specific taxonomic subsets. The ability to link taxonomic information to related datasets on NCBI and other life science databases via existing tools make NCBI-taxonomist a powerful approach to collecting and managing taxonomic data.This work was supported by the ARC Australian Laureate Fellowship [FL170100022] awarded to E.C.H.Conflict of Interest: none declared.


Scientific Reports 10.1038/s41598-020-59131-y, published online 07 February 2020Correction to: The original version of the Article contained an error in the Author Information section, where the statement of equal contribution was implemented erroneously: “These authors contributed equally: Ji Ho Lee, Jinhyung Cho and Kun Sang Lee.”. Ji Ho Lee is the first author, Jinhyung Cho is the second author and Kun Sang Lee is the corresponding author of this Article.The original Article has been corrected.


Background/Aim: Several observational studies showed a significant association between elevated iron status biomarkers levels and sepsis with the unclear direction of causality. A two-sample bidirectional mendelian randomization (MR) study was designed to identify the causal direction between seven iron status traits and sepsis.Methods: Seven iron status traits were studied, including serum iron, ferritin, transferrin saturation, transferrin, hemoglobin, erythrocyte count, and reticulocyte count. MR analysis was first performed to estimate the causal effect of iron status on the risk of sepsis and then performed in the opposite direction. The multiplicative random-effects and fixed-effects inverse-variance weighted, weighted median-based method and MR-Egger were applied. MR-Egger regression, MR pleiotropy residual sum and outlier (MR-PRESSO), and Cochran's Q statistic methods were used to assess heterogeneity and pleiotropy.Results: Genetically predicted high levels of serum iron , ferritin  and transferrin saturation  were associated with an increased risk of sepsis. No significant causal relationships between sepsis and other four iron status biomarkers were observed.Conclusions: This present bidirectional MR analysis suggested the causal association of the high iron status with sepsis susceptibility, while the reverse causality hypothesis did not hold. The levels of transferrin, hemoglobin, erythrocytes, and reticulocytes were not significantly associated with sepsis. Further studies will be required to confirm the potential clinical value of such a prevention and treatment strategy. Iron is considered an essential nutrient for both humans and pathogenic microbes. Iron limitation defends pathogenic microbes as a key form of innate immune, termed “nutritional immunity” , 2. InteSepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection . AlthougSeveral observational studies showed that patients with sepsis had significantly elevated levels of serum iron, ferritin, and transferrin saturation, but transferrin level was in the opposite direction –11. NeveThis study adhered to the STROBE-MR guidelines  and the https://gwas.mrcieu.ac.uk/)  from 11 cohorts (SD = 17.84). The summary-level GWAS data of the other three biomarkers  were available from a previous study, which was the re-analysis and meta-analysis result  from three GWAS cohorts  . The gen cohorts . For the cohorts . Fifty-tSummary-level data of GWAS for sepsis were obtained from a re-analysis study, in which the subjects included 10,154 sepsis cases and 452,764 controls from UK Biobank , 22. WomGenotype imputation and associated quality control procedures have been previously described –22. To cp < 5 × 10−8) and independent inheritance  without any linkage disequilibrium (LD) from GWAS summary data of iron status or sepsis. The SNPs with LD were identified and excluded by a clumping algorithm based on the 1,000 genomes reference panel. We also removed the SNPs with palindrome allele (A/T or G/C) to prevent strand ambiguity issues.Genetic instrumental variables were selected using the TwoSampleMR R package (version 0.5.6). We selected single nucleotide polymorphisms (SNPs) with a strong association -based method and MR-Egger statistical sensitivity analyses to ensure the robustness of pleiotropic IVs  and fixed-effects (FE) inverse-variance weighted (IVW) were used to assess the causal associations between iron status and the risk of sepsis. The effect measures were the odds ratio (OR) of the risk of sepsis, which was normalized to one opic IVs . A p-valhttps://www.ebi.ac.uk/gwas/) (https://pubmed.ncbi.nlm.nih.gov/). Second, a combination of the MR-Egger regression and MR pleiotropy residual sum and outlier (MR-PRESSO) methods were used to estimate the unknown directional pleiotropy. However, MR-Egger and MR-PRESSO analyses typically require more than 3 IVs   and PubMan 3 IVs . The MRPQ statistic was used to assess the heterogeneity of the instrument variable. The random-effects IVW model was used if the substantial heterogeneity was significant , ferritin , and transferrin saturation  were associated with an increased risk of sepsis. Results were consistent across random effect IVW and WM . Nevertheless, substantial heterogeneity among estimates of individual SNPs was detected in the analysis of Transferrin levels . Thus, the random effect IVW model was employed, of which the results showed no significant association .Conversely, low transferrin levels were significantly associated with increased risk of sepsis  and rs855791 (TMPRSS6) were associated with a significant effect of serum iron or transferrin saturation on sepsis, while SNPs rs1800562 (HFE) and rs2413450 (TMPRSS6) were significantly related to the causal effect of ferritin on sepsis . Using tThe second set of MR analyses aimed to assess potential causal effects of sepsis on iron status , 5. ResuIron is needed mainly for hemoglobin and erythrocytes production, therefore, we wondered whether the levels of hemoglobin, erythrocytes, and reticulocytes could affect the risk of sepsis and whether sepsis could influence the level of this biomarker. The results of MR analysis suggested no statistically significant effects on whether the sepsis served as exposure or outcome, which agreed with the results of sensitivity analyses . A randoIn this bidirectional MR study, we investigated the association of iron status biomarkers with the risk of sepsis, of which genetic variants that proxy the effect were identified from publicly available large-scale GWAS data. Our findings showed evidence that genetic predisposition to higher levels of serum iron, ferritin, and transferrin saturation was causally associated with a higher risk of sepsis. Genetic predisposition to sepsis did not appear to influence any of the studied iron status markers concentration .In contrast with the previous MR studies of iron status , 30, thevia dysregulated host-pathogens interaction , including serum iron (GWAS ID: ieu-a-1049), transferrin (GWAS ID: ieu-a-1052), transferrin saturation (GWAS ID: ieu-a-1051), ferritin (GWAS ID: ieu-a-1050), hemoglobin (GWAS ID: ebi-a-GCST004615), erythrocytes count (GWAS ID: ebi-a-GCST004601), reticulocytes count (GWAS ID: ebi-a-GCST004622), and sepsis (GWAS ID: ieu-b-69).This data can be found at: Publicly available datasets were analyzed in this MR study. GWAS summary-level datasets were downloaded from IEU OpenGWAS Project , Shandong Medical and Health Technology Development Project (2018WS193), and Qilu Wellness and Health Leading Talent Training Project in 2020.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Is the transition to remote cardiology ambulatory visits during the COVID-19 pandemic associated with disparities in patient access to care, ordering of diagnostic tests, and/or medication prescribing?In this cross-sectional study of 176 781 ambulatory cardiology visits, patients using COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals, have private insurance, and have cardiovascular comorbidities. Compared with pre-COVID in-person visits, clinicians during COVID-era video and telephone visits had a significantly lower odds of ordering any medication as well as most tests.Remote cardiology clinic visits were used more often by certain traditionally underserved patient groups but were also associated with less frequent testing and prescribing. This cross-sectional study examines ambulatory cardiology clinic visit data and whether the transition to remote visits during COVID-19 is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing. The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits.To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing.This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021.In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period.Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone).P < .001 for all comparisons), have private insurance , and have cardiovascular comorbidities . After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication  or tests, such as electrocardiograms  or echocardiograms .This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing. As there is currently a paucity of formal guidelines specifying best practices for remote cardiology visits, there may be unintended consequences from this new form of care that have yet to be identified.To test these hypotheses, we characterized the patient demographic characteristics and clinician ordering frequencies of medications and diagnostic tests at the visit level for all remote and in-person ambulatory cardiology visits at our multisite health system in the COVID-era period. We then compared these visits to those from the same period one year before, during the pre-COVID period.STROBE) reporting guideline for methods and results.12This cross-sectional study protocol was approved by the Cedars-Sinai Medical Center institutional review board. A waiver of participant consent was obtained given that the study used limited identifying information and there was no interaction with participants or impact on their clinical care. We followed the Strengthening the Reporting of Observational Studies in Epidemiology  platform (Epic Systems) or third party vendor . The COVID period of April 1, 2020, to December 31, 2020, was chosen as it was when remote visits were most frequent. The comparator cohort (pre-COVID) from April 1, 2019, to December 31, 2019, was used to minimize seasonal fluctuations in patient composition and ordering practices. Individual patients could have multiple included visits during the study period.For study estimators, we used visit-level encounter information available from the EHR to determine visit type , patient demographic characteristics, visit date, number of visits per patient during the study period, scheduled visit duration, clinician, encounter diagnoses, and all diagnostic and medication orders associated with each visit. For study outcomes, we investigated the ordering frequencies of the most common cardiology-specific diagnostic tests including electrocardiograms (ECGs), transthoracic echocardiograms (TTEs), coronary computed tomography angiography (CCTA), nuclear stress imaging, stress echocardiogram, exercise stress ECG, coronary artery calcium scan, cardiac magnetic resonance imaging (MRI), and external ECG monitoring tests (such as Zio patch monitors). Laboratory tests of interest included B-type natriuretic peptide (BNP), lipid panel, complete blood count, metabolic panel, coagulation studies, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests. We visualized the ordering frequencies of tests and medications by visit type categorized by month alongside local daily COVID-19 case rates in Los Angeles County as reported by the Los Angeles County Department of Public Health.2 test. Differences in continuous variables were evaluated using the t test or analysis of variance (ANOVA) test for multiple groups.Visits were stratified by time period (pre-COVID vs COVID era) and visit type (in-person vs video vs telephone). All ambulatory visits in 2019 were in person, which resulted in 4 main visit types: pre-Covid in-person, COVID-era in-person, COVID-era video, and COVID-era telephone. For each visit type, patient and visit characteristics were expressed as frequency counts and percentages. We compared rates of medication and diagnostic test ordering by visit type. The differences in discrete variables between groups were evaluated by the χTo adjust for the effects of patient and visit characteristics on ordering patterns, we performed multivariable regression. We used multivariable linear regression to study the association between visit type and the number of diagnostic tests ordered per visit. We used multivariable logistic regression to study the association between visit type and the odds of ordering at least one medication or one test as well as the odds of ordering individual diagnostic and laboratory tests. All multivariable analyses adjusted for patient demographics and visit characteristics that would potentially affect clinician ordering patterns  as well as calendar date (month and day) to account for potential changes in practice patterns as the pandemic progressed. Multivariable analyses additionally adjusted for individual clinicians  to account for possible differences in practice patterns across different clinicians. Analyses studying ordering practices over time did not adjust for calendar date, because patients were already stratified by month. All hypothesis testing was 2-sided and results were evaluated with a significance level of α = .05. All analysis was performed with R statistical software version 3.4.1  from November 2020 to February 2021.P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). Although patients from underrepresented racial and ethnic groups were seen at similar or slightly lower rates in the COVID-era period, they constituted a larger proportion of remote visits  . A larger proportion of remote visits were also with patients who had private insurance . Patients seen by remote visit had more cardiovascular comorbidities, including hypertension , coronary artery disease , atrial fibrillation or flutter , heart failure , and chronic kidney disease (3579 pre-COVID in-person visits (4.1%) vs 3112 COVID-era in-person visits [4.2%] vs 243 COVID-era video visits [5.1%] vs 827 COVID-era telephone visits [8.0%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). Despite having more comorbidities, patients seen by remote visit had fewer mean (SD) visits overall during the study period .The study cohort included 176 781 ambulatory cardiology visits, with 87 182 of these being in-person visits in the pre-COVID period, 74 498 COVID-era in-person visits, 4720 COVID-era video visits, and 10 381 COVID-era telephone visits. Among all visits, 79 572 patients were female (45.0%), 127 080 patients were Non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Although all visits in the pre-COVID cohort were in-person, 10 381 visits (11.6%) in the COVID-era cohort were by telephone and 4720 visits (5.3%) were by video. Comparison of baseline characteristics between the 4 visit types  demonstrated many statistically significant differences, and several clinically meaningful ones . PatientWhen comparing ordering practices between pre-COVID in-person, COVID-era in-person, COVID-era video, and COVID-era telephone visits, we found a decrease in the proportion of visits where at least one medication was ordered . The proWhen visualizing ordering practices over time, it appeared that rates of ordering tests and medications generally went up during months when there were lower COVID-19 daily case numbers and down when COVID-19 case numbers increased . HoweverIn an analysis of 176 781 ambulatory cardiology visits, we found significantly higher use of remote cardiology clinic visits among Asian, Black, and Hispanic individuals, those with private insurance, and those with cardiovascular comorbidities. We also identified a stepwise reduction in the ordering frequency of both diagnostic tests and prescription medications when comparing pre-COVID with COVID-era in-person and COVID-era video and COVID-era telephone visits. To our knowledge, this represents the first study to investigate how the rapid and dramatic increase in the use of telehealth is associated with changes in cardiovascular patient care in a real-world setting.15 Numerous studies have demonstrated the benefits of remote care using technologies such as event monitors and smartwatches targeted to specific cardiovascular disease processes such as arrhythmias, heart failure, or hypertension.7 Although these interventions have been largely studied in isolation, the COVID-era period is the first chance to study whether this assortment of modern telemedicine capabilities can result in accessible and effective virtual care in real-world practice.Although the use of telehealth has increased gradually during the preceding decades, its widespread use during the COVID-19 pandemic will likely lay the foundation for remote clinic visits as a more permanent and substantial part of future cardiovascular care.11 Although our data did not allow us to measure differences in care access, we were able to characterize overall differences in care usage. In our patient cohort, remote visits equally replaced the decrease in in-person patient visits in the COVID-era period. We found several differences in the patient populations that used remote care, but not all of the trends were expected. Consistent with expectations, patients with private insurance, a frequent proxy for high socioeconomic status, made up a larger percentage of both video and telephone visits.16 This is consistent with another recent study of primary care clinics serving low income individuals that reported that the shift to telehealth visits resulted in a modest decline in overall patient visits, mostly because of the inaccessibility of video visits for low income populations.1 We also found that older patients, which may have more difficulties with telemedicine technology, used video visits less frequently, although the mean (SD) age of patients using video visits was still 61.09 (16.49) years and 68.44 (15.99) years, respectively.18 However, other disparities that had been previously reported or postulated, such as those associated with race and ethnicity, were not identified.19 Although patients from underrepresented racial and ethnic groups were seen at similar frequency in the pre-COVID vs COVID-era periods, they in fact used video and telephone visits more frequently than White patients. We also found that patients using remote visits were more likely to have documented cardiovascular comorbidities, indicating comfort by both patients and clinicians in the delivery of complex care by telephone or video.The promise of telemedicine has always been tempered by concerns about disparities in access driven by the digital divide. Individuals who are older, have lower income, have less education, an underrepresented racial or ethnic group, live in rural areas, and have more chronic conditions are known to have less access to the internet and therefore possibly telemedicine services, especially video visits which require more technology investment and literacy.21 It may also be the case that patients who are older, from underrepresented racial and ethnic groups, or have more medical comorbidities find remote visits to be more appealing because they are comparatively less able to access in-person visits, whether that is because of greater barriers to transportation or scheduling.22 Indeed, a higher proportion of people of color work so-called essential jobs and may be less able to leave work to travel to in-person appointments.23Although this study was not designed to explain the observed differences in care utilization by patient groups, several possible reasons may be considered. One explanation may be a difference in perceived risk of attending in-person clinic appointments during the pandemic. Numerous studies highlighted in the press have drawn attention to the enhanced risk of COVID-19 infection among older individuals, people of color, and those with cardiovascular comorbidities, potentially convincing these patients and their clinicians to opt for remote visits.24 One could imagine, for example, that the lack of physical exam during remote visits with heart failure patients could result in the increased ordering of echocardiograms or lab tests such as BNP. Interestingly, we found the opposite to be true, with a decrease in the frequency of all diagnostics testing with video and telephone visits. The proportion of visits where at least one medication was prescribed decreased from more than two-thirds of pre-COVID in-person visits to half of COVID-era in-person visits to only one-third of COVID-era video visits and one-quarter of COVID-era telephone visits. These data are noteworthy because patients seen by remote visits had more cardiovascular comorbidities and were therefore more likely to require guideline-recommended medical therapies.We demonstrated that across all patients, there were also significant differences in practice patterns by visit type. Prior concerns have been raised about whether telemedicine visits could lead to the overuse of unnecessary testing and the overprescription of medications.25 A clinician may not think to order specific tests if not cued by certain findings on history of physical exam. This could be why there was still a further decrease in ordering frequency when comparing telephone with video visits, because telephone visits often provide even less information than video visits given the lack of a visual interface with the patient. The changes in testing, in turn, may have then affected prescribing practices. For example, reduced lab testing to monitor kidney function and electrolytes or lack of clinic-measured vital signs may have hindered clinical decision-making around the initiation and up-titration of frequently used cardiac medication such as beta blockers, ACE-inhibitors, and angiotensin receptor blockers. Further research investigating whether certain medication classes were more affected would be helpful.A portion of the decreased testing may be explained by reduced access, as many of these tests, such as lab tests, ECGs, echocardiograms, and stress tests, are often performed in the same facility and at the same time as the in-person clinic appointment. Some of the differences in testing may also be associated with shortcomings inherent to remote care such as a poorer understanding of the patient’s clinical picture because of decreased communication clarity and the inability to perform comprehensive physical examinations.Lastly, we studied the differences in ordering practices over time. It could be argued that the observed decreases in testing and prescribing were because clinicians were initially waiting for the COVID-19 pandemic to subside before advancing medical care. Across all visits, we found that ordering practices appeared to change in association with the severity of the local COVID-19 case incidence, but we found that the differences between in-person, video, and telephone visits persisted across nearly every month of the 9-month period of study. Nevertheless, additional follow-up studies after the pandemic has subsided are required to determine how long the decrease in diagnostic testing and medication prescription endures and whether it will have a significant impact on clinical outcomes.Several limitations to this study merit consideration. Although the strengths of this study include the large number of ambulatory visits from our multicenter institution and the completeness of the data, we studied visits from one medical system and geographical location. Our patient population was largely insured, primarily by private insurance or Medicare, and lived in an urban center, which may not capture certain patient populations most associated with adverse outcomes of the digital divide. Despite this, the diversity of our patient population, including by age, sex, and race contribute to the greater generalizability of our findings. There were also likely complex interactions that arose from both the COVID-19 pandemic as well as the change from in-person to remote visits. Deciphering the degree to which each of these factors contributed to changes in care utilization and practice patterns is difficult and we have attempted to disentangle these associations by limiting some comparisons across visit types to only the COVID-era  as well as by studying practice patterns over time to see if there were observable differences as the pandemic waned. As this is not a randomized study, we are unable to determine the degree to which there was bias from both patients and clinicians as to the selection of which patients were seen by in-person or remote visits. We did find that patients seen by remote visits had more medical comorbidities, which would suggest that the decrease in medication and diagnostic ordering with remote visits was not simply due to less sick patients being seen remotely. However, future prospective studies will be helpful for confirming our findings.The rapid and large scale transition from in-person to remote cardiovascular care during the COVID-19 pandemic has important implications for patient access to care as well as clinician practice patterns. In this large study of ambulatory cardiology visits, we found that during the height of the COVID-19 pandemic, remote cardiovascular care was more frequently accessed by patients who were younger, from underrepresented racial and ethnic groups, had private insurance, or had more cardiovascular comorbidities. There was a stepwise decrease in the ordering frequency of both diagnostic testing and medications when comparing pre-COVID in-person to COVID-era in-person to COVID-era video to COVID-era telephone visits. As a substantial proportion of future cardiology ambulatory care will likely continue to be delivered through remote visits, these changes in care access and practice patterns will have substantial ramifications with regards to both the efficacy and cost of future cardiovascular care.